{"1": {"fulltext": "", "height": "4560", "width": "2793", "jp2-path": "pathologysurgic00senn_0001.jp2"}, "2": {"fulltext": "Class __BIL\u00c2\u00a3lS\\nBook_ S4- 1 2.\\nOwn^tW\\nCOPSRIGHT DfcPOSir.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0002.jp2"}, "3": {"fulltext": "", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0003.jp2"}, "4": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0004.jp2"}, "5": {"fulltext": "", "height": "4441", "width": "2806", "jp2-path": "pathologysurgic00senn_0005.jp2"}, "6": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0006.jp2"}, "7": {"fulltext": "", "height": "4441", "width": "2806", "jp2-path": "pathologysurgic00senn_0007.jp2"}, "8": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0008.jp2"}, "9": {"fulltext": "THE\\nPATHOLOGY\\nAND\\nSURGICAL TREATMENT\\nTUMORS\\nBY\\nN. SENN, M.D., Ph.D., LL.D.\\nPROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE, IN AFFILIATION WITH THE UNIVERSITY OF\\nCHICAGO J PROFESSOR OF SURGERY, CHICAGO POLYCLINIC ATTENDING SURGEON TO PRES-\\nBYTERIAN HOSPITAL SURGEON-IN-CHIEF, ST. JOSEPH S HOSPITAL, CHICAGO.\\nSECOND EDITION, REVISED\\nILLUSTRATED BY 478 ENGRAVINGS, AND 12 FULL-PAGE\\nPLATES IN COLORS\\nPHILADELPHIA\\nW. B. SAUNDERS\\n925 WALNUT STREET\\n1900", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0009.jp2"}, "10": {"fulltext": "TWO cop.po\\nUbrary of Ce BfPet fc\\nAPR 2 01900\\nHegJsttr of Copyrlgj,^\\nCopyright, 1900\\nBy W. B. SAUNDERS\\nSECOND COPY,\\nELECTROTYPED BY PRESS OF\\nWESTCOTT THOMSON, PH1LADA, W. B. SAUNDERS, PHILADA.\\nif 0-0", "height": "4400", "width": "2806", "jp2-path": "pathologysurgic00senn_0010.jp2"}, "11": {"fulltext": "TO THE MEMORY\\nSAMUEL DAVID GROSS\\nA MASTER IN SURGERY A PIONEER IN PATHOLOGICAL ANATOMY A SURGEON\\nHONORED AND REVERED WHEREVER HIPPOCRATIC MEDICINE IS TAUGHT\\nOR PRACTISED; A MAN WHOSE EMINENT PROFESSIONAL\\nREPUTATION WAS CROWNED BY THE PURITY\\nOF HIS PRIVATE CHARACTER,\\nTHIS WORK IS\\nREVERENTLY AND AFFECTIONATELY INSCRIBED BY HIS FRIEND\\nTHE AUTHOR.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0011.jp2"}, "12": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0012.jp2"}, "13": {"fulltext": "PREFACE TO THE SECOND EDITION.\\nDuring the time that has elapsed since the appearance of the first\\nedition of this work, no great discoveries or advancements have been\\nmade concerning the nature and treatment of tumors. The parasitic\\norigin of malignant tumors continues to attract the attention of patholo-\\ngists and surgeons, but we have made very little progress in establishing\\nthis theory by actual facts. In the proper place will be found an\\naccount of recent work done in this direction, notably by Roncali, of\\nRome. The text has been carefully revised and many additions have\\nbeen made. A new section has been added on Sarcoma of the\\nDecidua. Many of the old illustrations have been eliminated, and are\\nreplaced by others intended to explain more satisfactorily the subjects\\nthey represent. Most of the new illustrations are original. The pub-\\nlisher has again placed the author under many obligations for his\\nliberality in inserting so many new illustrations.\\nN. SENN.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0013.jp2"}, "14": {"fulltext": "PREFACE.\\nThe appearance of a treatise on The Pathology and Surgical\\nTreatment of Tumors at this time needs no apology. Books\\nspecially devoted to this subject are few, and in our text-books and\\nsystems of surgery this part of surgical pathology is usually condensed\\nto a degree incompatible with its scientific and clinical importance.\\nAgain, the attention and energies of pathologists and surgeons during\\nthe last quarter of a century have been directed more toward the\\nfoundation and development of the new science of bacteriology and\\nthe advancement and improvement of operative technique than to a\\nmore thorough investigation of the equally important though less\\ninviting subject relating to the origin, nature, structure, clinical aspects,\\nand treatment of tumors.\\nEvery teacher of pathology and surgery knows how difficult it is\\nto impart to the student a knowledge of the structure and clinical\\ntendencies of the different kinds of tumors sufficiently accurate to\\nenable him to make a reliable diagnosis at the bedside. The gen-\\neral practitioner often remains painfully conscious of this defect in\\nhis early training, and the surgeon is frequently in doubt when to\\napply his art or when to pursue a conservative or palliative course\\nw T hen applied to for treatment by patients suffering from obscure\\ntumors or tumors presenting one or more of the numerous compli-\\ncations to which they are subject.\\nThe author has spent many years in collecting the material for this\\nwork, and has taken great pains to present it in a manner that should\\nprove useful as a text-book for the student, a work of reference for the\\nbusy practitioner, and a reliable, safe guide for the surgeon. For\\nthe purpose of simplifying diagnosis a special effort has been made\\nto trace every tumor to its proper anatomical starting-point and histo-\\n6", "height": "4402", "width": "2806", "jp2-path": "pathologysurgic00senn_0014.jp2"}, "15": {"fulltext": "PREFACE. 7\\ngenetic source, and to make a sharp histological and clinical distinction\\nbetween true tumors, inflammatory swellings, and retention-cysts.\\nThe increase in volume caused by a tumor is due entirely to erratic\\ncell-growth from a matrix of embryonal cells of congenital or post-\\nnatal origin the enlargement of a part or an organ caused by chronic\\ninflammation which so often simulates a tumor is due to proliferation\\nof pre-existing mature cells acted upon by pathogenic micro-organisms\\nor their toxines, and to the vascular changes and cell-migration charac-\\nteristic of inflammation while a retention-cyst essentially consists of\\nan accumulation of a physiological secretion in a pre-formed glandular\\nspace, the result of a mechanical obstruction.\\nThe classification of tumors in this work is in accord with this\\ntheory of the origin of tumors. The microbic origin of tumors is\\nbriefly disposed of, as it has not been established by any convincing\\nexperimental investigations or clinical observations. Should future\\nresearch demonstrate a direct causative relationship between certain\\nas yet unknown bacteria and the growth of some of the tumors, such\\ntumors would have to be eliminated from this group of pathological\\nproducts and be classified with the granulomata.\\nThe first part of this treatise is devoted to a general consideration\\nof tumors, and it is this part which is intended more especially for the\\nuse of students. Following the section on Classification, each class\\nof tumors is considered separately, beginning with benign epithelial\\ntumors and terminating with sarcoma, to which is appended a section\\non Retention-cysts. It will be observed that by following this course\\neach tumor is brought to the notice of the reader three different times.\\nRepetitions like these cannot fail in permanently impressing the sub-\\nject upon the memory of the reader. It has been deemed advisable\\nto discuss benign tumors first, as they do not deviate so far from the\\nnormal type of tissue-growth as do malignant tumors of the same\\ngerminal layer.\\nRetention-cysts are not true tumors, but they are discussed in the\\nlast section of the volume, as their differentiation from tumors is often\\nexceedingly difficult, and in their structure and clinical course they\\nresemble more closely tumor-formation than the products of inflam-\\nmation. A description of each class of tumors is followed by a con-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0015.jp2"}, "16": {"fulltext": "8 PREFACE.\\nsideration of the topographical distribution of that particular kind of\\ntumor in the different regions and organs of the body, with a\\ndescription of the different operative procedures for their removal.\\nThe intention of the author in illustrating the text so profusely\\nwas to keep constantly before the reader s eye the microscopical pic-\\nture of the tumor, which in many places is contrasted with the normal\\nstructure of the tissues corresponding with the anatomical location\\nof the tumor. The more difficult operations are fully described and\\nillustrated. More than one hundred of the illustrations are original,\\nwhile the remainder were selected from books and medical journals\\nnot readily accessible to the student and the general practitioner.\\nThe author desires to acknowledge his indebtedness to Mr. W. B.\\nSaunders, who has spared no expense in presenting this book to the\\nprofession, and to Mr. John Vansant and Mr. Thomas Dagney of his\\npublication rooms, for valuable assistance in supervising the details\\nof the preparation of the work also to Drs. Lecount and Mellish\\nfor a number of well-executed original drawings.\\nN. Senn.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0016.jp2"}, "17": {"fulltext": "CONTENTS.\\nPAGE\\nI. Origin and Nature of Tumors 17\\nDefinition, 19. Histological and Clinical Differences between a\\nTumor and an Inflammatory Swelling, 20. Histogenesis, 23.\\nII. Morphology and Multiplication of Tumor-cells 28\\nMorphology, 28. Karyokinesis, 30.\\nIII. Anatomy and Biology of Tumors 34\\nBlood-vessels, 35. Lymphatic Vessels, 35. Nerves, 36. Biology, 37.\\nRelation of Tumors to Adjacent Tissues, 40.\\nIV. Pathology of Tumors 42\\nFatty Degeneration, 43. Mucoid Degeneration, 44. Colloid Degen-\\neration, 44. Amyloid Degeneration, 45. Hyaline Degeneration, 45.\\nCaseation, 46. Calcification or Cretefaction, 47. Ossification, 47.\\nInterstitial Hemorrhage and Thrombosis, 47. Capsule of Tumor,\\n51. Lymphatic Glands, 51. Inflammation, 51. Ulceration, 52.\\nGrafting of a Malignant upon a Benign Tumor, 53.\\nV. Tumors in Plants and Animals 55\\nTumors in Plants, 55. Tumors in Animals, 57.\\nVI. Etiology of Tumors 60\\nCongenital Tumors, 60. Heredity, 61. Race, 64. Climate, 65. Age,\\n65. Sex, 67. Traumatism, 68. Irritation, 69. Inflammation, 69.\\nContagion, 70.\\nVII. Clinical Aspects of Benign and Malignant Tumors 71\\nRelative Frequency with which Different Organs are Affected by\\nTumors, 71. Benign Tumors, 72. Malignant Tumors, 74. Local\\nInfection, 75. Regional Infection, 75. General Infection, 76. Fre-\\nquency of Recurrence after Extirpation, yS. Intrinsic Tendency\\nof the Tumor to Destroy Life, 79.\\n9", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0017.jp2"}, "18": {"fulltext": "io CONTENTS.\\nPAGE\\nVIII. Transformation of Benign Tumors and Post-natal Embryonic\\nTissue into Malignant Tumors 80\\nTransformation of Benign into Malignant Tumors, 80. Transforma-\\ntion of Embryonic Tissue of Post-natal Origin into Malignant\\nTumors, 84.\\nIX. Diagnosis of Tumors 88\\nClinical History, 88. Length of Time Tumor has Existed, 89. Loca-\\ntion of Tumor, 89. Rapidity of Growth of Tumor, 89. Pain, 90.\\nTenderness, 90. Examination of the Patient, 91. Examination of\\nthe Tumor, 94. Tactile Examination, 96. Connection of Tumor\\nwith the Mother-soil, 97. Resistance and Consistence, 98. Pulsa-\\ntion, 101. Tenderness, 101. Crepitation, 102. Auscultation and\\nPercussion, 102. Rontgen Ray, 102. The Value of the Micro-\\nscope as an Aid in the Diagnosis of Tumors, 103.\\nX. Prognosis of Tumors 108\\nXI. Treatment of Tumors 113\\nMedical Treatment, 113. Radical Operation, 115; Ligation of the\\nPrincipal Blood-vessels Nourishing the Tumor, 116; Galvano-\\npuncture, 116; Parenchymatous Injections, 117 Injection of Ery-\\nsipelas Toxines, 118; Cauterization, 119; Ligature, 123; Galvano-\\ncaustic Wire, 124; Ecrasement Lineaire, 125; Avulsion, 126;\\nExtirpation, 126. Palliative Treatment, 129.\\nXII. Classification of Tumors 131\\nVirchow s Classification, 131. Cohnheim s Classification, 132. Wil-\\nliams s Classification, 133. Senn s Classification, 136.\\nXIII. Papilloma and Onychoma 137\\nPapilloma, 137. Histology and Pathology, 137. Transformation\\ninto Malignant Tumors, 140. Topography, 141 Skin, 141 Cornu\\nCutaneum, 142; Respiratory Organs, 144; Digestive Tract, 144;\\nUrinary Organs, 145 Female Organs of Generation, 146 Brain,\\n149. Diagnosis, 149. Prognosis, 149. Treatment, 150. Ony-\\nchoma, 150.\\nXIV. Adenoma 152\\nHistology and Pathology, 153. Etiology, 155. Topography, 156:\\nSkin, 157 Adenoma Sebaceum, 157 Adenoma Sudoriparum, 157\\nDigestive Tract, 1 57 Nasal Cavities, 1 59 Uterus and its Append-\\nages, 159; Thyroid Gland, 162; Mammary Gland, 167; Prostate\\nGland, 171 Lachrymal Gland, 172 Parotid Gland, 172 Testicle,\\n172; Liver, 173; Kidney, 175. Diagnosis, 175. Prognosis, 176.\\nTreatment, 176.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0018.jp2"}, "19": {"fulltext": "CONTENTS. II\\nPAGE\\nXV. Cystoma 178\\nEtiology, 180. Diagnosis, 180. Prognosis, 181. Topography, 181\\nTraumatic Epithelial Cyst, 181 Deep-seated Atheroma, 183\\nMucous Cysts, 185 Mesoblastic Cysts, 186 Thyroid Gland, 187\\nMammary Gland, 188; Ovary, 189; Vagina, 198; Testicle, 198\\nEye, 199; Cysts of the Vitello-intestinal Duct, 199; Allantoic\\n(Urachus) Cysts, 200; Bone, 200.\\nXVI. Carcinoma 203\\nDefinition, 203. Views Past and Present regarding the Origin and\\nNature of Carcinoma, 204: Histogenesis, 208. Histology, 212:\\nSquamous-celled Carcinoma, 213; Cylindrical-celled Carcinoma,\\n214; Glandular Carcinoma, 215. Malignancy, 215 Local Infec-\\ntion, 216; Regional Infection, 220; General Infection, 225. Eti-\\nology, 231 Heredity, 232 Traumatism, 233; Age, 234; Diet,\\n235 Climate, 236 Mental Depression, 236 Tuberculosis, 236\\nProlonged Irritation and Inflammation, 236 Microbes, 239.\\nPathology, 242. Histological Varieties of Carcinoma, 250:\\nSquamous-celled Carcinoma, 250; Cylindrical-celled Carcinoma,\\n252 Glandular Carcinoma, 253. Diagnosis, 256. Prognosis,\\n264. Treatment, 266 Palliative Operations, 269 Radical Oper-\\nations, 271. Topography, 273: Skin, 275 Lip, 280; Face, 282;\\nMouth, 289; Tonsil, 291; Tongue, 292; Parotid, 298; Thyroid,\\n300 Mammary Gland, 303 CEsophagus, 323 Stomach, 326\\nIntestines, 335 Rectum, 339 Testicle, 346 Penis, 347 Ovary,\\n350 Uterus, 353 External Female Generative Organs, 370 Eye,\\n372 Bladder, 372 Kidney, 374.\\nXVII. Fibroma 378\\nDefinition, 379. Histogenesis and Histology, 379. Retrograde Meta-\\nmorphoses, 382. Etiology, 383. Symptoms and Diagnosis, 383.\\nPrognosis, 384. Treatment, 385. Topography, 385 Skin, 385\\nMucous Surfaces, 389 Subcutaneous Connective Tissue, 390\\nAbdominal Wall, 391; Nose, 391; Mammary Gland, 396;\\nUterus, 397 Ovary, 397 Vulva, 398 Gums, 399 Periosteum\\nand Bone, 400, Serous Surfaces, 401. Cholesteatoma, 401.\\nXVIII. Lipoma 404\\nDefinition, 404. Histology, 404. Regressive Metamorphoses, 405.\\nAnatomical Varieties, 405. Symptoms and Diagnosis, 406. Prog-\\nnosis, 407. Treatment, 408. Topography, 408 Subcutaneous\\nAdipose Tissue, 408; Eyelids, 411; Subserous Lipoma, 411;\\nSubmucous Lipoma, 412 Meninges of the Brain and Spinal Cord,\\n413; Intermuscular Lipoma, 413; Periosteum, 413 Joints, 413;\\nTendon-sheaths, 414; Eye, 414; Broad Ligament, 414; Vulva,\\n414; Scrotum, 414.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0019.jp2"}, "20": {"fulltext": "12 CONTENTS.\\nPAGE\\nXIX. Myxoma 415\\nDefinition, 415. Histology, 416. Etiology, 417. Symptoms and\\nDiagnosis, 417. Prognosis, 417. Treatment, 418. Topography,\\n418: Skin, 418; Intermuscular Spaces, 418 Nose, 419; Middle\\nEar, 420 Nerve-sheaths, 420 Glands, 421.\\nXX. Chondroma 422\\nDefinition, 422. Origin, 422. Histology, 424. Retrogressive Meta-\\nmorphoses, 425. Etiology, 426. Symptoms and Diagnosis, 427.\\nPrognosis, 427. Treatment, 428. Topography, 428 Cartilage,\\n428 Bone and Periosteum, 429 Joints, 430 Salivary Glands,\\n431; Testicle, 432 Ovary, 432 Connective Tissue, 432. Chon-\\ndroma Branchiogenes, 432.\\nXXI. Osteoma 434\\nDefinition, 434. Histogenesis, 435. Histology, 435. Anatomical\\nVarieties, 437. Symptoms and Diagnosis, 437. Prognosis, 437.\\nTreatment, 437. Topography, 438 Cranial Bones, 438 Frontal\\nSinus, 440 External Meatus, 441 Jaws, 441 Brain, 441 Epiph-\\nyses of the Long Bones, 442 Muscles and Tendons, 442 Seat\\nof Fracture, 443 Orbit, 443 Eye, 444 Subungual Osteoma, 444.\\nXXII. Odontoma 445\\nDefinition, 445. Classification, 445. Epithelial Odontomes, 445.\\nFollicular Odontomes, 445. Fibrous Odontomes, 446. Cemen-\\ntomes, 446. Compound Follicular Odontomes, 446. Radicular\\nOdontomes, 446. Composite Odontomes, 447.\\nXXIII. Angioma 447\\nDefinition, 447. Histogenesis, 449. Histology, 449. Complica-\\ntions, 451. Anatomical Varieties, 452. Symptoms and Diag-\\nnosis, 456. Prognosis, 456. Treatment, 456. Topography, 458\\nSkin and Mucous Membranes, 458 Deep Connective Tissue,\\n459 Bones, 461 Intracranial Angiomata, 462 Liver, 462\\nMammary Gland, 463 Tongue, 463 Muscles, 463 Larynx, 464.\\nXXIV. Lymphangioma 465\\nDefinition, 465. Anatomical Varieties, 465. Histology and Histo-\\ngenesis, 465. Regressive Metamorphoses, 471. Symptoms and\\nDiagnosis, 472. Prognosis, 473. Treatment, 474. Topography,\\n474: Tongue, 474; Lips/474; Neck, 475; Subcutaneous and\\nSubmucous Connective Tissue, 477 Uterus, 477.\\nXXV. Lymphoma 478\\nDefinition, 478. Histology and Histogenesis, 480. Retrograde\\nMetamorphoses, 480. Symptoms and Diagnosis, 481. Treat-\\nment, 484.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0022.jp2"}, "21": {"fulltext": "CONTENTS. 13\\nPAGE\\nXXVI. Myoma 485\\nDefinition, 485. Embryology, 485. Rhabdomyoma, 486. Leio-\\nmyoma, 487. Histology and Histogenesis, 487. Regressive\\nMetamorphoses, 491. Symptoms and Diagnosis, 491. Prog-\\nnosis, 492. Treatment, 492. Topography, 493 Uterus, 493\\nBroad Ligament, 519 Fallopian Tube, 520 Round Ligament,\\n521 Alimentary Canal, 521 Pharynx, 521 (Esophagus,\\n521; Stomach, 521; Small Intestines, 521; Rectum, 522;\\nBladder, 522.\\nXXVII. Neuroma 524\\nDefinition, 524. Embryology, 524. Histology and Histogenesis,\\n524. Regressive Metamorphoses, 530. Etiology, 530. Symp-\\ntoms and Diagnosis, 530. Prognosis, 531. Treatment, 531.\\nTopography, 532 Multiple Neurofibromata, 532 Cranial\\nNerves, 533 Spinal Nerves, 533 Upper Extremity, 533\\nLower Extremity, 533 Plexiform Neuroma, 534 Vulva, 535\\nPrepuce, 535.\\nXXVIII. Sarcoma 536\\nDefinition, 536. Histology and Histogenesis, 537. Morphology\\nof Sarcoma-cells, 541. Histological Varieties, 542. Regressive\\nMetamorphoses, 558. Local and General Infection, 561. Meta-\\nstasis, 564. Etiology, 566. Symptoms and Diagnosis, 568.\\nPrognosis, 571. Treatment, 571. Topography, 574: Skin,\\n574 Submucous Connective Tissue, 576 Fascial Sarcoma,\\n578; Lymphatic Glands, 580; Bones, 582; Histological Varie-\\nties, 583; Mammary Gland, 601 Thymus Gland, 604; Sali-\\nvary Glands, 604 Tongue, 606 Tonsil, 606 Intestinal Canal,\\n606; Omentum, 607 Kidney, 607 Uterus, 610; Deciduoma\\nMalignum, 612 Ovary, 613; Vagina, 614; Vulva, 615; Tes-\\nticle, 615 Brain and its Envelopes, 616; Eye, 616 Bladder,\\n616 Prostate, 617.\\nXXIX. Teratoma 618\\nDefinition, 618. Origin, 618. Endogenous Teratomata, 620. Ec-\\ntogenous Teratomata, 620. Branchial Cysts, 623. Embry-\\nology and Anatomy, 624. History, 625. Classification, 626.\\nMucous Branchial Cysts, 628. Atheromatous Branchial Cysts,\\n628. Serous Branchial Cysts, 629. Hemato-cysts of Branchial\\nClefts, 629. Etiology, 630. Diagnosis, 631. Prognosis, 631.\\nTreatment, 632. Dermoid Cysts, 635. Definition, 636. His-\\ntology, 637. Regressive Metamorphoses, 639. Diagnosis, 640.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0023.jp2"}, "22": {"fulltext": "14 CONTENTS.\\nPAGE\\nPrognosis, 641. Treatment, 641. Topography, 641 Trunk,\\n641 Thorax, 642 Face, 644 Palate and Pharynx, 645\\nScalp and Dura Mater, 646 Eye, 647 Tongue, 647 Rec-\\ntum, 649; Auricle, 650; Ovary, 651; Scrotum, 655.\\nXXX. Retention-cysts 657\\nDefinition, 657. Histology, 658. Etiology, 660. Symptoms and\\nDiagnosis, 661. Prognosis, 664. Treatment, 664. Topogra-\\nphy, 665 Thyroid Gland, 665 Ovary, 665 Skin, 666; Mu-\\ncous Membrane, 668; Hydrokolpos, 671; Hydrometra, 671\\nHydrosalpinx, 672; Trachea and Bronchial Tubes, 674;\\nAppendix Vermiformis, 674 Bile-ducts, 675; Pancreas, 678\\nKidney, 699 Testicle, 704 Mammary Gland, 706 Salivary\\nGlands, 707.\\nINDEX 711", "height": "4418", "width": "2806", "jp2-path": "pathologysurgic00senn_0024.jp2"}, "23": {"fulltext": "PATHOLOGY\\nSURGICAL TREATMENT\\nOF\\nTUMORS.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0025.jp2"}, "24": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0026.jp2"}, "25": {"fulltext": "THE\\nPATHOLOGY AND SURGICAL TREATMENT\\nOF\\nTUMORS.\\nI. ORIGIN AND NATURE OF TUMORS.\\nThe subject of tumors is one of the much-neglected departments\\nof surgical pathology. Laboratory investigation, experimental research,\\nand clinical observations have revolutionized the etiology and pathology\\nof inflammatory diseases during the last decade. During that time the\\nattention of pathologists has been occupied largely in the etiological\\nand pathological elucidation of infective diseases, while surgeons have\\nexpended their energies in enlarging the scope of operative surgery\\nby an increased knowledge thus gained, and by the diminution of the\\nimmediate and remote risks to life of operative procedures attending\\nthe general adoption of antiseptic and aseptic precautions. The benefit\\nto humanity in the saving of life and the lessening of suffering derived\\nfrom these investigations and from improved practice is incalculable.\\nThe great work initiated by Pasteur, Lister, and Koch has inaugurated\\na new era in the study and treatment of disease, and must serve as\\na permanent foundation for all future investigations. When we realize\\nthe amount of suffering and the number of deaths resulting from tumors,\\nit appears somewhat strange that this vast department of pathology\\nhas received so little attention on the part of modern investigators.\\nIt is true that recently a great deal of work has been done to establish\\nthe microbic origin of malignant tumors, but no positive results have\\nbeen obtained so far, and we must confess that but little additional\\nlight has been shed on the etiology and pathology of tumors since\\nthe epoch-making labors of Virchow and Cohnheim.\\nHistory. The old authors regarded tumors as something entirely\\nforeign grafted upon the organism. John Hunter taught that a drop\\nof blood, being accidentally extravasated, became organized and as-\\nsumed a growth independent of the adjacent tissues, and continued to\\ngrow till it was limited by some obstacle opposed to it. Effusion of\\n2 17", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0027.jp2"}, "26": {"fulltext": "18 PATHOLOGY AND TREATMENT OF TUMORS.\\nlymph has been considered as a possible cause. It was suggested that\\nin the development of the tumors the lymph played the same role\\nclaimed by Hunter for the extra- vascular blood. Chronic inflammation\\nwas regarded for a long time as the essential etiological factor. These\\nand many other vague theories advanced in regard to the origin and\\nnature of tumors prior to the time they were recognized as a part of\\nthe body they inhabited, the result of proliferation of pre-existing cells,\\ndo not merit an extended discussion in a modern text-book. Schleiden\\nestablished the cell theory which inaugurated the science of biology\\nSchwann showed from a cellular basis the analogy of the structure of\\nplants and of animals.\\nThe study of tumors in plants and in the lower animals has done\\nmuch in adding to our knowledge of the etiology and pathology of\\ntumors. Pathological processes in plants are much simpler than in\\nanimals, owing to the absence in the former of many complicating fac-\\ntors, such as nerves and blood-vessels at the same time, the plants are\\nconstructed upon a much simpler embryological plan. Both animal\\nand vegetable cells have in common the nitrogenous carbon compound\\ncalled protoplasm. Johannes Muller applied the cell theory to the\\nstudy of tumors. Virchow elaborated this doctrine in establishing by\\nhis immortal researches the motto of his great work on cellular path-\\nology, Omnis cellida e cellula. Cohnheim imparted a new stimulus to\\nthe study of tumors by advancing a novel theory in reference to\\ntheir origin. It appears recently that Durante of Rome was the\\nreal originator of the theory of the embryonic origin of tumors, as\\nhis publication on this subject antedates that of Cohnheim by one\\nyear. Virchow taught that an epithelial tumor could develop from\\nconnective tissue. Cohnheim referred every tumor to its proper embry-\\nonic layer, and claimed that a tumor never had its origin from mature\\ntissue, but always developed from a matrix of embryonic tissue. This\\nessential tumor-matrix he traced back to its embryological source. He\\nbelieved that during the process of cell-differentiation in the embryo\\ngroups of cells not utilized in the growth of the embryo, or displaced,\\nwere arrested in their further development, and remained in a latent\\ncondition until their activity was awakened later, when the product of\\ntheir proliferation resulted in the formation of a tumor. This theory\\nfound many supporters, but at the present time only a few authors\\nuphold it in its entirety. As we shall see further on, it has much to\\nrecommend it, but it does not satisfactorily explain the origin of all\\ntumors. In the absence of better proof of the origin of tumors, the\\nwriter will adhere to the doctrine advanced by Cohnheim, and in addi-\\ntion to it will claim that the essential tumor-matrix may be composed", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0028.jp2"}, "27": {"fulltext": "ORIGIN AND NATURE OF TUMORS. 19\\nof embryonic cells, the offspring of mature cells which for some reason\\nhave failed to undergo transformation into tissue of a higher type, and\\nwliicJi may remain in a latent, immature state for an indefinite period\\nof time, to become, under the influence of either hereditary or acquired\\nexciting causes, the essential starting-point of a tumor.\\nIt has been the good fortune of Roux to discover isolated colonies\\nof cells in the middle, more rarely in the inner embryonal layer of\\nfrog embryos, sometimes in large numbers once as many as thirteen\\nscattered among the other cells. Barfurth, in his experiments in the\\nregeneration of the embryonal layers, observed that by puncturing and\\nturning inward the ectoderm of the gastrulse that a growth of cells\\nvery like a dermoid took place. Grawitz traced some of the tumors\\nof the kidney. to islets of separated and displaced suprarenal tissue.\\nThese experiments and observations have a very important bearing\\nupon the development of tumors from displaced embryonal cells.\\nDefinition. So long as our ideas in reference to the origin and\\nnature of tumors rest exclusively on a theoretical basis, it is evident\\nthat no satisfactory definition can be given. The definition of each\\nauthor must necessarily vary according to his views on the subject.\\nA few definitions will be given to corroborate the correctness of this\\nstatement. John Hunter thus defines a tumor A tumor is a circum-\\nscribed substance produced by disease, and different in its nature and\\nconsistence from the surrounding parts. Neoplasm is a new growth\\ncharacterized by histological diversity from the matrix in which it\\ngrows, is the description of a tumor given by J. Bland Sutton. Bar\\nregards the characteristic feature of a tumor as an active multiplica-\\ntion of cells which takes place independently of inflammatory pro-\\ncesses. The process which leads to the formation of tumors he calls\\na monstrosity in the development of cells. Liicke wrote on the\\nsubject of tumors from the standpoint that a tumor is an increase of\\nvolume by the production of new tissue without a corresponding physi-\\nological function. Cohnheim, in consonance with his definite ideas\\nconcerning the origin of tumors from embryonic tissue, and the difference\\nbetween the character of the tissues of which they are composed and\\nthe structure of the tissues in their immediate vicinity, describes a tumor\\nas a circumscribed, atypical production of tissue from a matrix of\\nsuperabundant or erratic deposit of embryonic elements. From these\\ndefinitions it becomes apparent how difficult it is to give even an\\napproximately correct definition of a tumor. Many pathologists have\\nregarded tumors as a localized form of hypertrophy, but upon making\\na closer comparison we find that, to whatever extent the adapted hyper-\\ntrophy may develop, the overgrown part maintains itself in the normal", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0029.jp2"}, "28": {"fulltext": "20 PATHOLOGY AND TREATMENT OF TUMORS.\\ntype of shape and structure, while a tumor is essentially a deviation\\nfrom the normal type of the body in which it grows, and, as a rule, the\\nlonger it exists the more marked becomes the deviation (Williams).\\nOne of the greatest difficulties in the way of a proper appreciation of\\nwhat is meant by a tumor is a failure on the part of authors and teach-\\ners to draw a dividing-line between tumors and inflammatory swellings.\\nThat tumors should have been confounded with inflammatory swellings\\nbefore the essential causes of the latter were discovered and understood\\nis not strange, but that these entirely different pathological processes\\nshould not be separated sharply at the present time is inexcusable.\\nIt has been the writer s custom for ten years, in his lectures, didactic\\nand clinical, to make a sharp distinction between a tumor, an inflam-\\nmatory swelling, and retention-cysts. In writing this book this dis-\\ntinction will be maintained by eliminating from discussion all affections\\nof which the microbic origin has been established, as well as swellings\\ncaused by retention of a physiological secretion, the latter of which\\nwill be discussed in a separate part of the book, and the definition of\\na tumor will therefore be framed upon a more limited basis. The\\ndefinition of a tumor should explain its origin, its histological character-\\nistics, and its behavior toward its immediate environment. A tumor is\\na localized increase of tissue, the product of tissue-proliferation of embry-\\nonic cells of congenital or post-natal origin, produced independently of mi-\\ncrobic causes. This definition refers all tumors histogenetically to embry-\\nonic cells, which, according to Cohnheim, may be of congenital origin,\\nor which, according to the writer s views, may also be of post-natal\\norigin, being derived from pre-existing mature tissue in consequence\\nof injury or disease, and, failing to undergo the normal transformation,\\nmay give rise to tumor-formation in the same manner as embryonic\\ncells of fetal origin. This definition also excludes mature tissue and\\npathogenic microbes as etiological factors in the production of tumors,\\nthus establishing a well-defined line between a true tumor and an\\ninflammatory swelling. It is not necessary to include absence of func-\\ntion in the definition, as this applies equally, if not more forcibly, to\\nswellings of an inflammatory origin. The writer does not claim that\\nthis definition is above criticism, but it will convey to the student what\\nis so essential in teaching a correct idea concerning the histogenesis\\nand the essential pathological features of tumors, which knowledge will\\nenable him, later, at the bedside to make a correct differential diagnosis\\nbetween a true tumor and an infective swelling.\\nHistological and Clinical Differences between a Tumor and an\\nInflammatory Swelling-. According to our definition, the most im-\\nportant histological difference between a tumor and a swelling caused", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0030.jp2"}, "29": {"fulltext": "ORIGIN AND NATURE OF TUMORS. 21\\nby infection consists in the fact that in the former the localized increase\\nof tissue is the result of proliferation of embryonic cells (of pre- or post-\\nnatal origin) which are not utilized in the growth and development\\nof the body or in the repair of injured or diseased parts, constituting\\nthus a process entirely distinct and independejit of the tissues i?i its\\nimmediate vicinity while an inflammatory swelling results from tissue-\\nproliferation provoked by the action of pathogenic microbes or their\\ntoxines upon pre-existing mature tissue-cells. The incipient pathological\\nproduct is therefore always more localized and better defined in tumor-\\nformation than in inflammatory affections. A benign tumor always\\nremains local, tissue-growth being limited to the fixed primary matrix.\\nA malignant tumor has a similar local origin, but it gives rise to dissem-\\nination by migratio7i of cells into the adjacent tissues or by their trans-\\nportation to distant parts through the lymphatic or general circulation.\\nIn the production of an inflammatory swelling the fixed tissue-cells\\nwhich have been exposed to pathogenic microbes or to their toxines\\nparticipate the new cells produced mingle with the corpuscular ele-\\nments of the blood, reaching the inflamed area through damaged cap-\\nillary walls caused by the same agents, and constituting with the trans-\\nudation the inflammatory product. Inflammatory affections lack from\\nthe very beginning the localized character of a true tumor. Progressive\\nand often very speedy extension by continuity and contiguity of struct-\\nure is one of the most conspicuous clinical features of inflammatory dis-\\neases as compared with tumor-formation, and the existence or absence\\nof such manifestations is often of great importance to the surgeon in\\nmaking a correct differential diagnosis between a tumor and an inflam-\\nmatory swelling. Another important point in the early differentiation\\nbetween a tumor and a swelling of infective origin is the durability of\\nthe new tissue-product. The tissue of which a tumor is composed is\\npermanent. While in cases of progressive marasmus the subcutaneous\\nfat disappears ultimately almost completely, a fatty tumor in such an\\nindividual remains unaffected, showing its independence from the gen-\\neral laws of nutrition and waste that govern the body. A tumor never\\ndisappears except by removal or destruction. There is no authenticated\\nrecord of spontaneous disappearance of a tumor or of disappearance\\nof a tumor under any kind of internal medication. In all cases in\\nwhich such a termination is said to have taken place we have instances\\nin which an infective swelling was mistaken for a tumor. The growth\\nof a tumor is usually progressive. Some of the benign tumors, such\\nas neuroma and osteoma, reach a certain size, when further growth is\\nspontaneously arrested. The nearer the tumor-elements resemble nor-\\nmal tissue, the greater the probability of spontaneous cessation of\\nx", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0031.jp2"}, "30": {"fulltext": "22 PATHOLOGY AND TREATMENT OF TUMORS.\\ngrowth. The inflammatory product, whether the result of an acute\\nor of a chronic process, is composed of tissue which is destined to suc-\\ncumb sooner or later to the microbic influences which produced the\\ninflammation. The blood-corpuscles and the embryonic cells, the prod-\\nuct of the fixed tissue-cells, are destroyed by the primary cause of the\\ninflammation, either quickly or slowly according to the type and intensity\\nof the inflammatory process. One kind of swelling which has been,\\nand still is, erroneously designated as a tumor is the struma miasmatica.\\nAccording to our views, a struma due to miasmatic causes is not a\\ntumor, because the early use of proper therapeutic agents, such as the\\ninternal and external use of iodine, by removing or rendering harmless\\nthe primary, as yet unknown microbic cause, succeeds in effecting a\\ncure. Under the influence of iodine fatty degeneration, disintegration,\\nand absorption of the cells of a parenchymatous struma are effected\\nand a restitution ad integrum takes place. The swelling or pseudo-\\ntumor disappears because the remedy administered has succeeded in\\nremoving or in neutralizing the primary cause. A hyperplasia of tissue\\ndue to an infective cause is amenable to absorption or removal on\\nremoval of the primary cause, but no such termination can be expected\\nin the case of a tumor, whatever its structure and character may be.\\nWe must therefore regard permanency of the new tissue as one of the\\nevidences in favor of a doubtful enlargement being a true tumor while\\nearly, and especially acute, degenerative changes would indicate an inflam-\\nmatory origin. The general symptoms are also to be taken into con-\\nsideration in the differential diagnosis between a tumor and an inflam-\\nmatory swelling. Acute suppurative inflammation is attended by such\\nviolent local and general symptoms that it is seldom mistaken for\\nmalignant disease. Chronic inflammatory affections, such as tubercu-\\nlosis, gumma, and actinomycosis, are often mistaken for tumor, and\\nvice versa. Local and general increase of temperature is usually absent\\nin all benign tumors, and is either absent or only slightly increased in\\nmalignant tumors. In chronic inflammatory affections a slight rise in the\\nlocal and general temperature is often observed. The use of the clinical\\nthermometer is therefore indicated in obscure cases in making a differ-\\nential diagnosis between a tumor and an inflammatory affection. The\\nexclusion of the granulomata (granulation-swellings) produced by the\\nbacillus of tuberculosis, the actinomyces, the unknown microbe of\\nsyphilis, and the bacillus of glanders from the list of tumors has greatly\\nnarrowed the field of this part of pathology, and it is possible that\\nfurther restriction will take place when convincing proof can be fur-\\nnished of the microbic origin of one or of both varieties of malignant\\ntumors. As soon as it can satisfactorily be shown that carcinoma and", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0032.jp2"}, "31": {"fulltext": "ORIGIN AND NATURE OF TUMORS. 23\\nsarcoma are caused by microbes, they must be classified with infective\\nswellings, and not with tumors. From the present standpoint of patho-\\nlogical and bacteriological investigations we are forced to include these\\naffections among the non-infective neoplasms. Enlargement of the\\nsuperficial veins and oedema, such common symptoms of inflammatory\\nlesions, are occasionally present in rapidly-growing malignant tumors\\nin fact, it may be stated that the nearer a malignant tumor resembles\\ninflammatio7i, the greater is its malignancy.\\nHistogenesis. A tumor never originates de novo, but is always an\\nintegral part of the organism, the product of tissue-proliferation from\\na matrix of embryonic cells. Tumor-formation consists in the growth\\nand development of pre-existing immature tissue-elements. The struct-\\nure and character of a tumor depend upon the stage of the arrested cell-\\ngrowth and the embryonic layer from which the matrix is derived. For\\ninstance, a matrix of epithelial cells from the epiblast in which cell-\\ngrowth was arrested near the completion of the process of differen-\\ntiation will in all probability become the starting-point of a benign\\nepithelial tumor on the other hand, if the development of the same\\ncells was arrested at an earlier stage, the proliferation will result in\\ntissue of a lower type, and the resulting tumor will be a carcinoma.\\nThe same holds true of mesoblastic tumors the more imperfect the\\ndifferentiation, the greater the tendency to the production of a sarcoma\\nthan to that of a fibroma. The tumor-cells always correspond in type\\nto the embryonic cells from which they are derived. In cases of dermoid\\ncysts in man we never find heterologous structures we always look\\nfor the products of tissue-proliferation representing the normal tissues\\nfrom the epiblast. While we expect to find in such instances in the\\ninterior of the tumor hair or other products of epithelial proliferation\\nand degeneration, we never find feathers nor any other heterologous\\ntissues while in birds, when dermoid cysts occur, we find no hair, but\\ninvariably feathers. So the products of a displaced epiblastic matrix\\nalways represent normal tissue-elements in an abnormal place. Tumors\\nof the connective-tissue type are invariably derived from a matrix of\\nmesoblastic tissue, and all epithelial tumors are connected with the\\nepiblast or hypoblast or spring from a displaced matrix from either\\nof these embryonic layers. As Jn the majority of cases the tumor-\\nmatrix is composed of immature cells of fetal origin, it will be necessary\\nto discuss in detail the\\nDifferentiation of Tissue in the Embryo and the Origin and\\nDisposition of the Germinal Layers. During the earliest stages of\\ndevelopmentthe embryo is composed of a mass of indifferent cells. At this\\ntime it would be impossible to make a distinction under the microscope.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0033.jp2"}, "32": {"fulltext": "24 PATHOLOGY AND TREATMENT OF TUMORS.\\nSegmentation of the eggs of the frog was first described in 1836\\nby Prevost and Dumas. Pander in 1847 distinguished in the embryo\\nof the chick three layers the external, the serosa the internal, the\\nmucosa and the middle, the muscular layer. This classification of\\nthe germinal layers corresponds to the more modern into epiblast,\\nhypoblast, and mesoblast. Bar, the pupil of Pander, called the ger-\\nminal layer stratum proligerum, and divided the embryonic tissue into\\ntwo principal layers, (1) animal and (2) vegetative. Each of these\\nlayers he subdivided into two layers, the first (1) skin and (2) muscles,\\nthe second (1) vascular and (2) mucous. More recently His divides the\\nunspecialized tissue of the embryo into two layers, (1) archiblast and\\n(2) parablast. The archiblast includes all the tissues which are later\\n.ung\\nch uw ao sp dd df\\nFig. i. Transverse section through embryo of chick two days old; X 100 (after KSlliker) dd, hypo-\\nblast; ch, cord; uw, primitive vertebra; u n h, primitive vertebral canal; a o, primitive aorta; ung,\\nprimitive urinary channel; sp, cleft in lateral plates (first indication of pleuro-peritoneal cavity), which\\nthrough the same is lost in the hpl and intestinal connective-tissue plates df, which are connected through\\nthe mesoblast mp mr, medullary tube; h, epiblast thickened at some points. The embryo at this time is\\ncomposed of two epithelial layers, the outer the epiblast, the inner the hypoblast, connected by the middle,\\nthe mesoblast.\\ntransformed into epithelial cells, and it is equivalent to the epiblast\\nand the hypoblast. The most active tissue-changes occur during early\\nembryonic life. It is during this time that specialization of the indiffer-\\nent cells takes place, upon which specialization depends the formation\\nof different tissues and organs according to the demands of the indi-\\nvidual or the adaptation of cells to their immediate environments. The\\ndivision of embryonic tissue into epiblast, hypoblast, and mesoblast\\nwill be retained in this book, in preference to including the epiblast\\nand hypoblast under the one term archiblast, since in the discussion\\nof epithelial tumors the student will more readily comprehend the loca-\\ntion of the tumor, as well as the structure of the epithelial cells, by\\nseparating the epidermal (epiblastic) from the mucous (hypoblastic).\\nBased upon the researches of Remak, Reichert, and Kolliker, embry-\\nologists trace all the tissues and organs of vertebrate animals, includ-\\ning man, to these three germinal layers which are found in embryos\\na few days old. In the embryo of the chick two days old (Fig. 1)\\nthese germinal layers can plainly be distinguished, and the complicated\\narrangement between the outer and inner layers and the mesoblast can\\nbe traced distinctly.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0034.jp2"}, "33": {"fulltext": "ORIGIN AND NATURE OF TUMORS. 25\\nA few words concerning the disposition of these germinal layers\\nduring the differentiation of their cells. From the epiblast are devel-\\noped all the tissues and organs composed of epidermis, the skin, the\\nhair, the nails, all cutaneous glands, including those terminating in\\nthe mouth, also the lens of the eye and the epithelial lining of the\\ncavity of the mouth, the nasal passages, and the labyrinth of the ear.\\nReichert was the first to prove that the medullary plate, the primitive\\ncentral nervous system, is formed by the epiblast, and consequently\\nthat the brain and the spinal cord are epiblastic structures a discovery\\nwhich was later corroborated by the investigations of Remak and\\nK611iker.\\nThe epiblast at the stage of development we are now considering\\nis arranged in the shape of a double tube namely, first the covering\\nof the whole body (epidermis), and secondly, its central part, the med-\\nullary tube while the hypoblast constitutes a single tube, the gastro-\\nintestinal canal with its glandular appendages. The hypoblast fur-\\nnishes the whole epithelial lining of the digestive tract and the urinary\\norgans, and from it are also developed the glands of the mucous lining\\nand the glandular elements of the pancreas, the liver, the lungs, the\\nthyroid, and the kidneys. The middle germinal layer, the mesoblast,\\nforms the framework of the body, the bones, the connective tissue,\\nthe nerves, the muscles, the serous membranes, the vascular organs,\\nincluding the lymphatics and the ductless glands, the thymus, and the\\nspleen. The differentiation of the cells that takes place in the embryo\\nlimits their function to the part or organ to which they belong. No\\ntransition from one type to another takes place. The law of the specific\\ngenetic nature of the tissues as now generally recognized is observed in\\nthe embryo everywhere, and it remains in force during the entire life of\\nthe individual. In the growth of tumors the same law applies. One\\nof the most convincing proofs that the specific nature of imperfectly\\ndifferentiated cells is permanently retained is the familiar clinical fact\\nthat a displaced matrix of embryonic epithelial cells, isolated from the\\nepiblast or hypoblast and buried in the mesoblast, when it becomes the\\nstarting-point of a tumor invariably results in the formation of an\\nepithelial growth. Such an embryological enkatarrhophy is most prone\\nto take place where the most complicated tissue-changes occur in the\\nembryo, as about the orbit, the genital organs, and the muco-cutaneous\\njunctions. Some of the cells remain in a state of incomplete differen-\\ntiation for a long time even in man, as shown by the development of\\nthe teeth, the thymus, the mammary gland, the organs of generation,\\nthe bones, etc. These and many other facts prove the possibility of\\ntissues remaining in a dormant condition for variable periods, and then", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0035.jp2"}, "34": {"fulltext": "26 PATHOLOGY AND TREATMENT OF TUMORS.\\nassuming, under the influence of an increased physiological or patho-\\nlogical stimulus, renewed activity, growth, and development. During\\na certain time of the life of the individual, or in consequence of acquired\\npathological conditions, cells may arise where they have no legitimate\\nexistence, or at a time when they ought not to be produced, or to an\\nextent beyond the physiological limits. In this manner monstrosities\\nand malformations are produced in the embryo, and later tumors are\\nformed from such latent imperfectly specialized tissue under the same\\nconditions. We know that certain organs up to the time of puberty\\nremain to a certain extent in a dormant condition, not keeping pace\\nwith the general growth of the body but when the period of puberty\\narrives, the genital organs, the mammary gland in the female, the skin\\nand its appendages, are suddenly stimulated by a physiological impetus\\nwhich results in increased tissue-growth. In pathology the proof of\\nthe correctness of this assertion is based on the fact that during this\\nperiod are prone to appear certain epithelial tumors which are seldom\\nmet with before the age of puberty or late in life. There is no fact\\nbetter establislicd in pathology than that during this time of life, charac-\\nterised by the highest degree of post-natal tissue-activity, the intrinsic\\ncapacity of cell-production in an cpiblastic matrix of cells is suddenly\\naroused, and the new tissue thus produced results in the formation of an\\nepithelial tumor. It is during this time of life that we most frequently\\nmeet with dermoid cysts in their favorite localities, branchial cysts, and\\nadenoma of the breast. We have reason to believe that many persons\\nthe possessors of the essential tumor-matrix of congenital or post-natal\\norigin fail to become the subjects of a tumor either from an insufficient\\nintrinsic capacity of cell-growth and reproduction on the part of the\\nlatent cells composing the matrix, or owing to an inadequate degree of\\nlocal or general stimulation. Under such circumstances the cells of the\\nmatrix remain permanently in a latent condition.\\nA general excess of embryonic tissue under favorable post-natal\\nconditions gives rise to general giant growth. Localized excess repre-\\nsenting the different tissues of a part or an organ results in local giant\\ngrowth. Friedberg observed a case where, in a female child at the\\ntime of birth, the right leg was considerably larger than the left after\\nbirth symmetrical development failed to take place, and the larger limb\\nassumed giant growth, which fact induced Friedberg to assert that giant\\ngrowth is not only congenital, but progressive. If an excessive amount\\nof embryonic tissue is present at the time of birth, giant growth may\\ntake place at any subsequent period during life, awaiting a favorable\\nopportunity until an increased afflux cf blood to the part results in\\nincreased tissue-proliferation, the asymmetrical growth being due essen-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0036.jp2"}, "35": {"fulltext": "ORIGIN AND NATURE OF TUMORS. 27\\ntially to the amount of embiyonic tissue originally stored up in the\\npart.\\nAbnormal additional centres of embryonic tissue in the embryo\\nresult in all kinds of monstrosities, parasitic fetuses, supernumerary\\nfingers and toes, accessory glands, etc. A defective amount of build-\\ning material in the embryo is responsible for many of the fetal defects,\\nsuch as hare-lip, cleft palate, absence of or defective limbs, etc.\\nAnother familiar instance substantiating the correctness of the theory\\nof the origin of tumors from a matrix of embryonic cells is furnished\\nby the pregnant uterus. As a rule, hypertrophy of tissue is attended\\nand produced by increased physiological function. In the gravid uterus\\nthere is an increase of muscular tissue attending simply an increased\\nphysiological growth of an organ, unattended by a corresponding\\nincrease of function, but preparatory to a sudden emergency requiring\\ngreat functional activity. During pregnancy the muscular fibres re-\\nmain in a condition of rest during the intervals between slight mus-\\ncular contractions first observed and described by Braxton Hicks.\\nThe uterus receives an unusual blood-supply. We can explain the\\nattending muscular hyperplasia only by assuming the presence of a\\nsuperabundant deposit of embryonic cells awaiting a favorable oppor-\\ntunity to develop into mature, functionally-active muscular tissue.\\nThe origin of a tumor from post-natal embryonic tissue is suscep-\\ntible of a satisfactory explanation. Every surgeon can recall instances\\nof the development of tumors from inflammatory products scar-tissue\\nand immature callus. We must take it for granted that in such tissue\\ncells or groups of cells have failed to undergo transformation into\\nmature tissue, and that they perform in the production of tumors the\\nsame role as the congenital matrix of embryonic cells of Cohnheim.\\nIn the absence of a more plausible theory, the writer is forced to\\nconclude that every tumor is the product of tissue-proliferation of a con-\\ngenital or post-natal matrix of embryonic cells, aroused into activity by\\na general or local physiological stimulation or by congenital or acquired\\nabnormal conditions in its immediate environment.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0037.jp2"}, "36": {"fulltext": "II. MORPHOLOGY AND MULTIPLICATION\\nOF TUMOR-CELLS.\\nMorphology. The shape of a tumor-cell corresponds very closely\\nto that of the cells of the organ or part in which the tumor originated.\\nIn the growth of a tumor the cells retain their original type. The\\ndevelopment of the cells of benign tumors ultimately reaches the\\nhighest degree of perfection, so that under the microscope it is difficult\\nif not impossible to distinguish between tumor-tissue and the tissue\\nto which it belongs or which it represents. The macroscopical and\\nmicroscopical resemblance between a lipoma and normal fatty tissue and\\nan adenoma and normal glandular tissue\\nis often almost perfect. The cells of\\nwhich malignant tumors are composed\\ndo not attain maturity; consequently they\\nresemble more closely the fixed tissue-\\ncells in their juvenile state. From the\\nillustration showing the shape of young\\nconnective-tissue cells (Fig. 2) and sar-\\ncoma-cells, it will be seen that their\\nmorphology is more nearly identical than\\nwould be expected from the difference in\\ntheir source and the accomplishment of the ultimate object of their\\nexistence. The most striking difference between a sarcoma-cell and an\\nimmature connective-tissue cell under the microscope is the size and\\nnumber of the nuclei. The nucleus of the sarcoma-cell is large and\\noften multiple, showing greater vegetative activity as compared with the\\nmononucleated connective-tissue cell. Absence of uniformity of size\\nin the sarcoma-cells is another distinguishing criterion.\\nMost of the older text-books on pathology contain elaborate\\ndescriptions of a morphologically specific cancer-cell. The application\\nof this teaching in practice resulted in many mistakes in diagnosis by\\nplacing too much reliance upon the morphological appearances of cells\\nunder the microscope. It is stated above that the structure of the cells\\nof benign tumors is so closely akin to that of the normal cells of the\\npart which the tumor represents that the microscope alone cannot be\\nrelied upon in distinguishing between the pathological product and the\\n28\\nFig. 2. Embryonal connective tissue:\\nthe intercellular substance is only slightly\\ndifferentiated (after Piersol).", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0038.jp2"}, "37": {"fulltext": "MORPHOLOGY OF TUMOR-CELLS.\\n29\\nnormal tissue. This assertion will be strengthened by illustrations rep-\\nresenting a non-malignant epiblastic tumor and the middle strata of the\\nepidermis.\\nFig. 3. Cells from a spindle-celled sarcoma treated fresh in a solution of sodic chloride X 250 (after Perls).\\nIn carcinoma, the malignant tumor of the epiblast and hypoblast,\\nthe cells again bear a great resemblance to the cells which compose\\nthe respective germinal layers. Like sarcoma-cells, they do not attain\\nmaturity consequently they present in their structure more the type\\nFig. 4.\u00e2\u0080\u0094 Prickle-cells from papilloma of ski\\nX 250 (after Ziesing).\\nFig. 5. Prickle-cells from middle strata\\nof the epidermis (after Piersol).\\nof embryonic than mature epithelial cells. In contradistinction to the\\nnormal epithelial cells, we find that many of the carcinoma-cells arc\\npolynucleated. The caudate prolongation of many of the cells is not\\na characteristic feature of a malignant epithelial cell, as was formerly\\nsupposed, but is one of the results of rapid cell-growth and pressure", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0039.jp2"}, "38": {"fulltext": "30 PATHOLOGY AND TREATMENT OF TUMORS.\\nfrom without. The polymorphism of the cells of malignant tumors is\\nlargely due to the combined effect of these two factors in modifying\\ncell-form. The student should remember also that the contour of a\\ncell under the microscope will depend greatly on the direction of the\\ncutting in making the sections. Thus if, in case of a spindle-celled\\nFig. 6. Cells from an epithelial carcinoma of the bladder; X 250 (after Perls).\\nsarcoma, the section is made in the direction of the long axis of the\\ncell, the cell will present a spindle-shaped appearance on the other\\nhand, if the cell is cut transversely, it will present an oval outline or\\nwill appear round, as in cases of round-celled sarcoma. In conclusion,\\nit must be said that while polymorphism and multiple large nuclei\\nstrongly point toward the malignant character of cells, these conditions\\ncannot be relied upon in making a positive distinction between normal\\nand benign and malignant tumor-cells.\\nKaryokinesis. It is now generally conceded that every patholog-\\nical process has its physiological prototype. Cell-multiplication in\\ndisease may arise at a place where it is not needed, or at the wrong\\ntime, or to an extent beyond the limits of local normal requirement.\\nTumor-cells multiply, like most of the normal tissue-cells, by indirect", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0040.jp2"}, "39": {"fulltext": "MORPHOLOGY OF TUMOR-CELLS. 31\\ndivision, a process called karyokinesis. This is the method of repro-\\nduction of nearly all the fixed tissue-cells of a higher type in the\\nbody. This method of cell-segmentation was first described and care-\\nfully studied by Flemming, who termed the process karyomitosis. The\\nessential constituents of a cell are the protoplasm and the nucleus.\\nThere is a strong tendency at the present time to refer all kinetic\\nchanges in the cell-contents to the agency of the nucleus, and to ascribe\\nto the protoplasm the passive role of a nutritive substance. In the\\nimpregnated ovum influences of nuclear changes have been described,\\nbut at the same time it was shown that the protoplasm is capable of\\nautomatic as well as responsive action. Pfluger thought that gravita-\\ntion is the sole guiding factor in segmentation. According to Born,\\nHertwig, Weismann, and Kolliker, the protoplasm alone is isotropic,\\nbut Whitman thinks that this is far from the truth. Others, like Pfluger,\\nbelieve that the protoplasm contains physiological molecules from which\\norgans are developed. Polarity of the protoplasm and the nucleus\\nexists independently, and is not reciprocal. Contractions in the unfer-\\ntilized eggs have been observed. The protoplasm is an active rather\\nthan a passive structure. M. Nussbaum was the first to establish the\\nimportant fact that enucleate pieces of an infusorium are incapable of\\nregenerating lost parts, while nucleate fragments soon regain the specific\\nform. From this observation it will be seen that the nucleus is indis-\\npensable to the preservation of the formative energy of the cell, while\\nthe protoplasm performs an important but less essential role in the\\nreproduction of cells. Nussbaum very correctly asserts that both the\\nprotoplasm and the nucleus are necessary in a cell to enable it to per-\\nform its specific function and to reproduce its own kind. The nucleus\\ndoes not change its form except when it is the seat of active kinetic\\nchanges, while the form of the cell is changeable and is greatly influ-\\nenced by its environments.\\nThe researches of Flemming, Strassburger, Butschli, and others have\\ndemonstrated the great importance of the nucleus in the reproduction\\nof cells. The protoplasm under the highest powers of the microscope\\nis seen to consist of a fine reticulum of protoplasmic strings, the meshes\\nof which contain a homogeneous fluid. The mature cell is enveloped\\nby a separate cell-wall. The meshes of a similar network in the nucleus\\nare filled with a granular fluid. According to Carnoy and Mayzel, the\\nnucleus contains, besides, a distinctive substance called nuclein, or,\\nfrom its intrinsic capacity to receive and to hold coloring material,\\nchromatin. The nucleoli in mature cells are globular masses of\\nchromatin, one or several in number. It is the chromatin which, when\\nproperly stained, outlines the figures observed during the different", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0041.jp2"}, "40": {"fulltext": "32\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nstages of the kinetic process. The kinetic process is divided into stages\\ndifferently. Thus, Klebs makes four, while Strassburger describes the\\nprocess as consisting of three stages: (i) Prophase; (2) metaphase;\\nand (3) anaphase. During the first stage the nuclear chromatin arranges\\nitself in the form of an oval mass. The metaphase is the stage of the\\nequatorial crown when the nuclear spindle has an equatorial accumula-\\ntion of chromatin fragments. During the last stage the nucleus and\\nthe protoplasm of the cell are divided into two symmetrical halves and\\ncomplete the segmentation. Karyokinesis of the nucleus without\\ndivision of the protoplasm of the cell results in multinucleated and\\nA B\\nFig. 7. Cells from the epidermis of very young larva of newt (after Piersol) A, resting nucleus B, close\\nskein; C, loose skein D and E, mother-stars, seen from the polar field and appearing as the wreath stage;\\nF, mother-star from the side; G, migration of segments; H, daughter-stars; /and J, segments grouped\\nabout new polar fields (in J this protoplasm exhibits constriction) K s daughter-skeins (division of nucleus\\ncomplete, with slight constriction of cell-body) L, completed division of nucleus and protoplasm.\\ngiant cells. This incomplete karyokinesis frequently occurs in the\\ncells of malignant tumors. The different karyokinetic figures are well\\nshown in Figure 7. Cell-division by karyokinesis is called by Williams\\nagamoge?iesis, in contradistinction to sexual reproduction, which he\\nterms gamogcnesis. In slowly-growing benign tumors new cells are\\nadded to the growth by karyokinesis in stationary tumors the cells\\nlost by degeneration are replaced by the same process while in malig-\\nnant tumors the karyokinetic process assumes great activity, resulting", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0042.jp2"}, "41": {"fulltext": "MORPHOLOGY OF TUMOR-CELLS. 33\\nin rapid growth and imperfect development of the cells. Karyokinesis\\nin malignant tumors has received the careful attention of pathologists,\\nand passes through the same phases as in the reproduction of normal\\ntissue. In the centre of Figure 8 is seen a nucleus in which segmen-\\ntation is nearly completed, while other nuclei represent incipient kinetic\\nFig. 8. Nuclear division in the epithelial cells of the skin in Paget s disease of the nipple X 800 (after\\nKarg and Schmorl). The deepest section of the picture represents, in the form of a small segment, the cutis\\ninfiltrated with leucocytes. After this follows the epidermis with its hasal layer of cylindrical cells. The\\nepithelial cells show different stages of nuclear division. Large nuclei are seen in the incipient stage of seg-\\nmentation, surrounded by a light zone. In the centre of the field is a mass of chromatin threads in the stage\\nof star-formation. Several chromatin loops have been separated from the dividing nuclear mass. The neigh-\\nboring cells have been pushed sidewise. To the left and above, daughter-star with beginning constriction of\\nthe nuclear body. The threads of the achromatic figure are indicated. (Fixation and hardening in sublimate\\nand alcohol haematoxylin staining.)\\nchanges. It is natural to suppose that such speedy and frequently\\nimperfect karyokinesis would give rise to rapidly-growing, planless\\ngrowths characterized by their early invasion of adjacent tissue, gen-\\neral dissemination, and an intrinsic tendency to destroy the life of the\\npatient.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0043.jp2"}, "42": {"fulltext": "III. ANATOMY AND BIOLOGY OF TUMORS.\\nThe life-history of tumors is of great interest to the pathologist and\\nof the utmost practical importance to the surgeon. The student must\\nbecome familiar with the influences which favor and retard tumor-\\ngrowth before he can formulate a correct clinical distinction between\\nthe different varieties and outline a rational course of treatment. In\\nthe preceding sections we have studied the origin and growth of the\\nparenchyma of tumors. We traced the tumor-cells to their original\\nFig. 9. Channel polypus of cervix uteri; X 50 (after D. J. Hamilton): a, fibro-cellular stroma of tumor;\\nb, a. gland of uterine mucous membrane; c, a channel; d, lining of columnar epithelium.\\nsource and showed their manner of reproduction in the body. Before\\nconsidering the biology of tumors it will be necessary to discuss a few\\nof the more important points in their anatomy. The essential part of\\na tumor is its parenchyma it is this which imparts to a tumor its ana-\\ntomical characteristic and its clinical significance. The cells of a tumor\\nare always limited by or imbedded in a stroma of connective tissue.\\n34", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0046.jp2"}, "43": {"fulltext": "ANATOMY AND BIOLOGY OF TUMORS.\\n35\\nFig. 10. Fibro-chondroma from capsule of knee\\nX 400 (after D. J. Hamilton): a, cartilage-cells;\\nb. the matrix.\\nIn Figure 9 is shown an adenoma of the cervical canal of the\\nuterus in which the essential tumor-elements, columnar epithelial cells,\\nare attached to and limited by a powerful stroma of connective tis-\\nsue. This picture affords a good\\nillustration of the relation of the\\ntumor-cells to the stroma in benign\\ntumors of the epiblast and hypo-\\nblast. In malignant and mesoblastic\\ntumors the parenchyma appears as\\nan interstitial product, the cells being\\nenclosed on all sides by the stroma.\\nThe stroma or reticulum of a tumor\\nis always derived from the meso-\\nblast, and consists of some form\\nof connective tissue in greater or\\nlesser abundance (Fig. 10). In epiblastic and hypoblastic tumors the\\ntissue reaches the tumor from the base in mesoblastic tumors it fur-\\nnishes a framework for the tumor on all sides.\\nBlood-vessels. A tumor is nourished by the blood-vessels which\\nsupply the part or organ in which the tumor is located (Fig. 1 1). The\\nblood-vessels constitute an important part in the structure, character,\\nand life-history of a tumor. The vascularization of a tumor usually takes\\nplace by the formation of new blood-vessels from pre-existing vessels\\nin its immediate vicinity by a process of budding. A more atypical\\nblood-supply is sometimes procured by canalization of cells and the\\nentrance of blood into pre-existing hollow spaces or into connective-\\ntissue channels entering into communication with neighboring blood-\\nvessels. Most of the tumors contain a complete vascular system that\\nis, one or a number of arteries enter it from the periphery and divide\\ninto smaller branches, which terminate in a network of capillaries from\\nwhich the blood is returned to the general circulation through veins.\\nThe blood-vessels follow the connective tissue of the stroma, and in\\nvery soft and cellular tumors they often come in direct contact with\\nits parenchyma (sarcoma). The structure of the walls of blood-vessels\\nis often very defective, especially in soft and rapidly-growing sarcoma.\\nGreat vascularity of a tumor usually indicates rapid growth and imper-\\nfect development of the parenchyma-cells of the tumor. Perforation\\nof the walls of the blood-vessels by the tumor-tissue, especially the\\nveins, is often observed in malignant tumors, and leads to thrombosis\\nor embolism, or both of these complications may occur in rapid suc-\\ncession.\\nLymphatic Vessels. The existence of lymphatic vessels in tumors", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0047.jp2"}, "44": {"fulltext": "PATHOLOGY AND TREATMENT OF TUMORS.\\nwas first discovered by Van der Kolk, who, as well as Krause, found\\nthem in carcinoma (Fig. 12). Lucke and Klebs attempted to inject the\\nlymphatics of carcinoma of the lip before the extirpation of the tumor,\\nbut did not succeed in accomplishing the desired object. The benign\\ngrowths are scantily, if at all, supplied with lymphatics. In carcinoma\\nthey are undoubtedly always present a fact which explains on an\\nFig. 11. Blood-vessels of tumors (after Lucke) a, vascular injection in an osteoid chondroma; b,\\nreticulum of veins from a sarcoma of the parotid c, capillary network from a fibroma of the abdominal\\nwall d, same from a very vascular myeloid sarcoma of the lower jaw e, vascular network from a carcinoma\\nof the tonsil; J alveolar vascular network from a carcinoma of the breast; g, injected preparation from a\\ncarcinoma of the lip.\\nanatomical basis the manner of regional dissemination which is so con-\\nstantly observed during the clinical course of this tumor, irrespective\\nof its anatomical location.\\nNerves. But little is known concerning the innervation of tumors.\\nIn the myelinic variety of neuroma the production of new nerve-fibres\\nhas been demonstrated. The tenderness and the spontaneous pain", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0048.jp2"}, "45": {"fulltext": "ANATOMY AND BIOLOGY OF TUMORS.\\n37\\nwhich belong to certain varieties of other tumors would suggest the\\npresence of new nerve-fibres, and should induce pathologists to make\\nadditional researches relative to the nerve-supply of tumors. The want\\nof proper innervation undoubtedly determines largely the planless\\ngrowth of tumors.\\nBiology. The life-history of a tumor is greatly influenced by the\\ninherent formative capacity of its cells as well as by the. general condition\\nof the patient. Cells endowed with maximum reproductive power are\\nalways found in rapidly -growing malignant tumors, and the same type\\nof tumor grows with variable speed and attains unequal size in differ-\\nent individuals during the same length of time. In certain individuals of\\nc\\nFig. 12. Lymphatic vessels from a fungous carcinoma of the region of the hip-joint of a young man\\n(after W. Krause) a, lymphatic vessels of subcutaneous tissue which was attached to the stroma of the car-\\ncinoma; b-d, lymphatic vessels from the stroma of the carcinoma itself, which communicated with the\\nvessels of the subcutaneous tissue at b a lymphatic vessel projects beyond the level of the section.\\nthe same age, living under apparently similar conditions, a fatty tumor\\nmay not exceed the size of a walnut after a lapse of twenty years, while\\nin another person it may reach colossal dimensions in a much shorter\\ntime. This difference in the rapidity of growth of benign tumors can-\\nnot be explained upon any known physiological or pathological laws.\\nSome of the benign tumors grow to a certain size, and then remain\\nstationary permanently or for an indefinite period of time, when, under\\ncertain local or general acquired causes, there again takes place active\\ntissue-proliferation, which often assumes a much more active phase\\nthan during the first stage of tumor-growth. It has been observed by\\nLucke and others that pregnancy plays an important role in the etiology\\nand growth of tumors. This influence is particularly well marked in", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0049.jp2"}, "46": {"fulltext": "38 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumors of the uterus and its appendages and in tumors of the breast\\nthat is to say, tumors in organs the seat of prolonged and irregular con-\\ngestions during pregnancy and lactation. Age influences the type and\\nlocation of tumors. Benign tumors occur most frequently in young\\npersons, while carcinoma attacks in preference persons past middle age.\\nSarcoma manifests no such predilection for senile tissue. Benign tumors\\ngrow more rapidly in the young than in the aged, and malignant tumors\\nmanifest a greater degree of malignancy in children and young adults\\nthan in persons advanced in years. Clinical experience has shown that\\nacute infective diseases exert a retarding influence upon the growth of\\ntumors. A tumor composed almost exclusively of parenchyma-cells\\nis more prone to undergo early degenerative changes than is a tumor\\nin which the stroma predominates. The growth of all tumors requires\\nan adequate quantitative and qualitative blood-supply. The importance\\nof this requirement in furthering the growth of a tumor is well shown\\nby the tumors so frequently met with during the age of puberty\\ndermoid cysts. The growth of these cysts is determined by an\\nincreased physiological activity of the entire organism and more par-\\nticularly of the skin, its appendages, and the organs of generation\\nwhich is initiated at that time. The increased physiological blood-\\nsupply to special organs during this time of life explains the frequency\\nwith which we meet with dermoid cysts of the ovary, the face, the\\nbase of the tongue, and the neck in young adults. To determine the\\ngrowth of a tumor it is not only necessary to have an adequate blood-\\nsupply, but the blood itself must contain the nutritive and chemical\\ningredients necessary for the formation of the different kinds of tumor-\\ntissue. In the development of an osteoma it is not only necessary to\\nhave present an embryonal matrix of indifferent bone-cells, but the\\nblood must also bring to the part during the growth of the tumor the\\nproper constituent elements (the earthy salts) which enter into the\\nformation of bone. So, likewise, in a case of lipoma it is not only\\nessential to have present an adequate quantitative blood-supply, but the\\nquality of the blood brought to the tumor must be such as to produce\\nfat instead of connective tissue or bone.\\nAn increase of blood-supply favors tissue-growth, and we can trace\\nthis increased vascularization in connection with tumor-growth either\\nto a physiological increase or as one of the consequences of antecedent\\npathological conditions. The increased physiological blood-supply is\\neither general or local. The general increase gives rise to giant growth,\\nwhich consists in hyper-production of normal histological elements\\nthroughout the entire body local increase of physiological blood-\\nsupply leads to local hyperplasia, localized giant growth, which may", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0050.jp2"}, "47": {"fulltext": "ANATOMY AND BIOLOGY OF TUMORS. 39\\nimplicate an entire organ or limb. Anything which in the organism\\nwill determine an increased physiological blood-supply to a pre-existing\\ntumor-matrix favors tumor-growth an assumption well established in\\ncases of tumors of the breast commencing during pregnancy or lactation,\\nat a time when the organ receives a largely increased supply of blood,\\nwhich increase cannot fail in exerting a potent influence in stimulating\\ncell-proliferation from a latent matrix. So, in cases of uterine tumors,\\nthe periodical recurrences of congestion in the affected parts during\\nmenstruation create a condition which accelerates tissue-growth. Con-\\nsequently, myofibroma of the uterus almost without exception makes\\nits appearance during the childbearing period of life, and its further\\ngrowth is usually arrested with the cessation of menstruation. Sur-\\ngeons have utilized this clinical fact, and have adopted a therapeutic\\nresource which aims at diminishing the increased physiologial blood-\\nsupply to this organ by suspending artificially this periodical function\\nby the removal of the ovaries and the Fallopian tubes in the treatment\\nof some forms of myofibroma of the uterus.\\nA tumor frequently presents to the naked eye an appearance of\\nabnormal vascularization characterized by an increased circulation,\\neither arterial, venous, or capillary, as the case may be, according to\\nits anatomical location or the peculiarity of the structure of the new\\nblood-vessels in the tumor-matrix or its immediate vicinity. The most\\nstriking example of atypical vascularization is furnished by tumors\\nwhich present pulsation as one of their most conspicuous clinical\\nfeatures. By a pulsating tumor we understand, clinically, a tumor in\\nwhich to the usual evidences of tumor-formation are added the pathog-\\nnomonic symptoms of aneurysm. In such instances many of the larger\\nnew blood-vessels are either entirely devoid of a proper vessel-wall, or,\\nwhen this is present, it is defective, forming irregular cavities or spaces\\ninto which the blood enters from some adjoining vessel, returning either\\nin the same direction or emptying into another channel. This peculiar\\nstructure and arrangement of vessels in many sarcomatous tumors\\nwould explain the frequency with which pulsation can be felt in ex-\\namining them, more especially if they have their starting-point in the\\ninterior of a bone. Such tumors are noted for their rapid growth, and\\nhave repeatedly been mistaken for aneurysms.\\nLocal irritation increases tumor-growtk. Tumors located upon the\\nsurface of the body or in other parts exposed to irritating influences\\ngrow, as a rule, more rapidly than tumors occupying more protected\\nlocalities. The application of irritants, such as iodine, blisters, and\\nstimulating ointments, liniments, and plasters, produces the same effect.\\nThe same can be said of exploratory punctures and parenchymatous", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0051.jp2"}, "48": {"fulltext": "40 PATHOLOGY AND TREATMENT OF TUMORS.\\ninjections. The incomplete destruction of a malignant tumor by\\ncaustics is invariably followed by more rapid growth of the tumor-\\nremnants, extensive regional infection, and early general dissemination.\\nRelation of Tumors to Adjacent Tissues. The tumor-tissue is\\nproduced exclusively from the matrix of embryonic cells from which it\\nstarted the adjacent tissues take no active part in the growth of tumors.\\nThe adjacent tissues are acted upon by the tumor, but take no part in\\nits development. The benign tumors push the tissues aside or apart to\\nmake room for themselves the malignant tumors, particularly carci-\\nnoma, infiltrate the surrounding connective tissue and include it as a\\ntemporary passive constituent of the tumor-mass. The pre-existing con-\\nnective tissue under such circumstances is subsequently destroyed and\\nremoved by the tumor-tissue. Sarcoma follows connective tissue, nerve-\\nsheaths, and blood-vessels carcinoma invades the lymphatics, and it is\\nthrough them that regional dissemination takes place. A tumor always\\nenlarges in the direction offering the least resistance. One of the con-\\nstant effects of tumor-pressure is atrophy of the tissues exposed to\\npressure. Pressure-atrophy of the adjacent tissues is most certain to\\noccur, and is most marked if the tumor is anatomically so located that\\nits increasing size meets with great resistance. An ordinary sebaceous\\ncyst of the scalp or a dermoid cyst above the orbit, although of slow\\ngrowth, often produces by atrophy a cup-shaped depression in the\\nunderlying bone. A lipoma of great size occupying the panniculus\\nadiposus produces little if any pressure-atrophy, because the tumor\\nmeets with little or no resistance to its outward growth. The pressure\\nof a tumor upon a nerve often causes intense pain, and may eventually\\ndestroy its function. Prolonged compression of a large artery may\\nresult in the formation of a thrombus and the complete obliteration of\\na vessel. A carcinoma or a sarcoma may destroy the wall of a large\\nartery, such an occurrence becoming often the immediate cause of\\ndeath from hemorrhage. At other times a false aneurysm is estab-\\nlished in the same manner.\\nPerforation of a vein by malignant tumors, preceded or followed by\\nthrombosis, will be alluded to farther on as one of the many compli-\\ncations of carcinoma and sarcoma. Serious and often fatal complica-\\ntions may arise from the compression of an important internal organ\\nby a tumor. Thoracic and mediastinal tumors frequently destroy life\\nby causing compression of the heart, the lungs, or the large blood-\\nvessels. Abdominal tumors of large size often result in death from\\nmarasmus by interfering with digestion. Tumors impacted in the pelvis\\nmay cause retention of urine, compression of the ureters, and intestinal\\nobstruction.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0052.jp2"}, "49": {"fulltext": "ANATOMY AND BIOLOGY OF TUMORS. 41\\nBenign tumors frequently appear multiple primarily or in slow suc-\\ncession malignant tumors, while primarily multiple only in exceptional\\ncases, give rise to secondary tumors in the same region or in distant\\nparts. It can therefore be asserted, as a rule, that primary multiplicity\\nwould indicate a benign character of the tumors, while secondary\\nmultiplicity is almost an infallible evidence of the malignant nature of\\nthe primary tumor.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0053.jp2"}, "50": {"fulltext": "IV. PATHOLOGY OF TUMORS.\\nThe form of a tumor depends largely upon its location and on\\nthe structure of the tissues in its immediate neighborhood. A tumor\\ndeveloping from a surface and projecting beyond it, with a wide\\nbase, is said to be sessile. If the tumor becomes more prominent\\nand the base narrows, a pedicle forms, when it is called a pedun-\\nculated tumor. Such tumors attached to a mucous membrane are\\nusually described under the term polypus. If a tumor originates\\nfrom a part surrounded by tissues offering the same degree of resist-\\nance, it usually assumes a globular or an oval shape. If it occupies\\na locality covered in by a broad resisting structure, it becomes flattened\\nout, as is the case with intra-articular lipoma, called lipoma arborescens.\\nUnequal resistance over the surface of the tumor moulds it in all\\nimaginable shapes. The surface of the tumor may be smooth, lobu-\\nlated, or nodular. Benign tumors are usually smooth lipoma is often\\nlobulated sarcoma is either smooth or lobulated carcinoma is nodular.\\nThe density of a tumor depends on its structure, the character of the\\ntissues in its immediate vicinity, and the degenerative changes that have\\ntaken place. A tumor composed largely of parenchyma-cells is usually\\nsoft tumors supplied with a well-developed stroma are hard a tumor\\ncomposed almost exclusively of blood-vessels (angioma) is greatly\\nreduced in size under pressure a tumor with liquid contents (cyst)\\nordinarily presents fluctuation a solid but soft tumor (lipoma and sar-\\ncoma) is often mistaken for a cyst or an abscess, because on palpation\\na sense of fluctuation can be felt (pseudo-fluctuation). The color of\\ntumor-tissue is greatly influenced by its vascularity, the character of\\nthe cells of which it is composed, and the extent and nature of the\\ndegenerative changes which have taken place. Most of the benign\\nmesoblastic tumors present a whitish appearance. Sarcoma, as its name\\nindicates, resembles on section flesh. The cut surface of a firm carci-\\nnoma is very similar in appearance and density to a raw turnip. Fatty\\ndegeneration of the contents of the alveoli imparts to the cut surface\\nof the tumor a yellowish tinge. Hemorrhage into the substance of a\\ntumor produces pigmentation of various degrees, from almost black to\\na yellow tinge. The black color of melano-sarcoma and melano-car-\\ncinoma is a distinguishing feature of these forms of malignant tumors.\\n42", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0054.jp2"}, "51": {"fulltext": "PATHOLOGY OF TUMORS.\\n43\\nTumor-tissue, stroma and cells, is subject to the same pathological changes\\nas the normal tissues of the body. Among the more important of\\nthese changes are the regressive metamorphoses of the cellular elements.\\nFatty Degeneration. Fatty degeneration of the parenchyma-cells\\nof a tumor is one of the most frequent secondary pathological changes\\nobserved in tumors. The immediate cause of this form of degeneration\\nis a defective blood-supply hence it occurs most frequently in old\\nbenign tumors and in malignant tumors in which vascularization does\\nnot keep pace with the increase of tissue. It is a constant occurrence in\\nslowly-growing carcinoma of the lip and the breast. In ulcerating sur-\\nface epithelioma the fatty material can be squeezed out from the alveoli\\nin yellowish-white masses resembling the contents of a small retention-\\ncyst of the sebaceous glands. In glandular carcinoma the alveoli which\\nhave undergone this change present themselves on the cut surface as\\nyellow areas of variable size, from which the same kind of material\\nescapes under pressure. If this material is examined under the micro-\\nO\\nFig. 13.\u00e2\u0080\u0094 Fat-crystals X 250 (after Perls).\\nscope, nothing but a granular detritus can be seen, with here and there a\\nfat-crystal (Fig. 13) or a cholesterin-plate (Fig. 14). The fatty change\\ncommences as an infiltration of the cells, this infiltration finally resulting\\nin the breaking up of the cells into granular matter. The distinction of\\ncells by this or by any other form of regressive metamorphosis retards\\ntumor-growth but while the growth has become stationary at one place\\nit continues in other places, so that a tumor is seldom entirely removed\\nby degenerative changes. Degeneration commences either in the oldest\\npart of the tumor or in parts of it which by accident have been deprived\\nsuddenly or gradually of an adequate blood-supply. It is upon this\\nwell-known and thoroughly established pathological fact that surgeons", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0055.jp2"}, "52": {"fulltext": "44\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nhave made an attempt to imitate and anticipate the natural forces\\nwhich tend to limit or to arrest tumor-growth by cutting off the blood-\\nsupply from the part, as suggested by Wolfler in the treatment of\\nFig. 14. Cholesterin-plates X 250 (after Perls).\\ntumors of the thyroid gland, and by gynecologists in ligation of the\\nuterine arteries in the treatment of non-malignant tumors of the uterus.\\nMucoid Degeneration. The transformation of active tumor-cells\\ninto a harmless, innocent mucoid substance has been observed in tumors\\nbelonging to the connective-tissue type, fibroma and\\nchondroma, and also occasionally in adenoma. The\\npart of a tumor which undergoes this form of degen-\\neration becomes cystic.\\nColloid Degeneration. The exact chemical com-\\nposition of colloid material has not been determined.\\nScherer regards it as an albuminous substance in\\ncombination with a carbohydrate analogous to mucin\\nand metalbumin. Colloid material is a jelly-like,\\nstructureless substance derived by a degenerative\\nprocess from the parenchyma-cells or the stroma of a tumor. This\\nform of degeneration takes place in both benign and malignant tumors,\\nbut is observed most frequently in tumors of the thyroid gland, of the\\novary, and of the gastro-intestinal canal. If the parenchyma-cells\\nundergo this change, the colloid material appears in the protoplasm\\nof the cell at one or different points, and the process continues until\\nthe cell-walls give way, when the colloid material is liberated (Fig. 15).\\nFig. 15.\u00e2\u0080\u0094 Colloid de-\\ngeneration of the epithe-\\nlial cells of a cancerous\\ntumor of the mamma\\nX 400 (after D.J. Ham-\\nilton).", "height": "4417", "width": "2806", "jp2-path": "pathologysurgic00senn_0056.jp2"}, "53": {"fulltext": "PATHOLOGY OF TUMORS.\\nPlate\\nX", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0057.jp2"}, "54": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0058.jp2"}, "55": {"fulltext": "PATHOLOGY OF TUMORS. 45\\nColloid cysts of the ovary often attain a colossal size, and abdominal\\nsurgeons are well aware of the fact that such cysts are prone to\\nreturn even after what seemed a thorough removal of the tumor.\\nAmyloid Degeneration. The transformation of tumor-cells into\\na starchy substance takes place most frequently in the cells of malig-\\nnant epiblastic tumors, also in secondary carcinoma of the lymphatic\\nglands. We have no positive knowledge concerning the true nature\\nof the corpora amylacea found in certain tumors as one of the many\\ndegenerative changes, and in other pathological products. It is un-\\ndoubtedly an albuminate, as its micro-chemical actions correspond with\\nthose given by other albuminates. This substance has never been\\ndetected in the blood it is therefore reasonable to suppose that it is\\nformed in the places in which it has been found. In a specimen of cyst\\nof the choroid plexus in the museum of Rush Medical College numer-\\nous corpora amylacea were found in close proximity to a large blood-\\nvessel (PL i, Fig. i). The degeneration of an adenoma into a colloid\\nsubstance imparts to the tumor an entirely new aspect, transforming it\\nfrom a solid into a cystic tumor.\\nHyaline Degeneration. The product of hyaline degeneration dif-\\nfers from the amyloid substance in that it does not give the reactions\\nto iodine. The hyaline substance in tumors appears either alone, when\\nthe entire tumor has undergone degeneration, or in circumscribed places\\nsurrounded by the cells or stroma of the tumor. It is found in benign\\nand malignant tumors of all germinal layers. Tumors in which this\\nchange was marked have been called by different names tumeurs\\nheteradeniques (Robin) Schlauchknorpel-geschwulst (V. Meckel)\\ncylindroma (Billroth) Schleim-cancroid (Forster) Schlauch-sarcom\\n(Friedreich) siphonoma (Henle). Thiersch insisted that such tumors\\ndo not represent a special clinical or anatomical variety, but are tumors\\nin which parts have undergone regressive metamorphosis. Hyaline\\ndegeneration in other pathological products attacks in preference the\\nsmall blood-vessels, and it is more than probable that when it occurs\\nin tumors it begins in the same place and extends from the blood-\\nvessels to the stroma or the parenchyma-cells. Hyaline degeneration\\nmost frequently attacks endothelial structures, but it extends into the\\nconnective-tissue spaces where the hyaline substance is deposited, as is\\nshown on Plate 2, (Fig. i). A very interesting tumor of the orbit,\\nwhich tumor in all probability started from the internal angle of the\\neye, examined in the laboratory of Rush Medical College, showed very\\nextensive hyaline degeneration (PI. I, Fig. 2). If hyaline degeneration\\ncommences at the same time in several parts of the tumor, by coales-\\ncence large spaces are formed in which no tumor-elements can be found..", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0059.jp2"}, "56": {"fulltext": "4 6\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nCaseation. Local anemia is a recognized cause of caseation, but it\\nremains an open question whether this form of degeneration can occur\\nindependently of the bacillus of tuberculosis, so that when this kind of\\nmetamorphosis is found in a tumor it is well to inquire into the pres-\\nFig. 16. Petrifaction of a glioma (psammoma) of the brain; X 250 (after Perls) A, large laminated\\nconcrements; B, calcification of capillaries; deposition of the lime-salts in the form of homogeneous\\nmasses.\\nence of the specific influence which is known to produce tyrosis. A\\ntumor may become the seat of infection with the bacillus of tuberculo-\\nsis, and the presence of this specific cause will determine the character\\nof the regressive metamorphosis. It is only reasonable to assume that\\nthe atypical vascularization of tumors furnishes a condition favorable", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0060.jp2"}, "57": {"fulltext": "PATHOLOGY OF TUMORS. 47\\nto localization of floating germs, and consequently constitutes one of\\nthe causes of auto-infection.\\nCalcification or Cretefaction. This degenerative process has been\\nseen in all kinds of tumors and in all the cellular elements, paren-\\nchyma-cells and stroma. By this process a chalky substance is sub-\\nstituted for the tumor-tissue. It is usually preceded by fatty degener-\\nation at other times it prepares the way for ossification of the tumor.\\nIt occurs frequently as a marantic change in the arteries and cartilage\\nof the aged. The chalky material is deposited in the form of small\\ngranules in the tissues, taking the place of pre-existing degenerated\\ncells. In a normal condition the lime-salts are kept in solution in the\\ntissues by organic acids and by free carbonic acid. Deposition under\\nabnormal conditions is caused by diminution in the quantity of organic\\nacids and free carbonic acid, by the existence of insoluble in place of\\nsoluble lime-salts, or by an abnormal increase of lime-salts reaching\\nthe affected part, resulting in direct infiltration of the tissues. In some\\ninstances the entire tumor eventually is petrified, the inorganic substi-\\ntute retaining the shape of the original tumor.\\nThe so-called lime-metastasis described by Virchow has been ob-\\nserved in cases of extensive disease of the bones, and is caused by the\\nreturn into the circulation of the liberated lime-salts, which become\\ndeposited in distant organs, notably the kidneys and lungs. Petrifac-\\ntion was noted in a sarcoma of the soft tissues of the arm by Liicke.\\nMaceration of this part of the specimen in an acid, examined under\\nthe microscope, revealed spindle-shaped cells. Calcification frequently\\noccurs in benign epiblastic tumors and in adenomatous tumors, particu-\\nlarly of the thyroid gland and ovary.\\nOssification. Calcification in a tumor has frequently been mis-\\ntaken for ossification. We can speak of ossification only if, after the\\nremoval of the tumor, the specimen decalcifies and the remaining part\\nexhibits under the microscope the structure of bone. Ossification of\\nthe tumor-cells always takes place in osteoma. It occurs also in chon-\\ndroma and in dermoid cysts. Periosteal sarcoma is noted for its bone-\\nproducing capacity. In periosteal sarcoma of the cranial, pelvic, and\\nlong bones we find an irregular framework of long, delicate spicules\\nof bone, the spaces filled in with sarcomatous tissue. In some carti-\\nlaginous and sarcomatous tumors immature bone (osteoid tissue) is\\nformed in place of true bone.\\nInterstitial Hemorrhage and Thrombosis. The great vascularity\\nof some tumors and the imperfect structure of the walls of blood-vessels\\nfrequently result in spontaneous hemorrhage, or hemorrhage under\\nsuch circumstances is produced by a slight trauma, such as a contu-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0061.jp2"}, "58": {"fulltext": "48 PATHOLOGY AND TREATMENT OF TUMORS.\\nsion, a palpation of the tumor, or an exploratory puncture. The blood\\nescapes into pre-existing spaces (cysts) or is diffused through the\\nstroma of the tumor or between the cells. If the hemorrhage is con-\\nsiderable, the tumor increases suddenly in size and becomes more tense.\\nThe tension thus produced is also the cause of a sudden appearance\\nor increase of pain. The extravasation, if limited in quantity, is usually\\nremoved by absorption if this does not occur, it either leads to the\\nformation of a cyst or determines infection of the tumor by pathogenic\\nmicrobes. Hemorrhage always causes a change in the appearance of\\nthe tumor-tissue from the presence of the coloring material of the\\nextravasated blood which is imbibed by the tissues.\\nIf the hemorrhage is profuse, the presence of extravasated blood\\nin the tumor is often indicated on the surface, a few days after the\\naccident, by the appearance of ecchymosis. The atypical vasculariza-\\ntion of a tumor renders the blood-vessels peculiarly amenable to im-\\nplication during the degenerative changes of the tumor-tissue. For\\ninstance, if, according to the views taught by Rokitansky, new blood-\\ncorpuscles form from the endothelial lining of a new closed blood-space\\nby gradual growth and dilatation, this space is brought in contact with\\na vein-wall within or outside the tumor, and by a process of pressure-\\natrophy a communication is established between the pre-existing vein\\nand a new blood-channel. Such an occurrence determines atypical\\nvascularization of a high degree and imparts to the tumor important\\nclinical and pathological features. The blood entering such spaces\\nfrom adjacent vessels, and not meeting with normal resistance on\\naccount of a defective vascular wall, produces pulsation, and in many\\ninstances, if such abnormal vascularization exists on a large scale, there\\ncan be heard on auscultation a marked bruit caused by irregular dis-\\ntribution of the blood in the atypical vessels. These are the cases\\ndescribed by the older surgeons and pathologists as bone-aneurysm,\\nwhen the disease affects the bone. A simple hemorrhagic cyst re-\\nsembles one of these new blood-spaces, with or without a communi-\\ncation with adjacent vessels. The new vessels in a tumor, when\\nimperfect in structure and largely dilated, often become the seat of\\nmural thrombosis, the irregular surface of the defective intima pre-\\nsenting projecting points upon which, by conglutination, the third\\ncorpuscles of the blood become arrested and implanted, constituting\\nin the course of time a white thrombus, which, when it encroaches\\nupon the lumen of the vessel or blocks it completely, gives rise to\\ncoagulation-necrosis in the impeded blood-current on the distal side\\nor upon the surface of the white thrombus, furnishing the necessary\\nconditions for the formation of a red thrombus, which then completely", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0062.jp2"}, "59": {"fulltext": "PATHOLOGY OF TUMORS.\\n49\\nobstructs the circulation in the corresponding part of the vessel.\\nAnother form of thrombosis and obliteration of a vessel is met with as\\nthe result of perforation of the vessel-wall by a tumor, usually of a ma-\\nurc. Trachcie.\\nFig. 17. Thrombosing carcinoma-proliferation in the left jugular vein in carcinoma at the base of the\\nbrain (after Ziesing) ;;z, hyo-thyroid muscle g, proximal termination of inferior thyroid vein, with pro-\\njecting plug of tumor-tissue e and b, internal jugular vein e, cut open, showing intravascular part of\\ntumor, f: b, part of vein not laid open, and terminal part of facial vein; a, probe in jugular foramen rfj\\ncarcinomatous infiltration of cervical glands.\\nlignant type. This accident is one of the most interesting- conditions\\nin the pathology and clinical history of a malignant tumor. If, for\\ninstance, a carcinoma attacks a vein-wall, destroying pre-existing struo\\n4", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0063.jp2"}, "60": {"fulltext": "50 PATHOLOGY AND TREATMENT OF TUMORS.\\ntures by infiltration, retrograde metamorphosis, and pressure-atrophy,\\nuntil by perforation the tumor projects into the vein, forming a neo-\\nplastic thrombus composed of tumor-tissue, when the axial blood-\\ncurrent comes in contact with abnormal tissue, that tissue being devoid\\nof the physiological properties required for a normal circulation, the\\nthrombus increases in size by conglutination of the third corpuscle upon\\nthe most prominent part of the projecting tumor-mass, the neoplastic\\nthrombus serving as a foreign body in the vessel mural stasis of the\\nwhite corpuscles also takes place, the conglutinated and aggregated\\ncorpuscular elements of the blood furnishing a most favorable soil for\\nfurther cell-proliferation from the intravascular part of the tumor, which\\nnecessarily soon terminates in complete obstruction of the affected ves-\\nsel. The writer has seen the internal jugular vein obstructed in its entire\\nlength in cases of secondary glandular carcinoma of the neck (Fig. 17).\\nThe neoplastic thrombus always manifests a tendency to increase in\\nsize by infiltration of the temporary obstructing thrombus, the blood-\\ncoagulum with tumor-cells, and when loose fragments become detached\\nthey are carried along with the blood-current, and, arriving at a point\\nwhere the vessel is too narrow for their passage, become arrested and\\ngive rise to embolic metastasis. In some cases embolism takes place by\\nthe projection of the proximal end of the thrombus into the lumen of a\\nlarger vein isolated cells and small fragments, becoming detached, are\\nwashed away by the blood-current embolism in such cases establishes\\nindependent centres of tumor-growth wherever such tumor-infarcts\\noccur, the products of tissue-proliferation at the distant points corre-\\nsponding in every respect with that of the primary matrix. As in\\ncases of septicemia and pyemia the emboli produce at distant points\\nthe same characteristic tissue-changes that are typical of the primary\\nthrombus, so in cases of thrombosis and embolism in malignant growths\\nthe distant secondary tumor produced by an embolus from a neoplastic\\nthrombus corresponds in structure and type with the primary tumor.\\nThrombosis and embolism in such instances effect a transplantation,\\nas it were, of a part of the primary tumor to some distant part, the\\nsecondary tumors of embolic origin being the direct offsprings from\\nthe maternal or primary tumor. Dissemination of benign tumors by\\nthrombosis and embolism is unknown.\\nThe existence of thrombosis of many veins or of a large vein within, or\\nin the immediate vicinity of, a malignant growth should be suspected by\\nthe presence of oedema and enlargement of the subcutaneous veins in the\\nregion from which the blood is returned through the obstructed veins. In\\none case of complete obstruction of the entire lumen of the internal\\njugular vein which occurred as a complication of carcinoma of the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0064.jp2"}, "61": {"fulltext": "PATHOLOGY OF TUMORS. 51\\nlower jaw with extensive glandular infection, the oedema extended to\\nthe face on the same side and to the temporal region, and all the\\nsuperficial veins were greatly distended.\\nCapsule of Tumor. All benign tumors are encapsulated that is,\\na well-defined connective-tissue partition is interposed between the\\ntumor and the adjacent tissue, beyond which partition the tumor\\nnever extends. Malignant tumors are devoid of such a limiting\\nboundary-line between tumor and surrounding tissues. In sarcoma\\na capsule is often found, but pathologically it is absent, because it is\\ninfiltrated with tumor-cells and the cells permeate it and infect the\\nadjacent tissues. In carcinoma there is never even an attempt at the\\nformation of a capsule.\\nLymphatic Glands. Enlargement of the lymphatic glands in the\\nregion occupied by the tumor indicates one of two things 1 The\\nintroduction into the lymphatic channels of pathogenic microbes\\nthrough an ulcerating inflamed benign tumor; 2. The transportation\\nfrom a primary malignant tumor of tumor-cells through the lymphatic\\nchannels into the lymphatic glands. Enlargement of lymphatic glands\\nin connection with benign tumors never occurs unless the tumor by a\\nloss of continuity on the surface furnishes an infection-atrium for the\\nentrance of pathogenic microbes from without. The termination of\\nthe complicating lymphadenitis under these circumstances will depend\\nupon the number and kind of microbes that have reached the lym-\\nphatic glands. Sarcoma seldom gives rise to glandular infection. Car-\\ncinoma, superficial and deep, almost invariably is complicated sooner bv\\nlater by regional infection through the lymphatic vessels and glands.\\nThis subject will be discussed more exhaustively in the sections on\\nmalignant tumors.\\nInflammation. If inflammation occurs in a tumor, it is an unmis-\\ntakable proof that the tumor-tissue has become infected with patho-\\ngenic microbes. Infection may occur with and without a tangible\\ninfection-atrium. In the former case the tumor-tissue is exposed\\ndirectly to infection by an abrasion, a cut, a puncture, or an ulcer,\\nand through such defects pyogenic and other pathogenic microbes\\nreach the tumor-tissue, and produce there, as elsewhere, their specific\\npathogenic effect. In the absence of such a direct port of entrance\\nwe must explain the occurrence of inflammation by floating microbes\\nwhich reach the tumor with the circulating blood, and after localization\\nhas taken place incite inflammation in the same manner and to the\\nsame extent as when infection takes place through a more direct route.\\nTumor-tissue possesses a lower resisting power to inflammation than docs\\nnormal tissue hence inflammation often results in extensive suppuration", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0065.jp2"}, "62": {"fulltext": "52 PATHOLOGY AND TREATMENT OF TUMORS.\\na?id gangrene, which in the case of benign tumors- may result in a spon-\\ntaneous and permanent cure. Malignant tumors are often the seat of\\ninfection and inflammation, but there is not a single authenticated case on\\nrecord in which a spontaneous and permanent cure was effected in this\\nmanner. Inflammation, as a rule, increases the malignancy of malig-\\nnant tumors, and the effects produced by it increase the suffering and\\nhasten death. Inflammation in a tumor is often unintentionally pro-\\nduced by making an exploratory puncture without the necessary\\naseptic precautions and by making subcutaneous or parenchymatous\\ninjections.\\nUlceration. Ulceration of a tumor is either the result of accident\\nor it follows causes inherent in the tumor itself. In the great majority\\nof cases ulceration takes place when the tumor implicates the over-\\nlying skin or mucous membrane when, either in consequence of\\npressure-atrophy or of the destruction of the skin by the tumor, a\\nsurface defect is produced and the tumor-tissue is exposed to direct\\ninfection. Sometimes, when the skin has become greatly attenuated\\nby pressure from beneath, a small abrasion serves as a point of\\nentrance, and the destruction of skin is hastened by an infective\\ninflammation. The superficial ulcer in such cases is often the fore-\\nrunner of a deep phlegmonous inflammation of the tumor, followed\\nby more or less extensive sloughing. Suppurative inflammation and\\nabscess-formation not infrequently are the direct causes of the super-\\nficial ulceration.\\nAccidental ulceration is often produced by friction on the part of\\nthe clothing, by contusions and wounds, by the application of irritating\\nsubstances, and also by incomplete operations. The clinical behavior\\nof an accidental ulcer varies according to its size and the character of\\nthe tumor. An ulcerated surface communicating with a suppurating\\ncyst by a fistulous tract will not heal until the epithelial structures\\nlining the cyst-wall are destroyed by the suppurative inflammation or\\nare removed with the knife or destroyed by caustics. Defects of\\nbenign grov/ths caused by inflammation, by caustics, or by incomplete\\noperations heal, as a rule, in the same manner as do wounds of normal\\nsoft parts by granulation, cicatrization, and epidermization.\\nSpontaneous ulcers that is, ulcers caused by conditions inherent\\nin the tumor are constantly seen on the surface of carcinoma of\\nthe skin. The initial defect always occurs about the centre of the\\ngrowth, covered by a crust which, when removed, leaves a raw\\nand often bleeding surface. A spontaneous ulcer, as a rule, never\\nheals its tendency is to enlarge. The margins and the base pre-\\nsent the firm induration so characteristic of this form of carcinoma.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0066.jp2"}, "63": {"fulltext": "PATHOLOGY OF TUMORS.\\n53\\nUlceration of glandular carcinoma is frequently followed by slough-\\ning, suppuration, and putrefaction from the action of putrefactive bacilli\\nupon dead tissue. The sloughing and suppuration of such a carcinoma\\nusually give rise to a deep excavation in the centre of the tumor, in\\nwhich excavation the secretions stagnate and putrefy, becoming the\\nsource of a sickening odor. In ulcerating sarcoma the tumor-tissue\\noften projects far beyond the surface of the ulcer in the form of a\\nfungous mass, the fungus hcematodes of the old authors.\\nGrafting- of a Malignant upon a Benign Tumor. By the grafting\\nof a malignant upon a benign tumor is meant, not the transformation\\nFig. 18. Lipoma with a sarcoma grafted upon it (Liicke) a, fatty tissue; b, connective tissue; c, sarcoma.\\nof a benign into a malignant tumor, but the appearance of a malig-\\nnant tumor in the immediate vicinity of a benign tumor. Such an\\nintimate connection between a malignant and a benign tumor is shown\\nin Figure 18. The occurrence of the malignant tumor in such cases\\nappears purely accidental, and yet from an embryologieal standpoint\\na more intimate relationship in the etiology of the two entirely differ-\\nent tumors can be shown. For instance, in the specimen shown in", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0067.jp2"}, "64": {"fulltext": "54 PATHOLOGY AND TREATMENT OF TUMORS.\\nFigure 18 it is evident that the lipoma sprang from a matrix of embry-\\nonic cells in the panniculus adiposus, while the sarcoma had its origin\\nfrom a similar matrix in the connective tissue of the skin. It is more than\\nprobable that the embryonic cells composing the sarcoma-matrix were\\narrested in their development at an earlier stage than were the embryonic\\ncells in the adjoining fatty tissue consequently, the matrix in the skin\\ngave rise to tumor-tissue of an embryonic type, while the matrix in the\\nfatty tissues produced tumor-cells which possessed the intrinsic prop-\\nerty to develop into mature tissue. From the illustration it can readily\\nbe seen that the sarcoma would eventually invade the lipoma, the tissue\\nof which would yield to it in the same manner as would normal adipose\\ntissue.\\nIn concluding this section it is proper to recapitulate that tumor-\\ntissue is subject to the same degenerative changes as normal tissue altered\\nby accident or by disease, and that it constitutes a locus minoris resist-\\nentiae in the event of direct or indirect infection with pathogenic microbes.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0068.jp2"}, "65": {"fulltext": "V. TUMORS IN PLANTS AND ANIMALS.\\nBefore considering the etiological factors concerned in provoking\\ntumor-growth it will be of interest to learn something of tumors in the\\nlower animals and plants, for the purpose of showing that tumors occur\\nin frequency in proportion to the complexity of the organism they\\ninhabit that is to say, they are least frequent in plants and animals\\nof a low degree of development, and most frequent in man.\\nTumors in Plants. For the remarks on this subject the writer is\\nlargely indebted to the work of Mr. Williams on Ca?icer- and Tumor-\\nformation. The resemblance of tumors of the higher animal organisms\\nand those of plants was pointed out by Virchow years ago. In tumor-\\nformation we find kindred processes throughout the organic world.\\nEach cell leads to a certain extent a parasitic existence. If it were not\\nfor the restraining and modifying influence exerted by the whole\\norganism, each cell might develop into the form of the parental organ-\\nism. In proportion as the cells are highly specialized their primitive\\nreproductive function is either greatly diminished or altogether lost.\\nIn the higher organism certain cells remain unspecialized. Under\\nfavorable conditions certain unspecialized or indifferent cells may grow\\nand develop without regard to the requirements of the adjoining tissues\\nand of the organism as a whole. Tumors can be studied to better\\nadvantage in plants than in animals. Buds may remain in a latent\\ncondition for years, and yet under favorable conditions their activity\\nmay revive. Buds may arise on any part of the plant in fact, wherever\\nthere is an excess of nutritive materials capable of being utilized for\\ngrowth by the cells of the part, there buds arise. Under such circum-\\nstances buds may be formed wherever undifferentiated cells are present.\\nVegetable tumors are produced by abnormal bud-evolution. Mr.\\nWilliams classifies plant-tumors into three main groups. The first group\\nis represented by the discontinuous or circumscribed growths (Fig. 19),\\nto which the vaguely-used term of knaurs should be restricted, and\\nincludes all those nodules so often met with in the bark of the beech,\\nelm, oak, birch, holly, cedar, and other trees. These tumors corre-\\nspond with the benign cpiblastic tumors in man. The older nodules\\nare generally found lying completely isolated in the bark, enclosed in\\n55", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0069.jp2"}, "66": {"fulltext": "56\\nPATHOLOGY AND TREATMENT OF TUMORS,\\na distinct capsule. A narrow fibre-vascular pedicle may sometimes\\nbe seen connecting the younger nodules with the woody tissues of the\\ntrunk or stem. These tumors have been traced to abnormal growths\\nof adventitious or latent buds. The writer examined the branch of a\\ncedar tree which had evidently been injured, and found a tumor which\\napparently belonged to the second\\ngroup. From the tumor sprang a\\ntuft of flowering branchlets entirely\\ndifferent from the remaining branches.\\nIt is apparent that in this instance the\\ninjury excited tissue proliferation\\nfrom two distinct matrices, one re-\\nsulting in the formation of the tumor,\\nthe other resulting in the production\\nM\\nof branchlets bearing the generative\\na%\\nThe second group, comprising the\\ncontinuous tumors to which the\\nterm exostosis should be restricted\\nFig. 19. Five circumscribed tumors in the bark\\nof a holly tree; natural size (after Williams).\\nFig. 20. A continuous tumor (exostosis) from an\\nelm tree, in longitudinal section (after Williams).\\npresent themselves as nodose outgrowths of the trunk or branches\\n(Fig. 20). The stem and branches of a tree bear a great resemblance\\nin structure to the long bones. The centre or medulla corresponds to\\nthe medullar}- canal, the Avood to the bone-tissue, and the cambium\\nto the periosteum.\\nTumors belonging to this group often attain great size. Dutrochet\\nattributes these growths to an excessive local cell-proliferation of the\\ncambium layer, but their connection with the woody tissue of the stem\\nexists from the beginning and is never lost. Mr. Williams regards them\\nas abnormally-developed branches.\\nThe third group is represented by growths which present a surface\\nthickly studded with shoots and stunted branches, constituting a com-\\nbination of exostosis with diffuse bud-formations. The tumor of the\\ncedar branch alluded to represented both the second and third groups\\nof plant tumors. The production by these groAvths of large quantities\\nof proliferating, loAAdy-organized cellular tissue Avhich subsequently", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0070.jp2"}, "67": {"fulltext": "TUMORS IN PLANTS AND ANIMALS. S7\\nundergoes imperfect evolution constitutes the nearest approach in\\nvegetable pathology to the malignant tumors of animals. Every gar-\\ndener knows that injury to plants is one of the most common ways by\\nwhich latent buds in plants can be made to develop, and he makes use\\nof this knowledge in the propagation of some of the plants in which\\nlatent buds are most constantly found.\\nTumors in Animals. J. Bland Sutton has done more than any\\nother living author in adding to our knowledge concerning tumors in\\nanimals, and the writer can do no better than to quote freely from the\\nchapter on this subject in his excellent book, Tumors, Innocent and\\nMalignant, recently issued from the press.\\nLipomata. Fatty tumors are rare in animals. They are found most\\nfrequently in the subserous adipose tissue in horses, oxen, and sheep.\\nIn stall-fed oxen excessive accumulation of fat is common in the sub-\\nperitoneal tissue, especially in the omentum but such formations\\naccompany general obesity, and do not come into the category of\\ntumors.\\nOsteomata. These are very generalized tumors they have been\\nmet with in several species of fish. The bony outgrowths to which\\nthe term exostosis is applicable are of fairly common occurrence in\\nmammals, and their frequency on the bones of horses can be appre-\\nciated only after a visit to a veterinary museum.\\nOdontomcs are more frequent in animals than in man. The animals\\nin which they are found most frequently are the marmot, agouti, por-\\ncupine, goat, sheep, bear, kangaroo, horse, and elephant.\\nMyomata. Uterine myomata are almost unknown in mammals.\\nThe only specimen which came under the observation of Mr. Sutton\\noccurred in a female baboon, and was rather a general enlargement of\\nthe uterus than an actual tumor.\\nSarcomata have the widest zoological distribution. They occur\\nwith very great frequency, especially the round-celled and spindle-\\ncelled species they are met with in fish, birds, rats, mice, horses,\\nsheep, dogs, cats, goats, oxen, monkeys, bears, marsupials indeed, in\\nall the orders of mammals and in snakes.\\nEpithelial tumors in animals, wild or domesticated, form a subject\\nof great interest in its bearings on cancer and its allies. Unfortunately,\\nfew reliable observations pertaining to this subject are available. For\\ninstance, a cursory review of veterinary periodical literature would\\nindicate that epithelioma of the penis is a common disease in bulls\\nand horses, but a critical examination of the cases reported shows\\nclearly enough that many supposed examples of epithelioma are, as a\\nmatter of fact, instances of penile warts, and all competent histologists", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0071.jp2"}, "68": {"fulltext": "58\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwho have investigated this subject are unanimous in asserting that epi-\\nthelioma of the penis in horses and bulls is exceedingly rare. A\\nspecimen of secondary glandular carcinoma of the neck in a chicken\\nhas recently come into the writer s possession. The histological\\nFig. 21. Secondary glandular carcinoma of the neck of a chicken, X200 a, epithelial nests b, vessels.\\nstructure of the tumor, as shown in Fig. 21, is very similar as in\\nthe same organ in man. Wild animals in a state of nature and those\\nliving in confinement appear to be absolutely free from cancer.\\nAdenomata occur in domestic mammals. The bitch is especially\\nliable to tumors of the mammary gland that are analogous to the large\\nFig. 22. Carcinoma of the ovary of a chicken.\\nFig. 23. Frog with a supernumerary hind leg\\n(after Tuckerman).\\ncystic adenomata of women. These tumors often attain an enormous\\nsize. Large cystic adenomata with intracystic processes are occasion-\\nally seen in the udders of cows. The mammary glands of cats are", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0072.jp2"}, "69": {"fulltext": "TUMORS IN PLANTS AND ANIMALS. 59\\nliable to a disease histologically identical with mammary cancer in\\nwomen, but cancer such as attacks the human mamma is unknown\\nin cows, mares, ewes, goats, or bitches. Dogs are subject to ulcerating\\nsebaceous adenoma in the skin around the anus, the tumor being prone\\nto return after extirpation.\\nTeratomata are common enough among domestic animals, and\\nmany examples have been described in fish, frogs and other batra-\\nchians, lizards, snakes, birds, rabbits, etc.\\nCystic Tumors. The frequency of these tumors in vertebrata gen-\\nerally forms a striking contrast to the infrequency of connective-tissue\\nand epithelial tumors. While true cystic tumors are rare, cystic tumors\\nresulting from retention of a physiological secretion are frequently met\\nwith. Such conditions as hydronephrosis, congenital cystic kidney, and\\ndilatations of the vitello-intestinal duct have been observed. Hydrocele\\nof the tunica vaginalis is rare, because the funicular pouch in mammals\\nretains its connection with the general peritoneal cavity throughout\\nlife. Cysts arising in connection with the central nervous system have\\nbeen observed in foals, pigs, and calves. Hydrocephalus is fairly\\nfrequent, but spina bifida is rare. Oesophageal diverticulae are often\\nseen in horses, and the same animal is exceedingly liable to synovial\\ncysts and ganglia.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0073.jp2"}, "70": {"fulltext": "VI. ETIOLOGY OF TUMORS.\\nIn the first section the writer made an attempt to prove, so far as\\npresent knowledge of this subject will permit, that all tumors, benign\\nand malignant, have their origin from a matrix of embryonic cells of\\na congenital or post-natal origin. It remains to discuss here the influ-\\nences which enable the latent cells to assume active tissue-proliferation,\\nupon which depends the production of tumor-tissue. We regard the\\nmatrix of embryonic cells as the essential cause of tumorformatioji, without\\nwhich all intri?isic and external exciting causes are inadequate to produce\\na true tumor. On the contrary, we must admit that such a matrix will\\nremain harmless in the absence of congenital or post-?tatal exciting causes.\\nCertain cells never become specialized to a high degree, and conse-\\nquently retain their original inherent power of proliferation. Before\\ndiscussing the influence of heredity and post-natal exciting causes ref-\\nerence will be made very briefly to congenital tumors.\\nCongenital Tumors. In a certain sense the majority of tumors\\nare congenital in so far as the essential matrix of embryonic cells is\\nconcerned. 7/ is only in cases in which a tumor develops from a matrix\\nof embryonic cells of post-natal origin that the essential tumor-matrix is\\nnot congenital. When we speak of a congenital tumor, however, we\\nmean a tumor which is present at the time of birth. In such cases the\\ntumor-matrix is acted upon during intra-uterine life by influences which\\ndetermine tumor-formation, and the resulting product behaves clinically\\nafter birth in the same manner as do tumors of post-natal origin. We\\nmust therefore make a distinction between a true tumor and localized\\nhypertrophy or giant growth at the time of birth. There are in chil-\\ndren cases of partial obesity cases in which the adipose tissue of a\\ncertain region of the body is greatly in excess of the adipose tissue gen-\\nerally, and yet the characters of a tumor are wanting. Of such a nature\\nis the case related by Lebert, of a female aged nineteen, the left side\\nof whose abdomen Was the seat of an enormous increase of fat. This\\ngrowth began at the age of six months, and was thought to have\\nbeen congenital it grew in proportion to the rest of the body, and\\nceased to grow when the girl attained puberty. Lebert calls this a\\nlipoma diffusum. In giant growth the tissues are under the influence\\nof, and are controlled by, the same physiological laws which govern the\\ngrowth and development of the remaining tissues of the body, while a\\ncongenital tumor recognizes and obeys no such governing influences.\\nAngiomata are nearly always congenital. The tumors, although pres-\\n60", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0074.jp2"}, "71": {"fulltext": "ETIOLOGY OF TUMORS. 61\\nent at birth, are often overlooked, owing to their small size. Next in\\nfrequency as congenital tumors are the lipomata and cysts. Nearly\\nall benign tumors may have a congenital origin. Only in very rare\\ninstances have malignant tumors been found and recognized as such\\nat the time of birth. Cases of sarcoma in the cutis of the newly-\\nborn have been reported by Jacobi, Karewski, Ramdohr, Mundil-\\nlon, L. W. Marshall, K. King, Senftleben Weinlechner, and several\\nothers. Ramdohr has reported a case of congenital multiple angio-\\nsarcoma. The body of the child, which died shortly after birth,\\nshowed a large angio-sarcoma in the region of the chin, and twenty-one\\nsecondary superficial tumors also sixteen metastatic tumors of the vari-\\nous internal organs. Ahlfeld reports a case of congenital fibro-sarcoma\\nof the genital organs in a child three and a half years of age, and a\\ncase of congenital carcinoma in the distal end of an atresic rectum in\\na new-born infant. It is a significant fact that many tumors arise from\\nrudimentary organs, vestiges (Sutton), or accessory organs rests\\n(Sutton) which remain functionless in the body until the time of puberty,\\nwhen they become the starting-point of a tumor. Tumors from such\\nstructures seldom form during intra-uterine life, but appear later.\\nDifferent forms of retention-cysts have been found in infants at the\\ntime of birth. The mechanical obstruction causing the retention is\\nmore often the result of a faulty development of the ducts of secreting\\norgans than of other intra-uterine pathological conditions.\\nHeredity. Heredity in the etiology of tumors is a subject upon\\nwhich much has been said and written. We no longer speak of a\\ntumor-dyscrasia, but we cannot ignore the influence of heredity in\\nthe origin and growth of tumors. The laws of heredity depend upon\\nthe persistence of impressions (unconscious memory) in protoplasm\\n(Williams) hence every living thing produces new ones, each after its\\nown kind. It is by virtue of this property that, in the words of Sir\\nJames Paget, a mark once made in a particle of blood or tissue is\\nnot for years effaced from its successors. All are willing to admit\\nthat there is a difference in the susceptibility to disease among different\\nindividuals placed under the same conditions. Every military surgeon\\nknows that if a body of troops is quartered in a cold, damp garrison,\\nsome will be attacked by catarrhal affections of different organs, others\\nwill suffer from rheumatism, while the greater number will retain their\\nhealth after having been exposed to the same morbid influences. We\\nmust admit that a similar inherent susceptibility to tumor-formation\\nexists among different persons, and that such individual predisposition is\\noften the result of hereditary influences. Benign tumors are hereditary\\nin the same sense as monstrosities per excessum. Supernumerary toes", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0075.jp2"}, "72": {"fulltext": "62 PATHOLOGY AND TREATMENT OF TUMORS.\\nand fingers have appeared through several generations in the same\\nfamily. The same can be said of most of the non-malignant tumors,\\nparticularly angioma and lipoma. Very frequently such tumors were\\nnot only hereditary, but also occupied the same localities. Paget found\\ncarcinoma of the uterus in three generations grandmother, mother,\\nand. daughter. The writer has repeatedly met with carcinoma of the\\nbreast in two successive generations. Sibley relates an instance of\\ncarcinoma of the uterus affecting a mother and her five daughters.\\nWarren observed a cancer of the lip in the father in one son and two\\ndaughters cancer of the breast and in two grandchildren cancer of the\\nbreast. The most interesting instance of hereditary predisposition to\\ncarcinoma is reported by Broca:\\nFirst generation Madame Z. died of cancer of the breast in 1788, aged 60.\\nSecond generation four married daughters\\nA. Cancer of the liver, 62 years old, 1820.\\nB. Cancer of the liver, 43 1805.\\nC. Cancer of the breast, 5 1 1814.\\nD. Cancer of the breast, 54 1827.\\nThird generation Madame B., five daughters and two sons\\nFirst son died during infancy.\\nSecond son, cancer of the stomach, 64 years old.\\nFirst daughter, cancer of the breast, 35\\nSecond -x\\nThird 1 35-40 years old.\\nFourth liver, J\\nThe fifth daughter escaped the disease.\\nMadame C. had five daughters and two sons\\nThe sons remained free from cancer.\\nThe first daughter died of cancer of the breast in 1 837, 37 years old.\\nOf her five children, one daughter died in 1 854, of cancer of the breast, at the age\\nof 49.\\nThe second daughter died in 1822, 40 years old, of cancer of the breast.\\nThe third 1837, 47 uterus.\\nThe fourth 1848, 55 breast.\\nThe fifth 1856, 61 liver.\\nFrom these and other reliable observations it is evident that a predis-\\nposition to cancer may be derived by inheritance. Paget collected the\\nhistories of 322 cancerous patients with special reference to this point.\\nOf this number, there were seventy-eight, or nearly one-fourth, who\\nwere aware of cancer in other members of their families. The proportion\\nis much larger than could be due to chance, and its import is corrob-\\norated by the fact of many members of the same family being in some\\ninstances affected. It is evident that where a tumor is inherited the two\\nessential causes are transmitted from parent to child 1 A matrix of\\nembryonic cells 2. A lack of resistance on the part of the whole", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0076.jp2"}, "73": {"fulltext": "ETIOLOGY OF TUMORS. 63\\norganism or of the tissues in the immediate vicinity of the matrix to\\nretard tumor-growth. For the growth of a tumor it is not only essen-\\ntial to have present the necessary matrix of embryonic cells, but it is\\nequally essential that the environment of the matrix should not exert\\nupon the cells an inhibitory influence which would interfere with their\\nassuming active tissue-proliferation. If the controlling or inhibitory\\ninfluence of the tissues in the vicinity of embryonic cells set apart in\\nthe organism is diminished or completely abolished, such cells regain\\ntheir primitive reproductive activity and assume an individuality alone.\\nUnder such circumstances there is established a new centre of tissue-\\nformation which has no laws to obey and no orders to observe. In\\nsuch a new centre of growth there is a departure from the definite order,\\nlimitations, regular stages, and fixed periods of the normal growth.\\nLittle is known in regard to the force which holds in check perma-\\nnently or for an indefinite period of time the tissue-proliferation from\\nsuch a matrix. For want of a better knowledge this force has been\\ncalled physiological resistance. Heredity implies, therefore, in connec-\\ntion with the subject now under consideration, two things 1. A matrix\\nof embryonic cells 2. Suspended or diminished physiological resist-\\nance in the tissues of the entire body or in the immediate vicinity of\\nthe tumor-matrix. The existence of such a force has been demon-\\nstrated by experiments. Cohnheim and Maas introduced into the jugu-\\nlar veins of animals small pieces of young periosteum, with the expec-\\ntation that they would become arrested in the smaller branches of the\\npulmonary artery as emboli. The animals were killed in a few weeks\\nor months later, and the specimens examined to determine the extent\\nof tissue-growth from the periosteal grafts. The results were uniform.\\nThe periosteum retained its bone-producing properties and produced\\nbone, but the new product was always limited in size to the lumen of\\nthe vessel in which the periosteal embolus had become impacted.\\nWhen this size was reached further growth became arrested, and the\\nnew bone in the course of time underwent complete removal by\\nabsorption. It is apparent that the intrinsic force (physiological resist-\\nance) in the adjacent tissues exerted a positive influence in limiting the\\nproduction of bone from the periosteal graft to the lumen of the vessel.\\nThe same investigators have also shown that transplantation of grafts\\nof embryonal tissue is more successful than that of mature tissue.\\nLeopold, under the direction of Cohnheim, studied the fate of mature\\ntissue transplanted into the anterior chamber of the eye and the peri-\\ntoneal cavity in rabbits. He found that all tissue that had reached\\nmaturity was invariably removed by absorption in a short time, while\\nembryonic tissue taken from animals before they were born retained its", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0077.jp2"}, "74": {"fulltext": "64 PATHOLOGY AND TREATMENT OF TUMORS.\\nvitality and continued to proliferate tissue to an astonishing extent.\\nGrafts of fetal cartilage increased to from two hundred to three hundred\\ntimes their original size, giving rise to a temporary chondroma of several\\nmonths duration. Zahn repeated these experiments with the same\\nresults. In the growth of an osteoma tissue-proliferation takes place\\nfrom a matrix of osteogenetic cells, and we must assume that in the\\nimmediate vicinity of the matrix a diminution of the physiological\\nresistance of the tissues had taken place. In the transplantations of\\nmalignant tissue, that have almost without exception been followed\\nby negative results, we can explain the failures only by taking it for\\ngranted that the tissues in which the graft was imbedded presented an\\nadequate physiological resistance which prevented the growth and infil-\\ntration of the transplanted cells, and that the graft acted the part of an\\nabsorbable foreign body, and was subsequently removed by the wall of\\ngranulations thrown out by the injured tissues around the graft. The\\nphysiological resistance in the adjacent tissues permits grafts from be-\\nnign tumors only to grow to a limited extent if at all, after which they\\nare removed like any other aseptic absorbable substance, while the same\\nresistance offers an effective barrier to infiltration by cells from grafts\\ntaken from malignant tumors. From what has been said it follows\\nthat there are two essential factors present wherever a tumor grows\\nnamely An embryonal matrix, or at least a matrix composed of embry-\\nonic cells 2. A suspension or diminution of the physiological resistance\\nin the tissues in the immediate vicinity of the matrix. The absence of the\\nformer precludes entirely the possibility of the formation of a tumor,\\nand only the presence of the latter negative condition enables the matrix\\nto proliferate tumor-tissue. Future research must determine what con-\\nditions produce diminution of physiological resistance. We have reason\\nto believe that this predisposition to tumor-formation is often hereditary,\\nand that it can be produced artificially by acquired pathological con-\\nditions which weaken the tissues, such as irritation and inflammation.\\nThat the chemico-vital changes which take place in inflamed tissue\\ndiminish physiological resistance has been demonstrated unmistakably\\nby the experiments of Friedlander. It is therefore reasonable to sup-\\npose that a person born with the essential tumor-germs is more likely\\nto become the subject of tumor-formation when the part in which they\\nare located becomes the seat of accidental pathological conditions which\\nresult in diminution of the physiological resistance in the tissues sur-\\nrounding the matrix while persons born with a similar matrix not thus\\naffected may escape tumor-formation, the matrix-cells remaining in a\\nlatent condition throughout life.\\nRace. Race-influence plays an important part in the etiology of", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0078.jp2"}, "75": {"fulltext": "ETIOLOGY OF TUMORS. 65\\ntumors. Certain races are predisposed to special tumors. Negroes\\nsuffer more frequently from the different forms of fibroma than does\\nany other race. Keloid, fibroma of the skin, and myofibroma of the\\nuterus in women are exceedingly common among the negroes in the\\nSouth. Lipoma is very prevalent among the Hottentots. The unciv-\\nilized nations, in proportion to the population, furnish a smaller percentage\\nof malignant tumors than do the inhabitants of Europe and America.\\nClimate. It is said that the inhabitants of southern countries are\\nmore predisposed to tumor-formation than are the inhabitants of the\\nNorth; this applies particularly to carcinoma and sarcoma. Tumors\\nof the thyroid gland appear as endemic affections in certain parts of\\nEurope and in other countries. There is no doubt that malignant\\ntumors are unequally distributed over the world, being more prevalent\\nin some localities than in others. Heredity unquestionably plays an\\nimportant part in imparting to these tumors in some localities an en-\\ndemic character. The accumulation of many generations in particular\\nlocalities would naturally increase the number of the victims.\\nAge. Age has already been alluded to as an important determining\\ncause. It is a familiar clinical fact that certain benign tumors from\\nembryonic fetal remnants are likely to appear at the age of puberty,\\nat the time of post-natal life when the whole organism, and particularly\\nthe organs of generation and the mammary gland in the female, are in\\na state of the highest physiological activity. It is during this time of\\nlife that we most frequently meet with branchial and dermoid cysts, cysts\\nof the ovary and parovarian cysts, and adenoma of the mammary gland.\\nIn adult life fibroma, osteoma, chondroma, and other mesoblastic\\ntumors are more prevalent. Carcinoma manifests a predilection for\\nthe conditions incident to senile marasmus, occurring most frequently\\nin persons between fifty and seventy years of age. It is in individuals\\npast middle life that we most frequently see transformation of benign\\ngrowths, such as moles, papilloma, and warts, into malignant tumors.\\nThe conditions which determine such a change and which favor the\\nformation of carcinomatous tumors are not well understood. There is\\nanatomically such a thing as a non-malignant stage of cancer. In the\\nearly stage of epithelioma we find simply a superficial increase in the\\nthickness of the epidermic layer that is, the stage when carcinoma still\\nremains as a non-malignant growth but just as soon as the physio-\\nlogical boundary-line between the epithelial layer and the subjacent\\nconnective tissue is destroyed or is rendered permeable to migrating\\ncells in other words, just as soon as epithelial elements are found in\\nplaces where they have no legitimate existence we have to deal with\\na carcinoma.\\n5", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0079.jp2"}, "76": {"fulltext": "66\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nA glance at Plate 2, Figures 2 and 3, and at Figures 24 and 25\\nwill show the difference in the relation of epithelial cells in normal tis-\\ne d\\nFig. 24. Epithelioma of skin (after Thiersch): 1-2, ulcerated surface; 2-3, adjacent skin; a, hair-\\nfollicles with sebaceous glands made oblique by pressure from beneath b, sweat-glands c, epidermis, horny-\\nlayer, which extends for some distance over ulcerated surface d, avascular cell-masses of an epithelial\\nnature, formed into irregular tubes by softening, only slightly attached to the stroma in which they are\\nlodged, or separated from the walls of the alveoli during the hardening process in alcohol; e, connective-\\ntissue stroma.\\nFig. 25.\\n\u00e2\u0096\u00a0Columnar epithelioma of rectum (after Boyce) a, an epithelial process from skin of anus 5, a\\npapillomatous gland-crypt. (Obj. without eye-piece; logwood staining.)\\nsue and in carcinoma. In the former instance the epithelial cells are in\\nan avascular district outside of the limiting membrane, membrana pro-", "height": "4431", "width": "2806", "jp2-path": "pathologysurgic00senn_0080.jp2"}, "77": {"fulltext": "ETIOLOGY OF TUMORS.\\nPlate 2.\\n.5\\n4*\\n1. Endothelioma hyalinum from capsule of submaxillary gland (after Klelis 1 stroma b, smaller part of\\nstroma; c, hyaline substance; d, cells. 2. Mucous membrane of large intestine of pig $50 (after Klein). The\\ncapillary blood-vessels cut in different directions surrounding the crypts are injected with carmine gelatin. A\\nvertical section through the epithelium covering the skin -epidermis 350 (after Klein) rete Malpighii, or\\nrete mucosum b, granular layer (Langerhans) c, stratum lucidum (Schron) d, Stratum corneum.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0081.jp2"}, "78": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0082.jp2"}, "79": {"fulltext": "ETIOLOGY OF TUMORS. 67\\npria in the latter instance they have found their way through the limit-\\ning membrane and have reached the underlying vascular mesoblastic\\ntissues, where they have no legitimate physiological existence, and where\\nthey must be regarded pathologically as invaders. It appears that in\\nthe subepithelial tissues a change takes place coincident with the senile\\nchanges in the tissues of persons advanced in life. Thiersch advanced\\nthe ingenious hypothesis that this change consists in a disturbance of\\nthe normal relations between the skin and the underlying tissues, this\\ndisturbance being caused by senile changes and resulting in a loss of\\nresistance to the proliferating epithelial cells. There can be no doubt\\nthat in the aged some such alteration of tissue takes place, permitting\\nembryonic epithelial cells to part with their normal anchorage and to\\nfind their way by migration into the subjacent altered tissue, where they\\nare no longer subject to the physiological laws which govern the repro-\\nduction and growth of normal epithelial cells, and where, in consequence\\nof such aberration and lawless conduct, they produce a planless, func-\\ntionless growth which invades all tissues, regardless of their anatomical\\nstructure.\\nSex. Statistics show on the whole that the male sex is more\\npredisposed to tumor-formation than is the female. This difference\\nmay be accounted for in part by the male sex leading a more active\\nlife, and being subjected more to the exciting causes which later in life\\nbecome such a prominent feature in the etiology of tumors. Heredity\\naffects both sexes equally, and the difference in the frequency with\\nwhich tumors occur must therefore depend largely on occupation and\\nhabits of life. Of 1145 cases of tumor treated at the clinic of Berne\\nduring a period of twenty-five years, the males furnished 58.5 1 per cent,\\nand the females 41.49 per cent. C. O. Weber gives the proportion of\\nmales to females as 64 36. The proportion varies with the different\\nforms of tumors. Carcinoma of the skin is much more frequent in the\\nmale than in the female, while in glandular carcinoma the reverse is\\nthe case. Moore in 1861 found in England one carcinoma patient\\nto every 5846 men, and one female patient to eveiy 2461 women.\\nIn women tumors are more prone to occur during the childbearing\\nperiod of life than before and after. Carcinoma of the lip is common\\nin men, but extremely rare in women. Of 696 cases of carcinoma of\\nthe lip collected by Lortet, 527 were men and 69 were women, the\\nproportion of men to women being 7.6: 1. According to the writer s\\nown observations, carcinoma of the stomach and the rectum is more\\nfrequently met with in males than in females. In the female, carcinoma\\nof the breast and the uterus occurs probably more frequently than do\\nmalignant tumors of all the remaining organs.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0083.jp2"}, "80": {"fulltext": "68 PATHOLOGY AND TREATMENT OF TUMORS.\\nSocial Status. It has generally been claimed that the laboring\\nclasses furnish the largest contingent to the whole number of patients\\nsuffering- from carcinoma. The statistics from which this statement was\\ndrawn were collected almost exclusively from the practice of hospital\\nphysicians. A more careful inquiry into the actual facts shows that\\nthe reverse comes nearer the truth. M. d Epine found, in examining\\nthe mortality statistics of malignant tumors of the city of Geneva, that\\namong the well-to-do classes came 106 deaths from this cause to every\\nthousand inhabitants, while- the poor furnished only 72 to every thou-\\nsand. Walshe found that of a million of people in London in ten\\nof the unhealthiest districts, 127 died of malignant tumors; in ten\\nhealthier districts, 183 and in ten of the healthiest, 199. From similar\\nstatistics gathered in England and Wales, Moore came to the conclu-\\nsion that cancer becomes more frequent with the increasing prosperity\\nof the people. In the United States carcinoma has been on a gradual\\nincrease with the progress of civilization. The mortality from this\\ncause in 1850 was 9 for 100,000 inhabitants; in i860 it was 11.79; in\\n1870, 16; in 1880, 26; in 1890, 33.5.\\nTraumatism. The influence of a trauma in exciting tumor-growth\\ncan no longer be denied. The different forms of sarcoma frequently\\nfollow an injury. Numerous cases are on record in which sarcoma\\nfollowed a fracture of the long bones. The statistics of Boll, collected\\nwith a view to prove the traumatic origin of cancer, show that of a\\nlarge number of cases only about 12 or 14 per cent, were traceable to\\ntraumatism. Ziegler studied the influence of trauma in the etiology\\nof malignant tumors in 282 cases, 180 men and 102 women. He came\\nto the conclusion that in 1 8 per cent, of the cases a single trauma was\\nthe apparent cause of tumor-formation, while repeated injuries and\\nprolonged irritation were noted in 25 per cent. He regards trauma\\nand chronic irritations as potent factors in the causation of malig-\\nnant tumors. Traumatism alone can no more produce a tumor than\\ncan inflammation occur without the presence of pathogenic microbes.\\nThe trauma can act only as an exciting cause in stimulating a pre-\\nexisting matrix of embryonic tissue into active tissue-proliferation, or in\\nfurnishing by its remote effects on the tissue a post-natal matrix of\\nembryonic cells. In animals sarcomata are seen most frequently in parts\\nmost exposed to injury in fishes in the tail and fins, in frogs in the\\nlimbs, and in birds in the neck and wings. The writer believes that in\\na fracture of a bone which later becomes the seat of a sarcoma the\\ncells which are destined to furnish the bony callus fail to undergo the\\ntypical transformation from embryonic into mature tissue in consequence\\nof some local or general cause, and that from these cells the sarcoma", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0084.jp2"}, "81": {"fulltext": "ETIOLOGY OF TUMORS. 69\\ntakes its origin. Influenced by a preconceived idea, it is not difficult\\nto trace many of the local affections, including tumors, to a traumatic\\norigin. How long have we been in the habit of assigning to traumatism\\nthe first position in the causation of suppurative inflammation? Recent\\ninvestigations have demonstrated that no amount of traumatism can\\nproduce inflammation and suppuration unless the injured tissues become\\ninfected with the essential cause of inflammation pyogenic microbes.\\nTrauma in exceptional cases may and does act as an exciting cause\\nin the growth of a tumor, by diminishing the physiological resistance\\nof the injured tissues or by causing irritation or inflammation in the\\nimmediate vicinity of a pre-existing tumor-matrix or in more excep-\\ntional cases it furnishes both essential conditions for tumor-growth\\na post-natal matrix of embryonic cells and a diminution of physiological\\nresistance in the immediate vicinity of the new matrix,\\nIrritation. Prolonged irritation microbic, mechanical, chemical,\\nand thermal is a recognized exciting cause of tumor-growth. If we\\nexamine the topography of carcinoma, we find that it attacks parts\\nand organs that are most frequently the seat of prolonged and repeated\\nirritation. The clay pipe in smokers, the coal-dust in chimney-sweeps,\\nforeign bodies in the tissues or in hollow organs, carious teeth, and\\nother local irritants have for a long time been regarded as important\\ncauses in the production of tumors, more especially of carcinoma and\\nsarcoma. The influence of alcoholic drinks in the production of car-\\ncinoma of the oesophagus and stomach should be mentioned here.\\nA similar chronic local irritation is the chronic catarrh of the mucous\\nmembrane of the nose which so often precedes the formation of\\nmyxomatous tumors in this locality. Virchow very correctly mentions\\nthe frequent occurrence of cancer of the testicle where the organ\\nremains in the inguinal canal and is subjected repeatedly to pressure\\nand traction. The ovary is equally liable to carcinoma if it constitutes\\na part of the contents of a hernia. We shall assign to irritation and\\ninflammation an influence in the production of tumors similar to that\\nassigned to traumatism.\\nInflammation. Inflammation is never the sole cause of tumor-\\nformation. That it is an important factor in stimulating pre-existing\\nembryonic cells into a state of active tissue-proliferation few would\\ndeny. Friedlander has shown that embryonic epithelial cells, by virtue\\nof their ameboid movement, can penetrate a subjacent inflamed sur-\\nface. It has been shown that cancer-cells possess the same ameboid\\nmovement, which is a potent factor in the process of infiltration.\\nInflammation always hastens tumor-growth this statement applies\\nwith particular force to malignant tumors. If a tumor-matrix is within", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0085.jp2"}, "82": {"fulltext": "yo PATHOLOGY AND TREATMENT OF TUMORS.\\nthe limits of an inflamed area, it receives suddenly an increased blood-\\nsupply, which alone may be sufficient to arouse it from its dormant\\ncondition into active tissue-proliferation at the same time the inflam-\\nmation will result in diminution of the physiological resistance of the\\ntissues around the matrix, thus still further favoring tumor-growth.\\nContagion. Under this heading of the etiology of tumors it is only\\nnecessary to mention the malignant varieties, carcinoma and sarcoma.\\nThe popular fear of the contagiousness of these growths lacks founda-\\ntion. There is not a single well-authenticated case on record in which\\nthe disease was transmitted from man to man or from animal to animal\\nby contagion. The cases in which the disease was reproduced in the\\nsame individual at a point opposite the primary tumor (by contact) or\\nby bringing an ulcerating carcinoma frequently in contact with a distant\\npart, as by rubbing (Kaufmann), are few, and the auto-inoculation was\\nundoubtedly preceded by pathological conditions which in themselves\\nmight have furnished the essential conditions for tumor-growth, or\\nwhich, at any rate, created a favorable soil for the implantation of tumor-\\ncells. The negative results which have followed thousands of attempts\\nto reproduce carcinoma and sarcoma by implantation of fragments\\nof tumor-tissue in different animals furnish the most convincing proof\\nof the non-contagious and non-parasitic character of malignant tumors.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0086.jp2"}, "83": {"fulltext": "VII. CLINICAL ASPECTS OF BENIGN AND\\nMALIGNANT TUMORS.\\nThe clinical behavior of a tumor is determined by the nature of the\\nprimitive matrix, the anatomical structure and physiological importance\\nof the part or organ affected, and the relations of the tumor to the adja-\\ncent tissues. A tumor-matrix composed of embryonic cells of the\\nlowest degree of development is more likely to result in the formation\\nof a malignant tumor than is a matrix representing embryonic cells\\ncapable of development into tissue of the highest physiological type.\\nAgain, the type of a tumor will depend upon the germinal layer from\\nwhich the matrix is derived. A matrix from the middle germinal layer\\nwill produce a tumor of the connective-tissue type either a benign meso-\\nb I as tic tumor or a sarcoma. A matrix of embryonic cells from the epiblast\\nor hypoblast will give rise to either a benign epitlielial tumor or a carci-\\nnoma according to the intrinsic capacity of the cells to produce embryonic\\nor 7nature cells, and the resisting power of adjacent tissues. A tumor\\nof an important organ, such as the brain, heart, lungs, or digestive\\ntract, may destroy life by its presence producing mechanical conditions\\nincompatible with an essential function. Large tumors of less import-\\nant organs may by compression of an important organ produce the\\nsame result. Malignant tumors affecting important organs not only\\ngive rise to functional disturbances by their mere presence, but they\\nalso destroy the tissues of the part or organ affected, thus greatly\\nincreasing the danger to life. A benign tiimor remains limited to the\\npart or organ primarily affected malignant tumors, on the contrary,\\nignore all boundary -lines and affect adjacent tissues irrespective of their\\nanatomical structure.\\nRelative Frequency -with which Different Organs are Affected\\nby Tumors. Every clinician knows that certain tumors show a predi-\\nlection for certain tissues and organs. Fatty tumors occur most fre-\\nquently in the panniculus adiposus, enchondroma in the long bones\\nsarcoma affects most frequently the connective tissue, the glands, and\\nthe bones, while the muco-cutaneous orifices and the mammary gland\\nare the most frequent seat of carcinoma. C. O. Weber arranged the\\nfollowing table of organs and parts to show their predilection for\\ntumor-formation\\nTl", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0087.jp2"}, "84": {"fulltext": "J 2 PATHOLOGY AND TREATMENT OF TUMORS.\\nNo. of Cases.\\nOrgans of mouth, with maxillary bones 217\\nGlands 174\\nBones, excluding maxillary bones 161\\nSkin 93\\nGenital glands 86\\nLungs 64\\nNose, pharynx, antrum of Highmore 56\\nSubcutaneous and intermuscular connective tissue, muscles, and nerves 51\\nEyes and orbits 41\\nGenitals, including uterus 31\\nIntestines and anus 13\\nUrinary organs 13\\nBrain 13\\nThat the relative frequency with which different tissues and organs\\nare affected is inaccurately represented by this table follows from the\\nfact that it undoubtedly includes many chronic infective swellings which\\nwere formerly classified with tumors, and which even now are often\\nmistaken for tumors but the table is valuable in giving at least an\\napproximately correct idea of the topographical distribution of tumors.\\nBenign Tumors. A benign tumor always grows slowly. Myofi-\\nbroma of the uterus under favorable circumstances may attain great size\\nin the course of a few years (Fig. 26). Fibromata in other localities grow\\nless rapidly. Among the tumors of slow\\ngrowth, which, however, eventually often at-\\ntain great size, are the cystic adenomata and\\nchondromata. Slowness of growth must there-\\nfore be looked upon as an important clinical\\nfeature of a benign tumor. Every benign\\ngrowth is surrounded by a limiting capside,\\nwhich separates it from the adjacent tissues,\\nand beyond which it never extends. This isola-\\ntion from the surrounding tissues is the most\\nfig. ^.-submucous pedunculated distinctive anatomical feature of benign as\\nmyofibroma of the uterus (after compared with malignant tumors. The exist-\\nPaget) a, capsule b, tumor.\\nence of this connective-tissue capsule enables\\nthe surgeon in the majority of cases to remove benign tumors by enu-\\ncleation. If the capsule of a benign tumor, owing to anatomical pecu-\\nliarities of the surroundings, sends prolongations into the adjacent\\ntissues, as is sometimes the case in lipoma and fibroma, parts of the\\ntumor may be overlooked by the surgeon, and from them takes place\\na local recurrence later. We are therefore prepared to appreciate the\\nforce of the statement that incomplete removal of a benign tumor is\\nalways followed by recurrence unless the remaining part of the tumor", "height": "4437", "width": "2861", "jp2-path": "pathologysurgic00senn_0088.jp2"}, "85": {"fulltext": "BENIGN AND MALIGNANT TUMORS.\\nPlate 3.\\nGlandular carcinoma of the breast (after Klebs) i. epithelial layer of skin with long proliferating projec-\\ntions carcinoma-tissue of epithelial cells and connective tissue c, the same with predominance of epithelial\\ncells d, milk-ducts.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0089.jp2"}, "86": {"fulltext": "", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0090.jp2"}, "87": {"fulltext": "BENIGN AND MALIGNANT TUMORS. 73\\nis subsequently destroyed by suppurative inflammation or by degenerative\\nchanges.\\nEncapsulation of a tumor imparts to it another clinical feature of\\ngreat importance mobility. This mobility, however, may be diminished\\nor entirely prevented by the tumor being tied down by overlying firm\\nstructures, such as fascia, skin, and muscles. If the tumor is attached\\nto the bone, as is the case in chondroma and osteoma, it is from the\\nbeginning immovable, and so remains. The question of mobility of\\na tumor is a valuable point in differential diagnosis, and is of special\\nimportance in the case of tumors of the breast. An adenoma of the\\nmammary gland always remains movable, while in carcinoma of this\\norgan the tumor almost from the beginning is so intimately connected\\nwith the surrounding tissues that the palpating finger receives an im-\\npression as though the tumor were grasped and firmly held in place\\nby the surrounding tissues. Some of the benign tumors myxoma,\\nchondroma, and some forms of fibroma\u00e2\u0080\u0094 have received the reputation\\nof being semi-malignant on account of their occasional recurrence after\\nextirpation. A tumor is either benign or malignant there is no connect-\\ning-link between them. The recurrence of a tumor after extirpation may\\nbe explained as follows: I. The tumor was incompletely removed;\\n2. The primary tumor removed was malignant from the beginning;\\n3. A new tumor may develop in the scar of the operation-wound or\\nin its immediate vicinity. Local recurrence after the removal of a\\nbenign tumor has been observed most frequently in cases of chon-\\ndroma, myxoma, and fibroma\u00e2\u0080\u0094 tumors which, from their clinical\\nbehavior as well as from the fact that their extirpation is sometimes\\nfollowed by recurrence, have been regarded by many surgeons as\\nsuspicious or semi-malignant growths. We have reason to believe that\\nin most cases local recurrence was due to imperfect removal. These\\ntumors have a structure which renders their complete removal uncer-\\ntain. Fibroma, for instance, is often surrounded by minute nodules, not\\nlarge enough to be recognized by the naked eye,, which are in histo-\\ngenetic connection with the main tumor, and which, if the main tumor\\nis removed by enucleation, remain in the tissues from these nodules\\na recurrence takes place later. Such minute daughter-tumors arc no\\nevidence of the malignant nature of the primary tumor, as their histo-\\ngenetic connection with the primary tumor can be demonstrated. The\\njelly-like structure of a myxoma renders the outline of the tumor\\nirregular. Projections of the tumor between muscles and connective\\ntissue are often overlooked, .and if left in the bed of the tumor they\\ncertainly would give rise to local recurrence. Virchow years ago\\nshowed that chondroma originates not from the surface of a bone, but", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0091.jp2"}, "88": {"fulltext": "74 PATHOLOGY AND TREATMENT OF TUMORS.\\nin its interior. Surgeons seldom extend the operation far enough to\\ninclude every vestige of the tumor, hence the frequency with which\\nan enchondroma returns. If a tumor is removed completely and local\\nrecurrence takes place, it is more than probable that the primary tumor\\nwas of a malignant character, and that the relapse is the result of tissue-\\nproliferation from malignant cells left in the tissues. The clinical course\\nof the tumor in such cases makes a more positive and reliable diagnosis\\nthan the surgeon and pathologist. Finally, a new tumor may grow from\\nan additional congenital matrix of embryonic cells or from latent unutilized\\nembryonic cells in the scar or in its immediate vicinity.\\nMalignant Tumors. To the surgeon the most important clinical\\naspects of a malignant tumor are I. Rapid growth; 2. Absence of\\nlimitation of the growth 3. Local infection 4. Regional infection\\n5. General infection; 6. Frequency of recurrence after extirpation;\\n7. The intrinsic tendency of the tumor to destroy life. Rapidity of\\ngrowth, as compared with that of benign tumors, belongs to malignant\\ntumors as one of their salient clinical features. Some malignant tumors,\\nparticularly epithelioma of the skin, may remain in a latent stage for\\nyears before manifesting their true nature by rapid growth these are,\\nhowever, exceptional cases.\\nAbsence of a limiting capsule is common to all malignant tumors.\\nIn some forms of sarcoma, to the naked eye such a capsule exists, but\\nexamination of the tissues adjacent to it under the microscope shows\\nthat tumor-cells have passed through and beyond the capsule into the\\nconnective tissue. The apparent capsule in such cases has been a\\nsource of deception to the surgeon who enucleates such a tumor under\\nthe belief that it is non-malignant. The absence of a proper limiting\\ncapsule brings the tumor-tissue in direct contact with the surrounding\\ntissues, giving rise to local infection. The word infection as applied\\nto the process of dissemination of malignant tumors has a different\\nsignificance than when the same term is applied to the origin and\\nextension of acute and chronic infective diseases. In the latter case\\ninfection signifies the presence in the tissues of pathogenic microbes\\nwhich exert their specific pathogenic effect upon pre-existing tissues.\\nThe word infection used to indicate the local, regional, and general dis-\\nsemination of malignant tumors means the separation from the primary\\ntumor of cells which migrate into the surrounding connective tissue, giving\\nrise to local infection, or which are transported through the lymphatics of\\nthe region occupied by the tumor, causing regional infection or, lastly,\\nthe malignant cells find their way directly or indirectly into the general\\ncirculation and become arrested in some distant part or organ as tumor-\\nemboli, resulting in general infection or general dissemination.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0092.jp2"}, "89": {"fulltext": "BENIGN AND MALIGNANT TUMORS. 75\\nLocal Infection. Local infection of a malignant tumor is caused\\nby the migration of tumor-cells from the place in which they were\\nproduced that is, from the primary tumor into the connective-tissue\\nspaces in the immediate vicinity of the tumor. This migration of cells\\nin all directions around the tumor results in a zone of tissue-infiltration\\nby malignant cells, each cell establishing in its new location an inde-\\npendent centre of tumor-growth. As soon as a malignant cell has left\\nits birthplace, it leads an independe?it existence and loses all histogenetic\\nconnections with the mother-tumor. It is the establishment of innumerable\\nindependent centres of tissue-proliferation in the zone of infiltration sur-\\nrounding a malignant tumor that determines its rapid growth. Infec-\\ntion from a malignant tumor implies, therefore, only the invasion of\\nadjacent or distant tissues by malignant cells it is an infection by cells\\ninstead of by microbes, as is the case in the production of infective diseases.\\nAnother great difference in the two kinds of infection is this in infec-\\ntive diseases the microbes act upon and alter pre-existing tissue-cells,\\nwhile in tumor-growth the pre-existing tissue remains passive, the tis-\\nsues of the tumor being derived exclusively from the tumor-cells.\\nAs a rule, local infection is much more pronounced and rapid in sar-\\ncoma than in carcinoma, hence greater rapidity of growth and larger\\nsize of the tumor.\\nRegional Infection. Regional infection consists in the transporta-\\ntion of tumor-cells through the lymphatic channels some distance from\\nthe tumor to the lymphatic glands in the region occupied by the tumor.\\nFamiliar instances of regional infection are secondary carcinoma of the\\nsubmental, submaxillary, and cervical glands in advanced carcinoma of\\nthe lip, and secondary carcinoma of the axillary glands in glandular\\ncarcinoma of the mammary gland. The regional dissemination of car-\\ncinoma is accomplished almost exclusively through the medium of the\\nlymphatics. The carcinoma-cells, after finding their way into a lym-\\nphatic channel within or near the tumor, are transported by the lymph-\\ncurrent, and are arrested usually in the first lymphatic gland, which\\nacts the part of a filter. The cell or cells establish here a new centre\\nof growth, from which the tissues of the ensuing secondary carcinoma\\nof the lymphatic gland are derived exclusively, the lymphoid cells\\ntaking no active part in the production of the tumor. From a gland\\nthus infected tumor-cells again reach the lymphatic channel on the\\nopposite side of the gland, and are taken up by the lymph-current and\\ntransported to the next lymphatic gland, where an additional centre oi~\\ntumor-growth is established. By this progressive regional extension\\nof the tumor the whole chain of glands between the primary tumor\\nand the proximal termination of the lymphatic system becomes in-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0093.jp2"}, "90": {"fulltext": "7 6\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nvolved. The lymphatic glands serve as niters and contribute much\\ntoward retarding general dissemination. General infection is likely to\\noccur at an early date if the lymphatic glands do not participate in the\\nregional extension of the tumor. The malignant cell after it has\\nbecome detached from the mother-tumor retains all the qualities in-\\nherited from it at birth, and consequently produces the same kind of\\ntissue, whether it remain in the vicinity of the tumor in the same region\\nor whether it is transported to the most distant organs. The secondary\\ntumors resemble the primary tumor histologically and clinically (Fig. 27).\\nRegional dissemination of a sarcoma takes place by a continuous\\ngrowth of the tumor, usually in the direction of fascia, blood-vessels,\\nor nerve-sheaths it is a local infection on a large scale. Occasionally\\na sarcoma gives rise to regional\\ninfection in the same manner\\nand through the same channel\\nas carcinoma.\\nAnother method of regional\\ninfection takes place by the dif-\\nfusion of particles of tumor-\\ntissue or free tumor-cells over\\nserous surfaces in the abdom-\\ninal cavity by the peristaltic\\nmovements of the intestines and\\nthe stomach, and in the pleural\\ncavity by the movements of the\\nlung during respiration. This\\nmanner of regional infection is witnessed most frequently in sarcoma\\nof the peritoneum and the pleura, and in carcinoma of any of the\\nabdominal organs or of the lung after the tumor has reached the serous\\ncavity.\\nGeneral Infection. General infection during the growth of a malig-\\nnant tumor is called metastasis that is, the reappearance of the same\\ndisease in a distant organ. When this stage is initiated the tumor is no\\nlonger local the disease has become general. No modern pathologist\\nregards as was formerly and quite recently done a primary malig-\\nnant tumor as a local manifestation of a general disease or dyscrasia.\\nA careful study of the pathology and histology of malignant tumors,\\nas well as the results of accurate clinical observation, has demon-\\nstrated that malignant tumors are primarily purely local affections,\\namenable to successful surgical treatment, and that they become gen-\\neral only by the dissemination of tumor-cells through the systemic\\ncirculation. Metastasis may occur in one of three ways: 1. Tumor-\\nFig. 27. Secondary sarcoma of lymphatic vessels of omen-\\ntum in the course of a medullary sarcoma (after Liicke).", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0094.jp2"}, "91": {"fulltext": "BENIGN AND MALIGNANT TUMORS. 77\\ncells reach the venous circulation directly by their entrance from the\\nprimary tumor or the regional glandular tumors into a vein 2. By\\nprogressive extension of the disease through the lymphatic channels\\nuntil the last filter, the last lymphatic gland, is passed, when the\\ntumor-cells reach the general circulation 3. By the passage of tumor-\\ncells through the chain of lymphatic glands into the pulmonary or\\nsystemic circulation without implicating the lymphatic glands. It is\\nstrange that the tumor-emboli are not more constantly arrested in the\\nfiner branches of the pulmonary artery. The result of post-mortem\\nexaminations of persons who died of malignant tumors would tend to\\nshow that such emboli readily pass the pulmonary filter, and may\\nbecome arrested in any of the more distant vascular organs. The\\nexemption of non-vascular tissues from metastatic carcinoma is one of the\\nmany proofs that malignant tumors are generalized by cellular elements,\\nand not through the agency of a virus or of microbes. Metastasis always\\ntakes place through the arteries. Usually the emboli are small (Fig. 28).\\nIn some cases perhaps a single cell becomes implanted upon the wall\\nof an arteriole, and later a thrombus is formed by tissue-proliferation\\nfrom this cell. In other instances a vessel of considerable size is\\nobstructed by a malignant thrombus. Metastatic tumors frequently\\nFig. 28. Embolism of the right pulmonary artery from a pigmented sarcoma of the thigh (after Liicke).\\nextend in the direction of a blood-vessel of considerable size, the mul-\\ntiple tumors with the blood-vessels and its branches presenting the\\nappearance of a bunch of grapes (Fig. 29).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0095.jp2"}, "92": {"fulltext": "78\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe number of emboli varies greatly, from a single metastatic tumor\\nto thousands of nodules. In some very malignant forms of carcinoma\\nand sarcoma the nodules are so numerous that the appearance of the\\nFig. 29. Medullary nodules in the course of an artery of the great omentum following a primary carcinoma\\nof the right tonsil (after Liicke).\\ninternal organs resembles very closely that of miliary tuberculosis.\\nMetastasis occasionally takes place in the aged who have been the sub-\\njects of latent carcinoma for years. In some instances the patients\\nwere not aware of the existence of the primary tumor until the pres-\\nence of a large and destructive metastatic tumor gave occasion to\\nconsult a physician. Sarcoma gives rise to general infection more\\nconstantly and at an earlier date than does carcinoma. Small-celled\\nsarcoma is more frequently followed by early and diffuse general dis-\\nsemination than are large-celled tumors.\\nFrequency of Recurrence after Extirpation.\u00e2\u0080\u0094 It has been shown\\nthat the recurrence of a benign tumor is always local, and is invariably\\nthe result of incomplete removal of the tumor. The recurrence after\\nthe removal of a malignant tumor is either local or metastatic in the\\nformer instance caused by incomplete removal of the primary tumor,\\nand in the latter instance a sad reminder that the operation was not\\nperformed early enough to protect the patient against general infection,", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0096.jp2"}, "93": {"fulltext": "BENIGN AND MALIGNANT TUMORS. 79\\nThe most competent surgeons are willing to admit that so far the best\\nresults of operations for malignant disease have not yielded more than\\nabout 15 to 25 per cent, of permanent recoveries. If we recollect how\\na malignant tumor reaches out in all directions into tissue which to the\\nnaked eye presents every indication of being normal, we can readily\\nunderstand why local relapse should follow so frequently even after\\nwhat seemed a thorough operation. Again, every surgeon has reason\\nto regret that in most cases he is called upon to operate for malignant\\ntumors after the disease has advanced beyond the limits of a successful\\nradical operation. In some instances no local recurrence takes place,\\nbut the operation was performed too late, and the patient succumbs\\nsooner or later to metastatic carcinoma or sarcoma. In such cases\\ngeneral infection had taken place when the operation was performed.\\nA local recurrence may take place from three to seven years after the\\noperation for carcinoma of the breast, as happened in a number of the\\nwriter s cases, and it may be postponed, according to Billroth, twenty\\nyears from the time of operation in cases of sarcoma. Sarcoma usually\\nreturns in the scar; carcinoma, either in the scar or in the adjoining\\nlymphatic glands.\\nIntrinsic Tendency of the Tumor to Destroy Life. If we reflect\\nupon the fact that with the best efforts of the surgeon only 15, and at\\nbest only 25, per cent, of all persons suffering from malignant tumors\\nescape a painful and lingering death from their immediate and remote\\neffects, we must admit that the intrinsic tendency of a malignant tumor\\nis to destroy life. The average duration of life of all persons suffering\\nfrom malignant tumors of all kinds and of all parts and organs of the\\nbody, without surgical intervention, is about three years. It is a source\\nof satisfaction to the surgeon to know that life is prolonged by radical\\nattempts to remove malignant tumors, and that in a fair proportion of\\ncases the disease never returns. Life is destroyed by regional or gen-\\neral dissemination involving important organs, by the primary tumor\\ninterfering with the function of an important organ, by hemorrhage, or,\\nlastly, by a progressive chronic sepsis or septico-pysemia caused by\\nan open ulcerating carcinoma or sarcoma. The so-called cachexia\\nwhich appears so constantly some time before the fatal termination\\nis the result of impaired nutrition and of the introduction into the cir-\\nculation from the tumor of toxic substances.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0097.jp2"}, "94": {"fulltext": "VIII. TRANSFORMATION OF BENIGN TUMORS\\nAND POST-NATAL EMBRYONIC TISSUE INTO\\nMALIGNANT TUMORS.\\nThe possibility of the transformation of a benign into a malignant\\ntumor has been asserted by a few and denied by most of the older\\nwriters on surgical pathology. The subject is of great interest to the\\npathologist, and of equal practical importance to the surgeon. Accum-\\nulated clinical observations, since the diagnosis of tumors has been\\nmade more accurate by increased knowledge of their pathology and by\\na more frequent resort to the use of the microscope in the examination\\nof tissue removed for diagnostic purposes and of fresh specimens after\\noperation, have brought more convincing proof of the possibility of\\nsuch an occurrence. As the result of his own observations the writer\\nis convinced not only that such a transformation is possible, but also\\nthat it takes place much more frequently than has heretofore been\\nsupposed. The writer is equally certain that malignant tumors not\\ninfrequently originate from embryonic tissue of post-natal origin.\\nTransformation of Benign into Malignant Tumors. The trans-\\nformation of a benign into a malignant tumor implies a change in the\\nJiistological structure of the cells of the benign tumor as zvcll as a change\\nin its environments. We have seen that the cells of which benign\\ntumors are composed resemble the normal cells of the part or organ\\nin which the tumor is located. In a myofibroma of the uterus the cells\\nresemble the connective tissue and the unstriped muscle-cells in the\\nuterine wall in which the tumor is located. The epithelial cells in an\\nadenoma of the breast cannot be distinguished from the epithelium of\\nthe acini and tubules of the mammaiy gland. The transformation\\ndepends, therefore, upon influences which accomplish such a change\\nfrom mature into embryonic cells. At the same time, and probably\\nfrom the same causes, the physiological resistance of the adjoining\\ntissues is diminished.\\nThe liability of benign tumors to become malignant is of interest\\nnot only as a subject of pathological study, but also in relation to an\\nopinion which is often made an argument for operations namely, that\\nif a tumor of any kind is left to pursue its own course, it is not unlikely\\nto become malignant. This belief, which is entertained by the general\\n80", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0098.jp2"}, "95": {"fulltext": "TRANSFORMATION OF TUMORS. 8 1\\nmass of the people, is a strong inducement for patients suffering from\\nbenign tumors to submit themselves to a timely operation. This pop-\\nular belief should be strengthened, not undermined, by the medical\\nprofession, as by doing so the patient s mind is relieved and all liability\\nto malignant disease from malignant tumors is removed, and this in-\\nformation and consolation should be imparted to the patient. Lebert\\nstates that he has twice met with tumors which were first benign, but\\nafterward became cancerous.\\nPirogoff relates three cases in which the removal of angioma was\\nfollowed by sarcoma at or near the seat of operation.\\nBenjamin Brodie relates a case in which he removed a tumor the\\ngeneral mass of which appeared to be fatty substance somewhat more\\ncondensed than usual, but here and there was another kind of morbid\\ngrowth, apparently belonging to the class of medullary or fungoid\\ndisease.\\nLebert and Benjamin Brodie reported each a case of unquestionable\\ntransformation of a benign into a malignant tumor. A few other\\nisolated cases are recorded, but such serious doubt was entertained\\nconcerning this matter that at the time Sir James Paget published his\\nLecttcres on Surgical Pathology (1870) he expressed himself in a very\\nguarded way on this subject It need not be denied that cancerous\\ngrowths may occur in tumors that were previously of an innocent kind,\\nbut I feel quite sure that these may be regarded as events of the\\ngreatest rarity. He believes that such transitional tumors were malig-\\nnant from the very beginning, and that the benignant stage simply\\nindicated latency of a carcinomatous growth. The occurrence of a\\ncarcinoma in a scar following an operation for the removal of a benign\\ngrowth he attributes to the trauma acting on the tissues and furnishing\\nthe necessary stimulus to the development of a carcinoma in persons\\nso predisposed by heredity.\\nSince Paget wrote on this subject numerous cases have been recorded\\nin which at the operation such mixed tumors were found, and in which\\ncases there could have been no doubt of the benign nature of the\\nprimary tumor. An interesting case of this kind came under the\\nwriter s observation. The patient was a married woman fifty-two years\\nof age, the mother of several children. For at least ten years she\\nsuffered from a pelvic difficulty which six years ago was diagnosed as\\nmyofibroma of the uterus. Since that time she has suffered from pro-\\nfuse menstruation. Examination disclosed a smooth tumor occupying\\nthe middle of the lower part of the abdominal cavity and reaching as\\nfar as the umbilicus. On vaginal examination the lower segment oi\\nthe uterus was found high up and was affected by the movements o(", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0099.jp2"}, "96": {"fulltext": "82\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nf\\n\u00e2\u0096\u00a0\u00e2\u0096\u00a0b-i\\nhit:\\n\u00e2\u0096\u00a0HHIIffi\\nFig. 30. Myofibroma uteri X I 5o\u00c2\u00bb\\n1\\n.4\\nwmM\\nFig. 31. Sarcoma which started in a myofibroma uteri transformation of a myofibroma into sarcoma X 485.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0102.jp2"}, "97": {"fulltext": "TRANSFORMATION OF TUMORS. 83\\nthe tumor. The absence of metrorrhagia and the clinical history spoke\\nin favor of the diagnosis previously made. On opening the abdomen\\nthere was found what appeared to be a large myofibroma of the uterus\\nspringing from the fundus between the cornua. The immobility of the\\npelvic part of the tumor induced the writer to make a more thorough\\nexamination, which revealed extension of the tumor-mass from the uterus\\nto the broad ligament on the right side. The operation proved to be a\\nvery difficult one. The entire uterus, with the pelvic mass on the right\\nside, was removed. An examination of the specimen showed an intersti-\\ntial myofibroma, the lower segment soft and continuous with the extra-\\nuterine part of the tumor. Microscopic examination of the upper, dense\\npart of the tumor showed the characteristic structure of a myofibroma\\n(Fig. 30), while sections from the lower part of the tumor, the infil-\\ntrated uterine wall, and the extra-uterine part of the tumor presented\\nthe typical picture of round-celled and spindle-celled sarcoma (Fig. 31).\\nThere could be no doubt in this case that the myofibroma had existed\\nfor at least ten years, and, as the sarcoma constituted a part of the\\ntumor, it was evident that it occupied that part of the tumor which had\\nundergone transformation from a benign into a malignant tumor. The\\nsarcomatous degeneration did not remain limited to the tumor in which\\nit had its origin, but extended to the uterus, and from here to the tis-\\nsues outside of it, but in connection with it. The writer has seen in the\\naged a number of instances in which papilloma assumed active growth\\nafter having been in existence for twenty or more years, and manifest\\nclinical evidences of their transition from benign into malignant tumors\\nhe has also witnessed the development of the most malignant form of\\nsarcoma in a small fibroma of the skin that had existed as a benign\\ntumor for years. The origin of sarcoma from pigmented moles is of\\ncommon occurrence and is generally recognized. In other cases the\\nnaevus pigmentosus is transformed into carcinoma. If the mole under-\\ngoes this transition, the principal seat of the carcinoma is in the super-\\nficial layer of the cutis and the rete mucosum, the altered cell-prolifera-\\ntion being limited to the epiblastic structures of the mole.\\nThe exciting causes in effecting a transition of a benign into a malig-\\nnant tumor are such local and general influences as transform mature\\ncells into embryonic cells, and which at the same time render the sur-\\nrounding tissues more passive to cell-infiltration. Among the local\\ncauses may be enumerated injury, prolonged or repeated irritation, and\\nincomplete removal of the benign tumor by excision or by cauterization.\\nThe writer regards the incomplete removal of a benign growth by the\\napplication of caustics as one of the most fruitful sources in the trans-\\nformation of a benign into a malignant tumor. Papilloma and fibroma", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0103.jp2"}, "98": {"fulltext": "84 PATHOLOGY AND TREATMENT OF TUMORS.\\nof the skin in localities exposed to friction by the clothing, the sus-\\npenders, etc. are liable to undergo such a transition. The incomplete\\nremoval of a myxoma of the nasal cavities by ecraseur, forceps, or paren-\\nchymatous injections, if these procedures are frequently repeated, is very\\nliable to give rise to sarcomatous degeneration of the growth. The\\nsenile state appears to exert a general influence which favors the change\\nof an innocent into a malignant tumor. Malignant tumors starting from\\na benign tumor are met with most frequently in persons advanced in\\nyears who were the subjects of benign tumors for from ten to thirty\\nyears, and the clinical history usually points to agencies enumerated\\nabove which have brought about this transition.\\nTransformation of Embryonic Tissue of Post-natal Origin into\\nMalignant Tumors. Cohnheim s theory of the origin of tumors is\\nnot applicable to tumors originating in the products of a chronic in-\\nflammation or in scar-tissue. The writer has for years maintained\\nthat embryonic tissue of post-natal origin may in the production of\\ntumors serve the same purpose as Cohnheim s congenital matrix.\\nIt is not difficult to understand that embryonic cells, during the pro-\\ncess of regeneration after inflammation or in the healing of a wound\\nor a fracture, may fail to undergo evolution into so complete a state\\nof perfection as the maternal cells which produced them, and that\\nsuch cells are set aside, and remain in the tissues in a latent condition\\nin a manner similar to that claimed by Cohnheim for his congenital\\nmatrix of embryonic cells. The exciting causes which stimulate such\\na matrix to tissue-proliferation are of the same nature as those de-\\nscribed in the section on the Etiology of Tumors. The kind of tumor\\nproduced by such a matrix will correspond to the type of tissue from\\nwhich the matrix was derived. Epithelial cells buried in a scar will\\nproduce an epithelioma. In the healing of a burn some of the new\\nepithelial cells which are derived from the epiblast and which are not\\nutilized in the process of epidermization become buried in the scar-\\ntissue, remain in an immature state, and not infrequently become later\\nthe starting-point of an epithelioma. Every surgeon knows that car-\\ncinoma not infrequently develops in scar-tissue. Such an origin of\\ncarcinoma is not limited to the surface of the body. Gynecologists\\nhave claimed for many years that carcinoma of the cervix of the uterus\\nis very prone to develop in the scar-tissue produced by extensive\\nlaceration of the cervix during labor. The embryonic cells upon which\\ndepends callus-production, when for some reason, local or general, they\\nfail to develop into mature tissue, not infrequently constitute the matrix\\nof tumor-formation, and instead of a normal callus a sarcoma is pro-\\nduced. Not long ago the writer observed an interesting case of this", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0104.jp2"}, "99": {"fulltext": "TRANSFORMATION OF TUMORS. 85\\nkind A man fifty years of age, apparently in perfect health, riding\\non horseback through a woods, struck his right shoulder against a\\ntree. He was unable to use his arm after the injury. The physician\\nwho examined the case pronounced the injury a fracture of the surgical\\nneck of the humerus. The fracture was treated in the customary man-\\nner. Three months later, another physician gave it as his opinion that\\nthe original injury consisted of a dislocation of the shoulder-joint for-\\nward and fracture cf the upper part of the humerus. Six months\\nafter the injury the patient entered St. Joseph s Hospital, Chicago.\\nThe patient was unable to use the arm. The upper part of the\\nhumerus was surrounded by a swelling which in the subcoracoid\\nregion presented on palpation distinct fluctuation. About the centre\\nof the swelling an additional point of motion indicated that the fracture\\nhad not united. Exploratory puncture of the tumor at a point corre-\\nsponding to the fluctuating area yielded blood and a few minute frag-\\nments of tissue resembling in their naked-eye appearances granulation-\\ntissue. The patient complained of a great deal of pain in the tumor,\\nextending in the direction of the shaft of the humerus. As the pain\\nwas greatly aggravated during the night, the patient was placed, on\\ngram doses of potassic iodide with mercurial inunctions over the\\nswelling. This treatment was continued for nearly two months with-\\nout making any impression on the subjective symptoms or on the size\\nof the tumor. Amputation through the shoulder-joint was made. The\\nupper five inches of the humerus was found almost completely de-\\nstroyed by a central myeloid sarcoma which had evidently started at\\nthe seat of the fracture. The cartilage of the humerus was completely\\ndetached by the tumor-mass, and the disease had reached the capsule\\nof the joint, which was carefully dissected away. The patient does not\\nrecollect having suffered any pain or impairment of function of the arm\\nprior to the injury; hence it is safe to assume that the sarcoma devel-\\noped, in consequence of the injury, from the embryonic tissue, which\\nwas arrested in its development into mature tissue by unknown local\\nor general influences.\\nMaas illustrates the influence of traumatism in effecting transition\\nfrom a benign into a malignant tumor by reporting the case of a med-\\nical student who had at the inner termination of the eyebrow an ordinary\\nsmall congenital angioma which was injured by a sabre-cut in a duel.\\nWithin two years a racemose aneurysm developed in the scar. Maas\\nconcludes that trauma can result in the formation of a tumor if the\\nessential embryonal matrix is present at the site of injury. We have\\nseen that a trauma acts as an exciting cause in provoking active tissue-\\nproliferation from a latent matrix of congenital embryonic cells, but", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0105.jp2"}, "100": {"fulltext": "86 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe case of Maas just quoted admits of another and more satisfactory-\\nexplanation. In the repair of the vessel-wounds inflicted by the sabre-\\ncut the angioblasts must necessarily have taken an active part. In the\\nevent of the new cells failing to undergo the necessary developmental\\nstages requisite in the ideal healing of an injured part, they would,\\naccording to our position, become available as tumor-forming elements,\\nand their histogenetic origin would determine the production of a vas-\\ncular tumor of more active tendencies than the primary tumor. The\\nwriter therefore believes that the trauma, instead of acting only as an\\nexciting cause, in this case furnished also the necessary tumor-matrix.\\nThe relationship of irritation to tumor-formation has recently increased\\nin prominence. As is well known, the psoriasis lingualis, laryngis, na-\\nsalis, and praeputialis, and the seborrhcea senilis of Richard Volkmann,\\nhave engaged, and still engage, very considerable attention. Schuchardt\\nin 1885, Rudolph Volkmann in 1889, and others have brought together\\na veiy considerable number of surface tumors which were preceded by\\nlong-standing sources of irritation and inflammation, such as, for ex-\\nample, those originating from soot-sifting, tar- and paraffin-working,\\nchronic sinuses, and lupoid and syphilitic ulceration. Cases in which\\nthere existed a combination between syphilis and carcinoma have been\\nreported by Lang and Doutrelepont. In 1859, O. Weber showed the\\netiological relations of lupus to carcinoma, and cases substantiating the\\ncorrectness of his observations were reported later by von Esmarch,\\nHebra, Lang, and others. Neisser reminds us that one ought not to\\nforget that complications of carcinoma and lupus occur, and in these\\ncases, owing to lack of resistance, in part, of the lupus tissue against the\\nencroaching cancer papillae, it is advisable to adopt early therapeutic\\nmeasures. Lesser commits himself on this subject as follows: Occa-\\nsionally pathological changes in tissue are the seat of epithelial carcino-\\nmata which are in no way directly responsible for the origin of tumors,\\nsuch as ulcers of the leg, syphilitic ulcerations, lupus, etc. E. Friend\\nof Chicago, under the tutorship of Kaposi made a very careful study\\nof the microscopic picture of tissue representing a combination of lupus\\nand carcinoma. Friend saw three cases of lupus vulgaris of the face\\ncomplicated by carcinoma in Kaposi s clinic (Fig. 32). The probabilities\\nare that the atypical proliferation of the epithelial cells in the inflamed\\ntissues, and the diminished physiological resistance of the tissues in their\\nimmediate vicinity, are the important factors in the production of carci-\\nnoma in lupoid tissue as well as in other pathological conditions represent-\\ning embryonic epithelial cells with a similar environment. The writer has\\nseen a number of instances in which a carcinoma developed on the sur-\\nface of a chronic ulcer of the leg. In such cases the islets of embryonic", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0106.jp2"}, "101": {"fulltext": "TRANSFORMATION OF TUMORS.\\n87\\nepithelial cells become the starting-point of a carcinoma when the causes\\nwhich maintain the ulceration have succeeded in diminishing the physio-\\nlogical resistance of the tissues in their vicinity sufficiently to permit the\\n1\\nFig 32 -Carcinoma in lupoid tissue (after Friend). Isolated tissue-masses, called by Leloir lupoma,\\nl. e irregularly and at different depths in the corium. Upper and papillary layer and rete Malpighi. appear\\nnormal. Below and interspersed in these nodules are round and elliptical bodies with nests of epitheual cells.\\nSection from lupus vulgaris of face complicated by carcinoma. (Zeiss, A., ocular No. 3.)\\nembryonic epithelial cells to migrate into the surrounding tissues. We\\nmust therefore admit that the transformation of a benign growth and of\\na matrix of embryonic cells of post-natal origin into a malignant tumor\\nis not only possible but probable when the embryonic cells, under the influ-\\nences of local or general causes, assume active tissue-proliferation, and\\ntheir migration is permitted by a diminished physiological resistance on\\nthe part of the adjacent tissues.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0107.jp2"}, "102": {"fulltext": "IX. DIAGNOSIS OF TUMORS.\\nThe diagnosis of tumors is a science and an art a science, because\\nthe accurate anatomical localization of a tumor and the correct appre-\\nciation of its character and tendencies presuppose a thorough knowledge\\nof anatomy, physiology, and pathology an art, because the determina-\\ntion of the exact location and character of a tumor often requires deli-\\ncate manipulation and the most intelligent application of all known\\ndiagnostic resources. The accurate eye and the trained sense of touch,\\nthe tactus crudities, are always at hand, and, as a rule, can be more relied\\nupon than can the use of complicated instruments in ascertaining the\\nlocation, extent, and pathological characteristics of a tumor. Prac-\\ntical instruction at the bedside and examination of patients under super-\\nvision of the teacher will accomplish more in rendering the student\\nfamiliar with the means of diagnosis than will the most painstaking-\\ndidactic teaching. An abundance of clinical material and thorough\\nand systematic examination by the students of the cases presented are\\nabsolutely necessary in acquiring the necessary diagnostic skill. The\\nwriter knows of no department of surgery more difficult to teach and\\nto comprehend. The interest of the student can be awakened and his\\nsenses be trained properly only by bringing him in contact with patients\\nand by encouraging him in making thorough and systematic examina-\\ntions. Oncology is usually imperfectly taught in our medical colleges\\nthis fact will go far in explaining the lack of interest of our students\\nin this, to them, perplexing subject.\\nClinical History. In each case of suspected tumor the clinical\\nhistory should be investigated carefully. A failure to carry out prop-\\nerly this, the initial, part of the diagnostic work has led many a distin-\\nguished surgeon astray in making a distinction between an inflamma-\\ntory swelling and a tumor. Every surgeon inquires almost instinctively\\ninto heredity as a possible factor in the production of a tumor. It is\\nnot only necessary to ascertain the existence of an hereditary influence\\nin the parents, but the investigation must be carried farther back, as we\\nhave seen that this element may not assert itself in the offspring, but\\nmay appear again in the second, third, or fourth generation. It is also\\nnecessary to determine the existence of heredity in more distant mem-\\nbers of the family uncles, aunts, cousins, and nephews as heredity\\n88", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0108.jp2"}, "103": {"fulltext": "DIAGNOSIS OF TUMORS. 89\\ndoes not descend on all members of a family in the same degree, as is\\nshown by the statistics quoted on this subject. The existence of tumors\\nin different members of the family and in related families of two or more\\ngenerations should be noted in estimating heredity as a possible etio-\\nlogical factor.\\nLength of Time Tumor has Existed. This part of the clinical\\nhistory is often indefinite and misleading. A tumor has often existed\\nfor years before being accidentally discovered by the patient or the phy-\\nsician. Patients generally fix as the date when the tumor appeared\\nthe time when it was accidentally discovered. By relying on the pa-\\ntient s statement in regard to the time the tumor commenced the sur-\\ngeon is liable to mistake a benign tumor for a malignant tumor or an\\ninflammatory affection. Due allowance must therefore be made in ref-\\nerence to the statements made by patients or their friends as to the\\nlength of time a tumor has existed.\\nLocation of Tumor. In eliciting from the patient the clinical his-\\ntory it is very important to ascertain from him, so far as possible, the\\nexact location of the tumor when it was first noticed. The student\\nshould be made to appreciate the importance of the questions put to\\nthe patient to elicit this part of the clinical history. In investigating\\nthe probable starting-point of a large abdominal tumor it is quite im-\\nportant for us to ascertain from the patient whether the tumor was first\\nnoticed above the pelvis or about the pelvic brim, and on which side.\\nIn a rapidly-growing ulcerating tumor of the neck the patient s state-\\nments will often render material aid in making a differential diagnosis\\nbetween secondary glandular carcinoma and lympho-sarcoma. In the\\nabsence of an appreciable source of carcinomatous infection the patient,\\nupon questioning him properly, will probably make the statement that\\nthe first thing he noticed was a movable, painless tumor under the skin.\\nThis information alone from an intelligent patient will exclude a surface\\ncarcinoma. An epiblastic surface tumor commences in the skin, and\\nthe patient s statement will often impart valuable information in dif-\\nferentiating between an ulcerating malignant tumor of the epiblast and\\none of the mesoblast. The relation of the skin or the mucous membrane\\nto the tumor in its early stages must be ascertained from the patient for\\nthe purpose of enabling the surgeon to connect the tumor with its matrix\\nderived from the different germinal layers, in all cases in which any doubt\\nremains as to the histogenetic source of the tumor.\\nRapidity of Growth of Tumor. The rapidity with which a tumor\\nhas increased in size should be taken carefully into account in the dif-\\nferential diagnosis between a tumor and an inflammatory swelling and\\nbetween a benign and a malignant tumor. We know how unreliable", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0109.jp2"}, "104": {"fulltext": "90 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe statements of patients are in ascertaining the previous clinical course\\nof a tumor. The patient must be requested to compare the size of the\\ntumor when first discovered with objects familiar to him, such as a\\nhempseed, a pea, a bean, a hazelnut, a walnut, a hen s egg, a plum,\\nan apple, an orange, a cocoanut, a child s head, an adult s head, etc.\\nBy comparing the size of the tumor when first discovered with its present\\nsize and estimating the time that has elapsed we are in possession of facts\\nwhich enable us to judge, at least in an approximately correct way, the\\nrapidity of growth of the tumor. As a rule, a benign tumor grows slowly,\\na malignant tumor rapidly the clinical behavior of a tumor is titer ef ore\\nvery important in making a differential diagnosis betzveen benign and\\nmalignant growtlis.\\nPain. Spontaneous pain was regarded for a long time as one of\\nthe most distinctive clinical witnesses of carcinoma as compared with\\nbenign growths. The idea that carcinoma is an exceedingly painful,\\ntorturing disease is deeply rooted among the people of all nations.\\nA peculiar lancinating, paroxysmal pain with nocturnal exacerbations\\nhas been described since the time of Hippocrates as characteristic of\\ncarcinoma. Physicians and surgeons have placed too much stress upon\\nthe diagnostic value of this symptom. A lancinating pain at variable\\nintervals and only of a moment s duration is described by many patients\\nsuffering from carcinoma of the breast and epithelioma of the lip, but\\nis by no means a constant symptom. The writer is sure that clinical\\nobservations will bear him out in making the statement that adenoma\\nof the breast causes more suffeidng than does carcinoma of the same\\norgaji and of the same size. He has known of numerous cases of car-\\ncinoma of internal organs in which the disease was painless from the\\nbeginning to the end. Sarcoma, as a rule, causes less pain than car-\\ncinoma. Benign tumors, with the exception of tumors of the nerves\\nor of their sheaths, produce pain only when, from their location or their\\nsize, they cause compression of a sensitive nerve. A small osteoma in\\nthe bony canal through which pass certain sensitive nerves will occasion\\nexcruciating pain, while a lipoma in the panniculus adiposus, of immense\\nsize and meeting with no resistance to its outward growth, will remain\\na painless affection throughout life.\\nTenderness. The pain produced by pressure results from com-\\npression of a sensitive nerve subjected to the pressure. Tumors of\\nthe nerves or of the nerve-sheaths most frequently give rise to pain\\non pressure. The subcutaneous painful tubercle is well known as the\\nmost sensitive tumor. Tumors of the nerve-sheaths of the terminal\\nnerves in the subcutaneous tissue, described by Recklinghausen, are\\nnot painful on pressure, owing to the looseness of the structures in", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0110.jp2"}, "105": {"fulltext": "DIAGNOSIS OF TUMORS.\\n91\\ntheir immediate vicinity. Tenderness in carcinoma and sarcoma depends\\neither on some unusual relation of the tumor to sensitive nerves or to\\nthe existence of complications, as pain is absent in the majority of cases\\nof uncomplicated malignant tumors. Tenderness is an exceedingly im-\\nportant symptom in differentiating between a tumor and a7i inflammatory\\nswelling, being usually absent in the former, and almost invariably pres-\\nent to a greater or less extent in the latter.\\nExamination of the Patient. The surgeon who limits his examina-\\ntion to the tumor does not do his duty to his patient, and is very liable to\\ncommit mistakes in diagnosis, prognosis, and treatment. A correct diag-\\nnosis implies more than a mere classification of the tumor for which\\nthe patient seeks relief: it includes a careful inquiry into the condition\\nof every important organ, the elucidation of the exact pathological\\nconditions in the tumor itself, and a careful investigation of its environ-\\nment. A correct diagnosis should furnish all the clinical and patho-\\nlogical data required to guide the surgeon in rendering a reliable\\nprognosis and in adopting a safe and judicious course of treatment.\\nSpecialists in surgery are very apt to overlook the importance of a\\nthorough and unprejudiced examination of the patient as the first step\\nin seeking reliable evidence upon which to build a correct diagnosis.\\nA careful examination of the clinical history of the case in reference to\\nthe possibility of the existence\\nof syphilitic infection should j*\\nnever be neglected. Sarcoma\\nand syphiloma have often been\\nconfounded, to the great detri-\\nment of the patients and almost\\nchagrin of the attending physi-\\ncian. If there is any doubt as\\nto the differential diagnosis be-\\ntween a tumor and a gumma,\\nthe patient should be given the\\nbenefit of the doubt by subject-\\ning him to a vigorous antisyph-\\nilitic treatment for several weeks.\\nVon Esmarch made recently the\\nstatement that more than forty\\ncases of supposed sarcomatous\\ntumors were sent to him for oper-\\native treatment, which yielded to\\nthe inunction treatment and the internal use of potassic iodide\\nf\\ni\\nk\\nv-~\u00e2\u0080\u0094 i\\nFig. 33. Syphiloma (after von Esmarch).\\nthe case shown in Fig. 33 five operations were performed,\\nIn\\nith", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0111.jp2"}, "106": {"fulltext": "92 PATHOLOGY AND TREATMENT OF TUMORS.\\nspeedy relapse after each. Sprinkling the ulcerated surface daily\\nwith potassic iodide resulted in marked improvement, and later a\\npermanent cure was effected by mercurial inunctions. The age\\nof the patient is of some importance in determining the probable\\ncharacter of the tumor, as it has been shown that benign tumors\\nare met with most frequently in persons not past middle life, while\\nmalignant tumors, on the whole, attack persons advanced in years. In\\nthis respect sarcoma constitutes frequently an exception, as it exempts\\nno age, being sometimes found in children less than ten years of age, as\\nwell as in persons far advanced in years. It must not be forgotten, how-\\never, that carcinoma occasionally is met with in young persons. The\\nwriter has seen carcinoma of the rectum in a boy eighteen years of age,\\ncarcinoma of the stomach in a man twenty-seven years old, carcinoma\\nof the breast in a female aged thirty, and carcinoma of the lip in a man\\nthirty-five years old. Sex, as we have seen, predisposes to tumors, both\\nbenign and malignant, of special organs. This can also be said of\\ncertain occupations. The general appearance of the patient often\\nenables the experienced surgeon at first sight to make a probable\\ndiagnosis between a benign and a malignant tumor. The wasting of\\nthe subcutaneous adipose tissue and the sallow complexion of the face\\nare familiar to the surgeon as indicating far-advanced malignant disease.\\nCEdema about the ankles and over the sternum is an indication pointing\\nin the same direction. Occasional hemorrhages from different organs,\\nas the kidneys, the bladder, the vagina, and the rectum, frequently call\\nthe attention of the surgeon to these organs as the probable seat of a\\nmalignant tumor. Mechanical obstruction in the different hollow vis-\\ncera in persons past middle life is caused more frequently by malignant\\ntumors than by all other causes combined. Functional disturbances of\\nall kinds must be investigated carefully and traced to the primary cause.\\nNeuralgic pain caused by tumor-pressure will often lead to the detec-\\ntion of the tumor. Obstruction to the venous circulation, if studied\\nwith the same object in view, will frequently reward the surgeon with\\na similar result. To show the importance of a careful and painstaking\\nexamination of the patient before venturing a diagnosis based upon a few\\nprobably unimportant local evidences, attention will be called to a few\\nconditions which frequently present themselves to the surgeon. Let\\nus suppose a patient presents himself suffering from a sarcoma of the\\nintermuscular fascia of the forearm. The tumor has attained the size\\nof a cocoanut, is movable, and has no connection with the overlying\\nskin. The patient s general health is not materially impaired. The\\nrapidity of the growth of the tumor, its shape, and its consistence\\nrender the diagnosis of sarcoma more than probable. The surgeon", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0112.jp2"}, "107": {"fulltext": "DIAGNOSIS OF TUMORS. 93\\nhas determined in his own mind that an amputation affords the only\\nchance to effect a radical operation with a view of preventing a recur-\\nrence in the future. Before informing the patient of his intentions he\\ntakes the necessary pains to look for contraindications. On further\\nexamination he finds a slight convergent strabismus, the liver enlarged\\nand nodular, and traces of albumen in the urine. The result of this\\nadditional examination has satisfied him that operative interference of\\nany kind is positively contraindicated, as general dissemination has\\nalready taken place, important organs being implicated. The exam-\\nination into the condition of the important organs has been the means\\nof saving the patient the pain, anxiety, and risks to life incident to a\\nuseless operation, and has prevented the infliction of additional reproach\\nupon modern surgery.\\nLet us suppose another case A patient advanced in years presents\\nhimself with a lipoma over the shoulder which has given him but little\\ninconvenience, but which he is anxious to have removed. As the\\npatient s general health, upon superficial examination, does not appear\\nto be impaired, the surgeon responds to the request of the patient.\\nThe patient is anesthetized and the tumor is removed. Suppression\\nof urine follows the operation. The patient is seized with uremic con-\\nvulsions and dies comatose. A post-mortem examination reveals the\\nexistence of a chronic interstitial nephritis. A careful examination of\\nthe urine would have furnished a positive contraindication to an opera-\\ntion, and would have been the means of preventing a premature death\\nfrom the immediate effects of the anesthetic.\\nIn calling special attention to the importance of searching for con-\\ntraindications to radical operations for carcinoma another hypothetical\\ncase will be alluded to A woman about middle life presents herself\\nfor the removal of a carcinomatous breast. The disease in the organ\\nprimarily affected has advanced to such an extent that the breast is\\nfirmly attached to the chest- wall infiltration of the axillary glands is\\nmoderate the patient s general health is not much impaired. She is in\\nthe hands of a careful, conscientious surgeon. The breathing attracts\\nhis attention it is short and frequent. He makes a careful physical\\nexamination of the chest, and finds a copious effusion in the pleural\\ncavity on the side corresponding with the diseased breast. If he had\\nany intention whatever to advise operative interference, this will soon\\nbe abandoned, as he has satisfied himself that the disease is beyond the\\nreach of an operation, as shown by the existence of a hydrothorax\\ncaused by extension of the disease through the chest-wall to the\\nparietal pleura.\\nThe hypothetical cases cited do not represent imaginary complica-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0113.jp2"}, "108": {"fulltext": "94 PATHOLOGY AND TREATMENT OF TUMORS.\\ntions, but illustrate many similar cases which the surgeon is called\\nupon to examine and treat, and they speak for themselves in showing\\nthe importance of subjecting tumor-patients to a thorough examination.\\nExamination of the Tumor. The examination of a tumor should\\nbe made in a systematic manner. Much information can be gained by\\nthe intelligent use of the sense of sight. Ocular examination is ex-\\ntended by the use of the ophthalmoscope, the otoscope, the rhino-\\nscope, the laryngoscope, the urethroscope, the cystoscope, and by the\\nemployment of different specula in the examination of tumors in local-\\nities inaccessible to inspection without the aid of these instruments.\\nInspection enables the surgeon in the examination to gain information\\nconcerning (i) color, (2) size, (3) form and structure of surface, (4) loca-\\ntion, and (5) transmission of light.\\nColor. The color alone often distinguishes the character and struct-\\nure of the tumor. In angioma of surfaces accessible to inspection the\\ncolor of the tumor will enable the surgeon to distinguish between the\\nvenous and the arterial variety. The venous angioma resembles in its\\ncolor venous blood the arterial angioma, that of arterial blood. The\\npigmentation of a sarcoma or a carcinoma distinguishes these most\\nmalignant of all tumors from the other varieties of malignant tumors.\\nDiscoloration of the surface of a tumor is also caused by interstitial\\nhemorrhage and by inflammation.\\nSize. The size of a tumor is significant to the surgeon, because\\ncertain tumors never exceed a definite size. Neuromata and osteomata\\nnever reach large size. They grow slowly, and when they attain the\\nmaximum size they remain stationary throughout life. Very important\\nfrom a diagnostic standpoint is a sudden variation in size. This is\\nobserved in vascular tumors, which under the influence of certain\\nagencies that cause intravascular tension increase in size and become\\nfirmer. A naevus in a child becomes more prominent and tense\\nduring the act of crying. The volume of a large venous tumor is often\\nmaterially affected by respiration, the size increasing during expiration\\nand diminishing during inspiration. In following the clinical history of\\na tumor careful measurements should be taken and recorded from time\\nto time. The eye should not be relied upon in ascertaining the increase\\nin size of a tumor. Fixed anatomical landmarks are readily available\\nguides in following the extension of a tumor toward its vicinity by\\nrecording at fixed intervals the measured distance between them and\\nthe margin of the tumor. When the measurements are taken the\\npatient and the part to be examined should always be placed in the\\nsame position.\\nForm and Structure of Surface. The shape of a tumor can often", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0114.jp2"}, "109": {"fulltext": "DIAGNOSIS OF TUMORS. 95\\nbe outlined by inspection, and if the tumor is sufficiently near the sur-\\nface, any irregularities in its contour can be recognized at the same time.\\nThe shape of the tumor is determined largely by the structure of the\\nmother-soil, the anatomical locality, and the resistance offered by the\\nsurrounding structures to the extension of the growth. Equal resist-\\nance on all sides determines a globular shape later, pressure results in\\nelongation of the tumor absence of resistance on one side gives rise\\nto a growth in that direction, followed by constriction at the base of the\\ntumor and by pedunculation. Central tumors of bone usually assume\\nthe shape of a spindle. A nodular surface is often presented by carci-\\nnoma, but it is also found in all tumors which have perforated organs\\nand tissues and grow free in all directions. The most malignant forms\\nof carcinoma and sarcoma have a smooth surface, owing to the predomi-\\nnance of their cellular elements over the stroma. Nodular projections\\nin carcinoma as well as in other tumors are produced by contraction of\\nthe stroma as well as by unequal resistance offered by the surrounding\\ntissues. Ulceration on the surface of a tumor represents from an\\netiological standpoint different things Superficial excoriations are\\nusually the outcome of purely local accidental causes, such as trauma\\nor the application of irritating remedies, and commonly heal upon the\\nremoval of the cause ulcerated surfaces occupied by a fungous mass\\nindicate the existence of a rapidly-growing tumor extensive ulceration\\ndevoid of massive fungous granulations point to the existence of a less\\nrapidly-growing tumor while deep, and especially crater-like, excava-\\ntions are indicative of speedy destruction of the central mass of the\\ntumor. Of special pathological interest is the character of the floor\\nof the ulcer whether it is clean or ragged, red, gray, dirty, or gan-\\ngrenous frequently, characteristic parts of the tumor are exposed on\\nthe surface of the ulcer. The secretion of the ulcer is of diagnostic\\nvalue in determining the stage of malignant degeneration and the\\ncharacter of the microbic infection which followed the exposure of the\\ntumor-tissue to the atmospheric air. Suppuration indicates infection\\nwith pyogenic microbes putrefaction of the secretions points to the\\npresence of putrefactive bacilli in the dead tissue attached to the sur-\\nface of the ulcer. Capillary bleeding from the surface of the ulcer is\\nan indication of the destruction of granulations by the tumor-tissue,\\nby pathogenic microbes, or by an injury; more profuse hemorrhage\\nresults from erosion of trie wall of blood-vessels of considerable size.\\nLocation. Ocular inspection often reveals the primary location of\\nthe tumor. A unilateral exophthalmos denotes the presence of a\\nretrobulbar tumor an unusual prominence of one of the cheeks and\\nthe presence of a projecting tumor of the nose on the same side point", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0115.jp2"}, "110": {"fulltext": "g6 PATHOLOGY AND TREATMENT OF TUMORS.\\nto the existence of a tumor of the antrum of Highmore. Inspection\\nis also useful in some cases in determining the character of the tumor\\nas, for instance, in the case of tumors of the lower lip, which tumors,\\nwith few exceptions, are epithelial cancers.\\nTransmission of Light. A tumor with clear liquid contents and\\ntumors composed largely of a colorless intercellular substance transmit\\nlight to a greater or lesser extent, rendering them translucent or trans-\\nparent as, for example, hydrocele of the neck, myxoma of the nasal\\ncavities, etc.\\nTactile Examination. Tactile examination is more important than\\nocular inspection in the examination of a tumor. The value of ocular\\nexamination has been overestimated greatly in the past. In ascertain-\\ning the exact location and extent of a tumor much more diagnostic\\ninformation is gained by the employment of the sense of touch than\\nby inspection with the aid of specula, if the tumor is accessible to\\ndigital examination. The mania on the part of surgeons and instru-\\nment-makers to invent new specula for the exploration of channels and\\ncavities accessible to digital exploration has about subsided, and in its\\nplace efforts are being made to instruct students more efficiently in the\\nuse of the finger in the examination of tumors. The acquirement of\\nthe tactus eruditus requires long and careful training. The student\\nshould be given an opportunity to handle and examine tumors of all\\nkinds, in order to familiarize himself with their structure and physical\\ncharacteristics by the sense of touch. Instruction of this kind will\\nimpart a thorough knowledge of the nature and extent of the degen-\\nerative changes which occur in the parenchyma and stroma of tumors.\\nThe careful digital palpation of the different normal tissues and organs\\nis an exceedingly useful exercise in acquiring a delicate sense of touch.\\nFluctuation can be studied advantageously by palpating a bladder or a\\nrubber bulb distended by water. In the examination of tumors in the\\nliving subject the teacher should inform the student what he is expected\\nto find and to feel before he proceeds to make the digital examination.\\nIf the tumor is large, manual examination takes the place of the digital.\\nIn bimanual examination both hands are employed. Bidigital exami-\\nnation means the use of one finger of each hand in the exploration of\\na tumor or other pathological product. The information gained by\\nmanual and digital examination is often used to corroborate or to\\nrender more accurate what has been learned from inspection. The\\ntactile sense is relied upon in deciding diagnostic points of the greatest\\npractical import to the surgeon, the most important being I. Connec-\\ntion of the tumor with the mother-soil 2. Resistance and consistence\\n3. Pulsation; 4. Tenderness; 5. Crepitation.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0116.jp2"}, "111": {"fulltext": "DIAGNOSIS OF TUMORS. 97\\nConnection of Tumor with the Mother-soil. The kind and extent\\nof the connection of a tumor with the mother-soil have an important\\nbearing on the nature of the tumor and on the selection of appropriate\\noperative measures. The degree of mobility of a tumor and the ease\\nwith which it can be displaced are determined largely by the nature of\\nits connection with the surrounding tissues. The wider the base of a\\ntumor and the more projections it sends out into the surrounding\\ntissues, the more pronounced becomes its immobility and the more\\nlimited the extent to which it can be displaced. If the tumor is attached\\nonly by a pedicle, it is freely movable and can readily be displaced.\\nSuch tumors in the abdominal cavity often become displaced in an\\naxial direction, resulting in twisting of the pedicle. If a tumor is sur-\\nrounded on all sides by resisting tissue, it is held firmly in place and\\ncannot be displaced. The immobility of a carcinoma is due to the\\nmany prolongations which the tumor sends out into the surround-\\ning tissues. A carcinoma is movable if it involves a movable organ\\nbefore the organ becomes attached by the extension of the tumor\\nbeyond the limits of the organ primarily affected. Tumors freely\\nmovable often become firmly attached to the surrounding tissues by\\ninflammatory adhesions following inflammation of the tumor resulting\\nfrom direct infection through an ulcerated surface, from auto-infection,\\nor from infection caused by exploratory puncture or by ineffective treat-\\nment. A branchial cyst is usually attached loosely to the surrounding\\ntissues, and can readily be enucleated, but after ineffectual attempts at\\nradical cure by irritating injections or after incomplete removal by\\nenucleation the whole or a part of the cyst-wall is found firmly attached\\nto important structures, rendering enucleation impossible and the\\nremoval by excision a difficult and dangerous procedure. In deter-\\nmining the mobility of a tumor its base should be grasped firmly, when\\nby moving it in different directions the degree of mobility and the ex-\\ntent of its connection with the mother-soil can be determined. If the\\ntumor is immediately under the skin or under the abdominal wall, the\\nexistence of attachments to the skin can be ascertained by gliding the\\nsuperimposed structures overthe surface of the tumor adhesions between\\nan abdominal tumor and the anterior abdominal wall can be ascertained\\nby observing the respiratory movements of the abdominal wall, or, if the\\ntumor is not too large, by displacing it by changing the position of the\\npatient or by moving it with the hands. The absence of inflammatory\\nadhesions or of neoplastic attachments of a struma to tissues other\\nthan the underlying trachea is demonstrated by the movements\\nimparted to the tumor by the trachea during deglutition. The extent\\nand location of attachments of tumors in some of the cavities for\\n7", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0117.jp2"}, "112": {"fulltext": "98 PATHOLOGY AND TREATMENT OF TUMORS.\\ninstance, the uterine cavity and the nasal passages can often be deter-\\nmined only by a careful use of probes and sounds. It can be laid down\\nas a rule that the more limited are the attachments of a tumor with the\\nsurrounding tissues, the more favorable is the prognosis and the bet-\\nter are the results following its operative removal. In the absence of\\ninflammatory processes, attachment of the tumor to the underlying\\nskin indicates that the tumor is malignant. The lymphatic glands in\\nthe region occupied by a tumor should always be subjected to a careful\\nexamination. Enlargement of the lymphatic glands in the vicinity of\\na tumor must always be regarded with suspicion. A consensual hyper-\\nplasia of the lymphatic glands may occur in consequence of the intro-\\nduction into the lymphatic channels of pathogenic microbes through\\nthe ulcerated surface of a benign tumor. In the absence of a tangible\\ninfection-atrium implication of the regional lymphatic glands, with few\\nexceptions, points to a malignant nature of the tumor. As lymphatic\\ninfection seldom accompanies sarcoma, when this condition exists inde-\\npendently of microbic infection the primary tumor in the great majority\\nof cases is a carcinoma.\\nResistance and Consistence. Resistance and consistence are vari-\\nable qualities of tumors. We seek to ascertain the density of a tumor\\nby fixing its base, and then ascertain its resistance to finger-pressure\\nat different points. To ascertain the density of a deeply-situated tumor\\nor of different parts of the same tumor, Middeldorpf advised the use of\\nacupuncture needles (Fig. 34), and he applied to this diagnostic aid the\\nterm akidopeirasty. The writer has found this diagnostic resource of\\ngreat value in the differential diagnosis of deeply-seated tumors of bone.\\nIf the tumor is an osteoma, the needle will be arrested when it reaches\\nthe surface of the tumor; if it is a periosteal sarcoma, the needle will\\npenetrate the soft parts of the tumor, and with its point plates or\\nspiculae of bone can usually be detected. If it is a central osteo-\\nsarcoma, the needle can be forced by pressure and by rotatory move-\\nments through the atrophic\\ncompact layer of the bone\\nencasing the tumor, after\\nFig. 34.\u00e2\u0080\u0094 Acupuncture needles used in exploring tumors by which it Can be forced\\nopeirasuc. through the soft tumor-mass\\nuntil the opposite side of the bone is reached without meeting with\\nany appreciable resistance. Exploratory puncture for this and other\\npurposes should be done under strictest antiseptic precautions, other-\\nwise puncturing may become the direct cause of infection. The needle,\\nbefore being used, should be sterilized by boiling or by heating it for\\na sufficient length of time in the flame of an alcohol lamp, and the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0118.jp2"}, "113": {"fulltext": "DIAGNOSIS OF TUMORS. 99\\nsurface where the puncture is to be made should be rendered aseptic\\nby thorough washing with warm water and soap, followed by washing\\nwith a strong antiseptic solution. After the removal of the needle the\\npuncture should be sealed hermetically with iodoform collodion. The\\nexistence of cysts in solid tumors can often be determined by the\\nsame method of exploration. Osteoma and chondroma are the benign\\ntumors noted for their density. Fibroma varies greatly in this respect,\\noften being nearly as hard as cartilage, in other instances being as soft\\nas a myxoma. Uterine fibroids present both extremes as to density.\\nA soft fibroma of the uterus usually contains muscle-fibres as the pre-\\ndominating histological element, and is generally much more vascular\\nthan the firm variety, in which we find more fibrous tissue and a less copi-\\nous blood-supply. The density of a malignant tumor is in proportion\\nto its benign tendencies. In soft malignant tumors the parenchyma-cells\\npredominate, the stroma is scanty, and the vascular supply is abundant.\\nThe softness of a malignant tumor is in proportion to its malignancy.\\nThe stroma in such cases is scanty, and the cells are numerous and are\\nendowed with a maximum capacity of tissue-proliferation the new cells\\nfind ready access into the surrounding tissues, hence early and exten-\\nsive infiltration determines rapid growth and early regional and general\\ndissemination. Elastic softness is manifested by many fibrous, fatty,\\nO* and sarcomatous tumors. Owing; to the softness of the tumor-tissue\\nin many cases of very malignant carcinoma and sarcoma, these tumors\\npresent on palpation a sense of fluctuation which is exceedingly decep-\\ntive, and which in many instances has led the surgeon to puncture or\\nincise such tumors under the belief that the swelling contained the\\nproducts of an inflammation. Pseudo-fluctuation is often elicited in the\\nexamination by palpation of benign tumors, notably myxoma and lipo-\\nma. Fluctuation is frequently absent in dense cysts, particularly if the\\ncyst-wall is of unusual thickness.\\nThe existence of a cystic tumor or swelling and the occurrence of\\ncystic degeneration in solid tumors can often be determined only by the\\nuse of an exploratory needle (Fig. 35) or a trocar. The ordinary hypo-\\n4\u00c2\u00bbU\\nFig. 35. Exploratory needle.\\ndermic needle answers an excellent purpose in ascertaining the presence\\nof liquid contents in a cyst. Syringes are, however, very liable to get out\\nof order, and this is more particularly the case on occasions when they", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0119.jp2"}, "114": {"fulltext": "IOO\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nare most needed. Another objection to the use of the hypodermic and\\nthe exploratory syringe is the difficulty experienced in securing and\\nmaintaining them in an aseptic condition and, lastly, it is difficult, if not\\nFig. 36. Senn s exploratory syringe.\\nimpossible, to hold the needle perfectly steady while the piston is with-\\ndrawn in aspirating the contents of the cyst. These objections to the\\nuse of the ordinary syringe in withdrawing the contents of tumors or of\\nswellings apply with special force to exploration of the brain, the peri-\\ncardium, and the pleural cavity. The writer, who has for a long time\\nbeen anxious to do away with the piston as a means of aspiration and\\nin making intra-articular and parenchymatous injections, has succeeded\\nat last in devising an instrument possessing all the merits of the ordi-\\nnary syringe, minus the objections to the piston. This instrument is\\nalso used exclusively in making intra-articular and parenchymatous\\ninjections. The fluid is withdrawn by aspiration performed by a strong\\nrubber bulb in place of a piston, and in making injections the fluid is\\npropelled by a column of elastic air. The remaining part of this\\nsyringe can readily be understood from Figure 36. Some care is neces-\\nsary in preventing serious complications arising from the employment", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0120.jp2"}, "115": {"fulltext": "DIAGNOSIS OF TUMORS. 101\\nof this exceedingly useful diagnostic aid. The usual strictly antiseptic\\nprecautions should never be neglected, as tumor-tissue is very suscep-\\ntible to infection, and in a great many cases the use of the exploring-\\nneedle in the hands of careless practitioners has resulted in serious and\\nfatal complications. The puncture should be made after the skin has\\nbeen withdrawn to one side, so that after the withdrawal of the needle\\nthe puncture in the deep parts will be subcutaneous. Injury to import-\\nant vessels and nerves should be avoided. In puncturing abdominal\\ntumors and swellings the needle should be inserted, if possible, extra-\\nperitoneally if this cannot be done, the puncture in the cyst-wall\\nshould be oblique, so that upon the removal of the needle there will\\nbe less liability of the contents escaping into the peritoneal cavity\\nthrough the puncture. In such cases the needle used should be small.\\nThe removal of a considerable portion of cyst-contents will diminish\\ntension, and thus prevent leakage through the puncture. The explor-\\ning-needle can also be used to ascertain the degree of density of the\\ntissues which it penetrates (akidopeirastic). If the contents of a sus-\\npected cyst fail to escape on making aspiration, the point of the needle\\nis further advanced or withdrawn while aspiration is frequently made\\nuntil the point of the needle is within the cyst. It may also become\\nnecessary to remove the needle and to insert it through the same\\nexternal puncture in different directions before the cyst is reached.\\nThe character of the fluid withdrawn will throw much light upon the\\nnature of the tumor. If no fluid is withdrawn, we often find in the\\nlumen of the needle fragments of tissue, which, when examined under\\nthe microscope, will furnish valuable information in reference to the\\nnature of the tumor. The exploratory syringe is a most valuable, and\\noften an indispensable, instrument in the differentiation between a tumor\\nand an inflammatory swelling.\\nPulsation. Pulsation is felt in certain tumors by placing the palmar\\nsurface of the hand against the tumor. Not all pidsating tumors are\\nvascular tumors. A solid tumor resting against a large artery receives\\nthe impulse from the artery. In such cases the pulsation can be felt only\\nin one direction, away from the artery. A pulsating tumor, angioma,\\nvascular myeloid sarcoma, diminishes in size under pressure, and the\\npulsations are not limited to one direction.\\nTenderness. The causation of pain by finger-pressure over the\\ntumor has already been alluded to as an evidence in the diagnosis of\\na tumor. Tenderness indicates either that the tumor is intimately con-\\nnected with a sensitive nerve or that the tumor has become infected and\\nis the seat of an inflammation. Under ordinary circumstances pressure\\nover a tumor docs not cause pain.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0121.jp2"}, "116": {"fulltext": "102 PATHOLOGY AND TREATMENT OF TUMORS.\\nCrepitation. Palpation of a tumor occasionally elicits a sense of\\ncrepitation. If the crepitation is caused by the presence of chalky\\nmasses or bone, it is rough if the plates of bone are thin, it is softer,\\nresembling the crepitation produced by the bending of parchment.\\nThe parchment crepitation is produced by making pressure upon\\na myeloid sarcoma in which the compact layer of the bone has been\\nreduced to thin plates or scales by pressure from within outward, and\\nin chondroma surrounded by a thin, yielding shell of bone.\\nAuscultation and Percussion. The ear, aided or unaided by the\\nuse of the stethoscope, can be utilized in the diagnosis of certain\\ntumors. Percussion is useful in the differential diagnosis of hernia and\\nof tumors occupying localities the most frequent seat of hernia. Per-\\ncussion is also useful in outlining a tumor in the chest and in the\\nabdominal cavity.\\nAuscultation is resorted to in the examination of pulsating tumors,\\nin which usually, a distinct bruit can be heard, and in the differential\\ndiagnosis of aneurysm and of tumors located in close proximity to a\\nlarge artery. It must be remembered that a blowing, rasping sound\\nis often produced by the narrowing of the lumen of a large artery\\nfrom outward pressure caused by a tumor.\\nThe diagnostic resources which have been described so far are\\nample, if carefully and thoughtfully applied, to enable the surgeon in\\nthe majority of cases to make a correct diagnosis. In obscure cases\\nit is advisable to repeat the examination at intervals of a few days,\\nweeks, or months, and at the same time to observe carefully the clinical\\ncourse of the tumor. A hasty diagnosis in obscure cases is justifiable\\nonly in urgent cases demanding prompt surgical interference. Whenever\\npermissible the surgeon should take sufficient time and, if necessary, make\\nrepeated examinations, and exhaust all diagnostic resources before he\\ncommits himself concerning the nature of the tumor.\\nRontgen Ray. During the year 1896 the diagnostic resources as\\napplied to tumors were increased by the discovery of the ;r-ray by\\nRontgen. As bone-tissue is impermeable to this ray, the shadow-\\npictures obtained by its use show clearly the outlines of bones and\\npathological formations containing bone. The Rontgen ray will be\\nof great value in locating osteomata and in showing their relations\\nto adjacent joints and other structures; in ascertaining the exist-\\nence of bone in mixed tumors and in demonstrating the early exist-\\nence, exact location, and size of myeloid and bone-producing periosteal\\nsarcoma.\\nIt remains to discuss", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0122.jp2"}, "117": {"fulltext": "DIAGNOSIS OF TUMORS. 103\\nThe Value of the Microscope as an Aid in the Diagnosis of\\nTumors. There is no doubt in the mind of the writer that the value\\nof the microscope as an aid in the diagnosis of tumors has been greatly\\nover-estimated. The greatest blunders in diagnosis and treatment have\\nbeen committed by surgeons of eminence through placing too great\\nreliance on the microscopic examinations of fragments of tumor-tissue\\nobtained either before operation or from the specimens removed. The\\nlate Emperor Frederic of Germany is a case corroborating the truth\\nof this assertion. His attending surgeon, Von Bergmann, made a cor-\\nrect diagnosis, basing his opinion upon the clinical aspects of the case.\\nA part of the tumor was removed and examined by the most dis-\\ntinguished pathologist the world has ever seen. His diagnosis was\\nbased upon what he could see under the microscope. In the sec-\\ntion examined he could detect nowhere any evidences of malignancy.\\nThe epithelial cells, greatly increased in number, retained their normal\\nrelation to the underlying tissues. All the pictures under the micro-\\nscope represented a benign papilloma. The disease, however, pursued\\nits relentless course, notwithstanding the favorable prognosis made,\\nand in a few months destroyed the life of the illustrious patient. The\\nunprejudiced surgeon will readily understand the source of fallacy in\\nthe diagnosis made by the pathologist. The part removed and exam-\\nined represented only one part of the tumor. The attached deep por-\\ntion contained the carcinoma-cells, and it was from this part that the\\nFig. 37. Warren s harpoon for the removal of tissue from solid tumors for microscopic examination.\\ndisease extended from one tissue to another. The case is an extremely\\nvaluable one in showing the importance of examining different parts\\nof a tumor if the microscope is to be relied upon in making a final\\ndiagnosis. The examination under the microscope of isolated cells is\\nnot to be relied upon, as all the varieties of tumor-cells have their\\ncounterpart somewhere in the normal tissues of the body. Instruments\\nconstructed upon the plan of a trocar have been devised by Wintrich,\\nBouisson, Bruns, Middeldorpf,and J. Collins Warren (Fig. 57), for the pur-\\npose of removing particles of tumor-tissue for microscopic examination.\\nThe objection to this method of obtaining tissue for examination is that\\nby taking the tissue from only one part of the tumor the part removed", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0123.jp2"}, "118": {"fulltext": "io4\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nmay not represent tumor-tissue, and may consequently lead to error\\nin diagnosis and multiple punctures are objectionable, as they are\\nlikely to give rise to considerable hemorrhage and to stimulate tumor-\\ngrowth. This method of procedure is, however, advisable when all\\nother diagnostic resources have failed and it is essential for the welfare\\nof the patient that a correct diagnosis should be made before an opera-\\nSSlSD\\n$m*\\n\u00e2\u0096\u00a0*sr*\\nw\\n^S*S^f^\u00c2\u00bb\\nFig. 38.\u00e2\u0080\u0094 Gumma of the liver (after Karg and Schmorl). In the centre of the field circumscribed foci,\\nmiliary gummata the same are composed of young granulation-tissue, and show in their centre evidences\\nof degeneration. The parenchyma-cells are seen as grayish-black stripes, and are separated from each other\\nby narrower stripes of cellular connective tissue.\\ntion is undertaken. Preparations of teased tissue are of but little value\\nfor diagnostic purposes. The fragment should be prepared properly,\\nand from it sections should be taken for microscopic examination.\\nOnly specimens which represent both cells and stroma in their proper\\nrelations enable the microscopist to interpret the character of the tumor.\\nHow difficult it is to distinguish the tissue of some tumors from the\\ngranulomata by the aid of the microscope can readily be seen by a", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0124.jp2"}, "119": {"fulltext": "DIAGNOSIS OF TUMORS.\\nI05\\n4*y%*r\\nX\\n3\\n_rj\\nu\\nto\\n13\\nif:\\nrt\\n5\\nto\\nO\\nO\\nin\\ng\\n3\\n5\\nrt\\nis\\n3\\nctf\\n-3\\n1\\nrC\\n-3\\ns\\n_o\\n;X\\n3\\nH\\nas\\npJCj\\nr;\\nO\\nG\\nft\\nr^\\ncd\\na\\nCfi\\nO\\nM\\n73\\n.E\\nZf!\\n5\\nC\\nu\\n1)\\nVI\\n0\\nf\\nft\\nU\\ns\\nw\\nciS\\nS\\n13\\nV\\n6\\ns\\nCJ\\n00\\nX\\nX\\na\\nIE\\nTJ\\nE\\nV\\nIS\\n3\\n3\\nU\\n5SI2A-J*\\nftp\\naj g 5 -o U\\nk- C V C C\\nI rt I", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0125.jp2"}, "120": {"fulltext": "106 PATHOLOGY AND TREATMENT OF TUMORS.\\nglance at Figures 38, 39, and 40. All these illustrations represent in\\nthe foreground embryonic connective tissue with a very scanty stroma.\\nWithout knowing anything about the clinical aspects, it will readily be\\nseen that it would be exceedingly difficult to distinguish between a\\nsmall round-celled sarcoma, young granulation-tissue, and a gumma.\\nIt is in just such cases that we seek additional light from a micro-\\nscopic examination.\\nTo illustrate still further the danger which may follow the use of\\nthe microscope as an exclusive and only means of diagnosis, the writer\\nwill relate a case which recently came under his observation. During\\nthe World s Fair held in Chicago he was consulted by a Russian\\ngentleman concerning several tumors which had developed in the scar\\nof an operation-wound. He gave the following history Age, forty\\nmarried the father of several healthy children merchant by occupa-\\ntion. In 1890 he noticed a swelling in the skin at a point corre-\\nsponding to the supraspinatus fossa of the right scapula. The tumor\\nwas movable and painless, but increased quite rapidly in size. He\\nconsulted his family physician in Russia, who pronounced the tumor\\na sarcoma of the skin and sent him to one of the most prominent\\nsurgeons in Berlin for operation. The Berlin surgeon made a diag-\\nnosis of gumma, placed the patient on specific treatment, and removed\\nthe tumor, more for the purpose of allaying the fears of the patient\\nthan with the expectation of any benefit being derived from the\\noperation. The patient followed the treatment faithfully, but in the\\ncourse of six months a tumor returned in the scar. He consulted the\\nsame surgeon, who at the patient s special request removed the tumor\\na second time, still claiming that it was not malignant. It was now\\ndecided to leave the diagnosis in the hands of the most competent\\npathologists. The surgeon sent a part of the tumor to an eminent\\nBerlin pathologist, and the patient sent the balance to the foremost\\nParis pathologist. The specimens were subjected to microscopic ex-\\namination, and each pathologist sent in a written report to the effect\\nthat the tumor was a gumma, and not a sarcoma. The patient was\\nnow placed on vigorous antisyphilitic treatment, including mercurial\\ninunctions, baths, and the internal use of corrosive sublimate and\\npotassic iodide in large doses. The wound after both operations healed\\nby primary intention. The patient is not aware that he ever con-\\ntracted syphilis, and never showed evidences of secondary or tertiary\\nmanifestations. When the writer examined the patient none of the\\nremote consequences of syphilis were discovered. The pale, large scar\\nfollowing the last operation was occupied by four tumors, covered by\\nintact scar-tissue and varying in size from that of a hazelnut to that", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0126.jp2"}, "121": {"fulltext": "DIAGNOSIS OF TUMORS.\\n107\\nof a walnut, all of them perfectly movable, and with no attachments\\nto the scapula. If ever a case of sarcoma of the skin was seen, this\\nwas one. Under the circumstances it was deemed prudent to advise\\nthe patient to return to his surgeon for a third operation. The writer\\ndoes not wish to under-estimate the value of the microscope as an aid\\nin the diagnosis of doubtful tumors, but he must insist that it cannot\\nbe relied upon in differentiating between a small round-celled sarcoma\\nand some of the granulomata under circumstances such as those\\ndetailed above. In doubtful tumors of accessible surfaces tumor-tis-\\nsue can be selected and removed\\nfor microscopic examination. Sec-\\ntions of such specimens are better\\nadapted for diagnosis by means\\nof the microscope than fragments\\ntaken from the depths of tumors\\nthrough the skin with the different\\nforms of harpoons. Another course\\nis sometimes necessary when the\\nsurgeon has decided to remove the\\ngrowth and is in doubt as to its\\nnature. Here the microscope is em-\\nployed during the operation as an\\naid in diagnosis. As soon as the\\ntumor is reached, when doubt still remains as to its character, a piece is\\nremoved and sections are made with a freezing microtome (Fig. 41) for\\nmicroscopic examination. The freezing microtome can be purchased at\\na small expense, and should have a place in the operating-room of every\\nhospital. The result of such an examination frequently settles all doubt\\nas to the nature of the tumor, and serves as a valuable guide to the\\nsurgeon in the performance of the operation. The microscope is an\\ninvaluable aid in the diagnosis of tumors, but the co7iclusio7ts based upon\\nthe re stilts of the examination are not infallible hence the importance of\\na careful study of the clittical aspects of the tumor, followed by a thorough\\nexamination of the patient, of the tumor, and of its environments.\\ng microtome.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0127.jp2"}, "122": {"fulltext": "X. PROGNOSIS OF TUMORS.\\nA reliable prognosis presupposes a correct diagnosis. To predict\\ncorrectly the probable termination of a tumor requires an accurate\\nknowledge of its life-history and of its relations to its neighborhood\\nand to the entire organism. The prognosis must therefore rest largely\\nupon a careful study of the clinical history of the tumor, its anatomical\\nlocation, its influence upon the adjacent tissues, and the general condi-\\ntion of the patient. It is when we are called upon to foretell the future\\nbehavior of a tumor that we realize most keenly the necessity of\\nmaking a searching examination of the patient as well as of the tumor.\\nFrom a prognostic standpoint it is absolutely necessary to divide all\\ntumors into the two great clinical divisions (i) benign and (2) malig-\\nnant. If we are able in the diagnosis to exclude inflammatory swell-\\nings, the next duty that presents itself is to differentiate between\\nbenign and malignant tumors. This task is easy in some cases, diffi-\\ncult or impossible in others. A carcinoma that has advanced to the\\nstage of ulceration with regional glandular infection is recognized at\\nsight a rapidly-growing tumor in bone or in periosteum in localities\\npredisposed to sarcoma is readily identified as such. Under other less\\nobvious circumstances the question as to whether the tumor is benign\\nor is malignant is not so easily decided. Carcinoma of some of the\\ninternal organs is often diagnosed only in the post-mortem room.\\nCarcinoma and sarcoma of accessible organs are frequently recognized\\nas such only after their clinical behavior has given unmistakable evi-\\ndence of their malignant character. It is evident that the surgeon\\nwho regards his own reputation and the welfare of his patient must be\\ncautious in rendering his verdict as to the probable course the tumor\\nwill pursue in the future and the ultimate fate of his patient. The\\nprognosis should be postponed until repeated examinations and, if\\nnecessary, the microscopic examination of tissue from the tumor have\\nfurnished conclusive evidence of the nature of the tumor. It is most\\nhumiliating to a surgeon to make a diagnosis of malignant disease, and\\nto render a prognosis in accordance with his views of the nature of the\\ntumor, and to find later, by its clinical course, that it was either a\\nbenign tumor or an inflammatory swelling. It is a disregard of a duty\\nimposed upon a surgeon to pronounce a malignant tumor non-malig-\\n108", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0128.jp2"}, "123": {"fulltext": "PROGNOSIS OF TUMORS. 109\\nnant upon a superficial, hasty examination, as the loss of time may\\nweigh heavily in the balance of failure of a too-long-postponed radical\\noperation. It must be apparent to the student that an intelligent, reliable\\nprognosis must necessarily rest on a correct diagnosis, and that a prog-\\nnosis should consequently be withheld from the patient and his friends\\nuntil the nature of the tumor has been ascertained by conclusive evidence.\\nA correct diagnosis having been made, the next question that pre-\\nsents itself to the conscientious surgeon is, To what extent should the\\nknowledge gained as to the nature of the tumor be communicated to\\nthe patient and his friends The prognosis in cases of benign tumors\\nshould be freely and candidly expressed to the patient, including the\\npossible risks of an operation and its probable result. A different\\ncourse should be pursued if the tumor is malignant. Under ordinary\\ncircumstances the writer regards it in the light of a cruelty to inform\\na patient directly that he is suffering from a malignant tumor. The\\npublic appreciates our shortcomings in the treatment of malignant\\ntumors, and with few exceptions an intelligent patient regards such\\na diagnosis as his death-sentence. The mental depression following\\nsuch a declaration not only destroys all happiness on the part of the\\npatient, but has a disastrous effect on the disease, and is an important\\nfactor in detracting from the immediate and remote results of an\\noperation. The surgeon is often placed in a very unenviable position\\nwhen importuned by the patient in reference to the nature of the\\ngrowth. The question, Have I a cancer is often squarely put to\\nhim, and the reply will either inspire hope or cause a despondency\\nfrom which the patient will never recover completely. It has been an\\ninvariable rule with the writer to inform the relatives as to the true\\nnature of the tumor, and to discuss with them the propriety of an\\noperation as well as its probable immediate and remote results. The\\npatient is informed that he is suffering from a tumor, and this statement\\nwill prove satisfactory in the majority of cases. If asked as to the\\npossibility of a recurrence, the facts are placed as gently as possible\\nbefore the patient. If ignorance is bliss, this adage has a special\\nsignificance in the case of a patient suffering from a malignant tumor.\\nIf the patient is not aware that he is suffering from what is regarded\\nalmost universally as a fatal malady, an operation inspires hope, and,\\nin place of the despondency often bordering on desperation that\\nattends a knowledge of the true nature of the tumor, the patient\\nlooks forward to a complete and permanent recovery. The surgeon\\nshould communicate to the patient s //rarest relatives or trie /ids the true\\nnature of the tumor and the probable results of an operation, but such\\ninformation should be withheld from the patient himself under ordinary", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0129.jp2"}, "124": {"fulltext": "no\\nPATHOLOGY AND TREATMENT l OF TUMORS.\\ncircumstances. There are exceptions to every rule, and circumstances\\nmay arise which make it imperative on the part of the surgeon to tell\\nthe patient the whole truth.\\nFrom an anatomical standpoint every tumor is benign in proportion\\nto its degree of isolation from the adjacent tissues and from the organ-\\nism. Benign tumors, as a rule, are encapsulated; consequently they\\nremain permanently as local affections having no connection whatever\\nwith the organism. The encapsulation of some forms of sarcoma is\\nmore apparent than real, as the capsule does not afford protection\\nto the surrounding tissues against invasion by tumor-cells yet when\\na capsule is present it imparts to the tumor a certain degree of benig-\\nnancy which is not observed in malignant tumors entirely devoid of a\\ncapsule, as is the case in carcinoma and in the most malignant varieties\\nof sarcoma. For reasons that have been explained, the soft, vascular\\ntumors belonging to the malignant type of tumors manifest the great-\\nest degree of malignancy. In tumors of this kind the stroma, which\\nalways acts more or less as a barrier to local and general dissemina-\\ntion, is always scanty and sometimes is nearly wanting. The cells\\nremain in their embryonic state, possess ameboid movements, and are\\nreproduced with great rapidity. Such tumors resemble inflammation\\nvery closely, and the surgeon is familiar with the well-known clinical\\nFig. 42. Carcinoma of mammary gland, showing numerous leucocytes between tumor-cells and along\\nthe course of blood-vessels (Surgical Clinic, Rush Medical College) a, carcinoma-cells b, stroma; c, brown-\\nish granules of blood-pigment d, area of new proliferation e, leucocytes.\\nfact that the nearer the anatomical and clinical aspects of a tumor\\ncorrespond with inflammation, the greater its malignancy. In rapidly-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0130.jp2"}, "125": {"fulltext": "PROGNOSIS OF TUMORS. in\\nmalignant tumors we find between the tumor-cells and in\\nthe course of blood-vessels a picture closely resembling inflammation\\n(Fig. 42).\\nThe immigration of blood-corpuscles into the parenchyma of a tumor\\nis caused by the imperfect development of the wall of the new blood-\\nvessels and by the favorable local conditions in the interior of the blood-\\nvessel for mural implantation. The imperfect wall of the blood-vessels\\nin the tissues of malignant tumors corresponds to the damaged capil-\\nlary walls in inflamed tissue, and permits the escape of numerous\\nleucocytes, and in some cases of red corpuscles. Rhexis is of frequent\\noccurrence in rapidly-growing carcinoma and sarcoma. The new cells\\nin soft vascular malignant tumors possess ameboid movements in the\\nhighest degree, and encounter few obstacles on their way from the\\ntumor into the surrounding tissues with greatly impaired physiological\\nresistance. Cells originating under such circumstances are very liable\\nto lose their connection with the mother-soil and to wander away\\ninto the surrounding tissues or to enter the lymphatic vessels or the\\nblood-vessels, thus giving rise to early regional and general dissemina-\\ntion. The intrinsic danger of a tumor consists in its capacity to impli-\\ncate the adjacent tissues and the organism that is, in its giving rise to\\nregional and general i7ifection. This capacity is possessed to the highest\\ndegree by the soft vascular carcinomata and sarcomata tumors that are\\nin contact with the surrounding tissues from the beginning, without any\\nattempt at the formation of a barrier between abnormal and normal tissue.\\nIn carcinomatous tumors location plays an important part in deter-\\nmining the degree of malignancy of a tumor. For years it has been\\nbelieved and taught by authors and teachers that for some unknown\\nreason epithelioma was a less malignant affection than glandular car-\\ncinoma, the so-called scirrhus. For a long time epithelioma w T as\\ndescribed as a tumor separate from carcinoma proper. It was also\\nasserted that epithelioma remained as a purely local affection that\\nit did not give rise to regional and general dissemination. A more\\nextended and accurate clinical observation of this form of carcinoma\\nhas convinced pathologists and surgeons that an epithelioma eventually\\nbecomes diffuse by regional and general dissemination, and destroys\\nlife in the same manner as a deep-seated carcinoma. The writer has for\\nyears claimed that the greater benignancy of a surface carcinoma as com-\\npared with a deep-seated carcinoma depends entirely upon its location.\\nIn epithelioma of the lip, as well as in the case of any other carcinoma\\nof a free surface, the tumor can grow only in one direction, while a\\nsimilar tumor located in an organ surrounded by tissues on all sides\\ngrows from the very beginning in all directions. The field for local", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0131.jp2"}, "126": {"fulltext": "H2 PATHOLOGY AND TREATMENT OF TUMORS.\\ninfection of a surface carcinoma is therefore limited as compared with\\nthat of a glandular carcinoma. The increased area of tissue in contact\\nwith a glandular carcinoma as compared with that of a surface carci-\\nnoma will readily account for the more constant and earlier occurrence\\nof regional infection. Another important element determining earlier\\nand more constant regional infection in glandular carcinoma is pressure\\ncaused by the tissues encroached upon by the tumor. In surface carci-\\nnoma this element in the diffusion of the tumor is absent, and consequently\\nmigration of carcinoma-cells into the surrounding tissues is retarded.\\nThe location of a tumor is also an important factor in estimating\\nthe danger to life in the case of all benign growths. An osteoma\\non the external surface of the skull always remains as a harmless\\naffection, while a similar tumor on the side of the cranial cavity may\\nproduce distressing symptoms, and may finally result in death from\\ncerebral compression. A papilloma on the surface of the skin pro-\\nduces no symptoms, while the same kind of tumor in the larynx\\nmay destroy life by suffocation. A subserous fibroma of the uterus\\nbecomes a source of danger only from its size, while a small sub-\\nmucous tumor is a frequent cause of profuse and even dangerous\\nhemorrhage. In connection with the location, the size of a tumor\\nmust also be taken into consideration in estimating its danger to life.\\nLarge tumors are prone to undergo various kinds of degenerations\\nwhich in themselves may become a source of danger. A tumor that\\nhas undergone extensive degeneration is also more likely to become\\ninfected with pathogenic microbes. Large tumors of the ovary and\\nthe uterus by displacing abdominal and pelvic organs may cause fatal\\ncomplications by pressure. A similar source of danger attends tumors\\noccupying the cranial cavity and the thorax. Large tumors of the\\nthyroid gland and malignant tumors of the lymphatic glands of the\\nneck become dangerous to life from compression of the trachea.\\nA few words in reference to what may be expected from operative\\ninterference in the treatment of tumors Complete removal of a benign\\ntumor is never followed by recurrence. The same favorable result will\\nfollow a thorough removal of a sarcoma or a carcinoma if the operation\\nis performed before regional infection lias taken place. The removal of\\na carcinoma or a sarcoma after regional dissemination has taken place\\nis followed sooner or later by recurrence in the great majority of cases.\\nNothing but palliation can be expected from the removal of the primary\\ntumor in all cases in which the disease has become general by metastasis.\\nThe partial removal of a malignant tumor with extensive regional\\ndissemination is often followed by aggravation of the local conditions\\nand hastens the fatal termination.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0132.jp2"}, "127": {"fulltext": "XI. TREATMENT OF TUMORS.\\nThe treatment of a tumor must necessarily vary according to its\\nnature, structure, and location. The removal of malignant tumors is\\nindicated if this can be done before the disease has passed beyond the\\nreach of a radical operation. The operation in such instances meets\\nan indicatio vitalis, because the intrinsic tendency of a malignant tumor\\nis to destroy life. The removal of a benign tumor for a similar indi-\\ncation is called for only if the tumor occupies a locality where by its\\npresence it produces mechanical conditions incompatible with the func-\\ntion of an important organ. In other cases benign tumors are removed\\nfor the purpose of correcting functional disturbances, for cosmetic\\nreasons, and with a view of protecting the patient against the risks\\nof a possible transition into a malignant tumor. The treatment of\\ntumors divides itself into (i) medical, (2) surgical, and (3) palliative.\\nIt is superfluous in this connection to make the assertion that a\\nrational treatment must be based on a correct diagnosis. It is the\\nrecognition of the nature, location, and clinical tendencies of tumors\\nthat distinguishes the honest and competent surgeon from the char-\\nlatan. The cancer-quack calls every swelling a tumor, and his influ-\\nence among the people is not due to the success he scores in the\\ntreatment of carcinoma, but is gained by subjecting benign tumors,\\nretention-cysts, and inflammatory swellings to a similar barbarous\\ntreatment, and claiming the results thus obtained as so many victories\\nover cancer. We have reason to believe that many of the alleged\\npermanent results following operations for malignant disease were cases\\nof mistaken diagnosis. Many a gumma and tuberculous ulcer has\\nbeen removed by honest, able surgeons under the belief that they were\\noperating for carcinoma. Gummata of bone have frequently been mis-\\ntaken for sarcoma. The number of permanent results claimed for rad-\\nical operations for malignant disease would be greatly decreased if we\\ncould eliminate all cases of mistaken diagnosis. Professor von Esmarch\\nyears ago called attention to the frequency with which tubercular ulcers\\nand gumma are mistaken for carcinoma.\\nMedical Treatment.\\nSince we have learned to distinguish between true tumors and infec-\\ntive swellings the indications for medical treatment have almost disap-\\n8 118", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0133.jp2"}, "128": {"fulltext": "114 PATHOLOGY AND TREATMENT OF TUMORS.\\npeared. No kind of internal medication has any influence whatever in\\nlimiting tumor-growth, much less in causing the disappearance of a tumor.\\nIt is interesting for the student to know what has been done in the past\\nin the way of internal administration of medicines in the treatment of\\ntumors. Mercury was recommended by Boerhaave, and the effects of its\\ndifferent preparations were praised by Gama, Akenside, Mariot, Gooch,\\nGmelin, Buchner, Tauchnow, and many others. Rust and his pupils\\nhad great faith in the use of Zittmann s decoction. Arsenic was intro-\\nduced in 1775 by Lefebure in the form of arsenious acid. Fowler s solu-\\ntion found many admirers, among them Desault, Klein, Rust, Wenzel,\\nHill, Walshe, Thomson, and more recently Washington Atlee. The\\nlast-quoted authority had great faith in the internal use of arsenic after\\noperations for carcinoma, as he believed the drug had a positive influ-\\nence in retarding, if not preventing, a recurrence. He invariably admin-\\nistered this drug after an operation for cancer, and gradually increased\\nthe dose until it produced slight intoxication, when the use of the drug\\nwas not suspended, but the dose was diminished. He insisted that if\\npatients could not take a drop of Fowler s solution they should be\\ngiven a fraction of a drop that is, that the use of the drug should\\nbe continued under all circumstances and for a long time. Preparations\\nof gold were used by Duportail and Duparcque the salts of copper,\\nby Gauret, Gerbier, Solier, and De la Romillais chloride of barium, by\\nCrawford and Mittag. Mineral waters, especially those containing prep-\\narations of iodine, enjoyed a good reputation for a long time, and were\\nrecommended in the highest terms by such men as Wagner, Travers,\\nWalshe, Flinsch, Klaproth, Ullmann, Littre, Friese, Copland, and\\nDemme. Preparations of iron were regarded with favor by Carmichael\\nand Daniel Brainard. Animal charcoal was recommended by Weise\\nin 1829. The highest praise was conferred upon conium maculatum\\nin its day in the treatment of carcinoma. It was used first for this pur-\\npose in 1 76 1 by Stork; after him it was recommended in terms of the\\nhighest praise by Recamier, Neuber, Gunther, Camper, Baudelocque,\\nTrousseau, and Solon, and it is extensively prescribed even at the pres-\\nent day by N. S. Davis of Chicago, De Haen, Andree, Fothergill,\\nand Alibert. Almost all the narcotics have had their advocates in\\nthe treatment of carcinoma. The fame of condurango was of short\\nduration. Introduced by Bliss of Washington, it soon reached great\\npopularity among both laymen and the members of the medical pro-\\nfession. Men like Andrews of Chicago and Eichhorst of Zurich ex-\\ntolled its merits. Like all other famous cancer remedies, it soon fell\\ninto well-deserved innocuous desuetude. Some of the surgeons of\\nfifty and a hundred years ago resorted to rigid antiphlogistic treatment.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0134.jp2"}, "129": {"fulltext": "TREATMENT OF TUMORS. 115\\nValsalva, Broussais, Brechet, Poteau, Dzondi, and Lisfranc claimed that\\nthey could eliminate the cancerous material by copious and frequently-\\nrepeated venesection. Local abstraction of blood was recommended\\nby Velpeau. More recently, surgeons aimed to remove the virus of\\ncancer by derivatives. After operative removal of the growth setons\\nwere inserted at different parts of the body. Other surgeons used the\\nmoxa and blisters to meet the same indication.\\nAs a matter of historical interest, it should be known that Auzias\\nTurenne suggested syphilization to counteract the carcinoma virus.\\nWe can readily understand why the different mercurial preparations\\ncommanded the attention and received the approbation of the most\\ninfluential members of the profession for the longest time. Gummata\\ndiagnosed as carcinoma disappeared under this treatment, and the\\nresults thus obtained gave the remedy its great reputation. We have\\nno authenticated proof that mercury or any of its preparations has ever\\nbeen instrumental in retarding the growth of a tumor. The same can\\nbe said of all other internal remedies. The internal administration of\\nmedicines at the present time receives consideration only in the treat-\\nment of some of the complications that may arise and in improving\\nthe general health of the patient.\\nRadical Operation.\\nThe complete removal of a benign tumor furnishes the best illus-\\ntration of what is meant by a radical operation. A radical operation\\nfor the removal of a tumor has for its object the complete removal of\\ntumor-tissue. If this object is attained, the tumor, whether benign or\\nmalignant, will not return. The removal of a benign tumor generally\\nconstitutes a radical operation, owing to the structure of the tumor\\nand to its complete isolation from the adjacent tissues by a limiting\\ncapsule. Incomplete removal of a benign tumor is followed by recur-\\nrence, in which event the operation does not deserve to be called\\nradical, because it failed to accomplish what is understood by the term\\nradical. A radical operation undertaken for the removal of a carci-\\nnoma is radical in the estimation of the surgeon who in dealing with\\nthe tumor has made every effort to comply with the meaning of the\\nword; but in the majority of cases he has been deceived, as is subse-\\nquently shown by a local recurrence. The term radical means more\\nand more to the surgeon as he becomes more familiar with the path-\\nways and the extent of local and regional infection of malignant tumors.\\nRadical operations include 1. Ligation of the principal blood-\\nvessels nourishing the tumor; 2. Galvano-puncture 3. Parenchym-\\natous injections; 4. Injection of erysipelas toxines 5. Cauterization;", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0135.jp2"}, "130": {"fulltext": "Ii6 PATHOLOGY AND TREATMENT OF TUMORS.\\n6. Ligation 7. Galvano-caustic wire 8. Ecrasement lineaire 9. Avul-\\nsion 10. Extirpation. Most of the modern surgeons resort almost\\nexclusively to the use of the knife in undertaking the radical operation\\nin the removal of tumors both benign and malignant. The bloodless\\nprocedures are seldom resorted to, but they deserve a brief description,\\nas cases not adapted to extirpation may present themselves, or patients\\nmay positively object to the use of the knife, and under such circum-\\nstances it is wisdom on the part of the surgeon to yield to their request\\nrather than to give them an opportunity to seek the services of char-\\nlatans as devoid of a moral sense of responsibility as of a knowledge\\nof the science and art of surgery.\\nLigation of the Principal Blood-vessels Nourishing- the Tumor.\\nIt has been stated in the section on the Etiology of Tumors that\\na tumor can grow only if it receives an adequate quantitative and\\nqualitative blood-supply. Sudden or progressive anemia of a tumor\\ndetermines degeneration of the tuntor-tissue. Surgeons have made a\\npractical application of this knowledge, and have resorted to meas-\\nures calculated to deprive the tumor of the necessary blood-supply\\nby ligating the principal arteries nourishing the tumor. This method\\nof treatment was first introduced in 165 1 by Harvey. It has been\\nmost frequently resorted to in the treatment of tumors of the thyroid\\ngland.\\nWolfler has recently revived and improved the operation. It has\\nbeen shown that ligation of the superior and inferior thyroid arteries\\non both sides has a curative effect in the treatment of non-malignant\\ntumors of the thyroid gland.\\nIn inoperable cases of malignant tumors of the pharynx and the\\nupper part of the neck the primitive carotid artery has been tied\\nrepeatedly without even temporary benefit.\\nLigation of the uterine arteries has recently been proposed as a\\nconservative operation in the treatment of bleeding fibroids of the\\nuterus. The results so far obtained are not conclusive as to the merits\\nof the operation. It is possible that in the future benign tumors of\\nother organs will be treated successfully upon the same principles.\\nLigation of the principal arteries nourishing a tumor is occasionally\\nresorted to advantageously as an operation preliminary to a subsequent\\nextirpation.\\nGalvano-puncture. Electricity was used in the treatment of tu-\\nmors by De Haen. Galvanism came next in use. In a case of a large\\nsarcoma of the neck in which Liicke resorted to galvanism the tumors\\nappeared to become smaller and more movable under its use, but care-\\nful observation showed that the reduction in size and the temporary", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0136.jp2"}, "131": {"fulltext": "TREATMENT OF TUMORS. 117\\nimprovement followed the subsidence of an accompanying inflamma-\\ntion, and that the treatment had no effect whatever on the tumor.\\nThis has been the uniform experience of surgeons in the external\\napplication of electricity in the treatment of tumors. Electro-puncture\\nand galvano-puncture have found special application in the treatment\\nof cystic tumors. At the International Medical Congress held in\\nPhiladelphia in 1876, Semeleder of Mexico read a paper on this sub-\\nject, from which it appeared that electricity was destined to supplement\\nthe knife in the treatment of ovarian cysts. Apostoli made similar\\nclaims for this agent in the treatment of myofibroma of the uterus at\\nthe International Congress held in the city of Washington. It is now\\ngenerally conceded that electro-puncture and galvano-puncture occa-\\nsionally bring about improvement, but the results have not been\\nsuch as to entitle this therapeutic resource to be included among the\\nradical measures in the treatment of tumors. The application of the\\nelectrolytic action of the galvanic current was first made use of by\\nNelaton. As the electrolytic action is attended by gas-formation, Bill-\\nroth did not resort to electrolysis in the treatment of vascular tumors,\\nas he feared that the gas evolved might enter the blood-vessels and\\nproduce dangerous if not fatal gas-embolism. Electrolysis has a lim-\\nited sphere of application in the treatment of superficial naevi.\\nParenchymatous Injections. Injections of solutions of perchlo-\\nride of iron have had an extensive application in the treatment of\\nvascular tumors. The use of coagulating substances as injections into\\na vascular tumor is attended by great risks, and should entirely be\\nabandoned. Fatal embolism has attended this procedure by the separa-\\ntion of a fragment of the blood-clot, with the result of causing sudden\\ndeath. In other instances the injection was followed by suppuration,\\nthrombo-phlebitis, and pyemia. Thiersch injected into carcinomatous\\ngrowths a solution of nitrate of silver, with the object of bringing\\nabout speedy degenerative changes. This treatment proved a com-\\nplete failure. Broadbent used for the same purpose dilute acetic acid,\\nwith similar negative results. Carbolic acid and other antiseptic sub-\\nstances have been used in the treatment of malignant tumors, but none\\nof them have answered the expectations of those surgeons who regard\\nwith favor the microbic origin of malignant tumors. The use of ani-\\nline dyes, introduced by Mosetig von Moorhof, has had an extended\\ntrial, but so far no positive results have been realized. The employ-\\nment of parenchymatous injections in the treatment of inoperable\\ntumors should be encouraged, as it is within the range of possibility\\nthat there may be found a substance which, when brought in con-\\ntact with the tumor-tissue, may prove beneficial either by its destructive", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0137.jp2"}, "132": {"fulltext": "Il8 PATHOLOGY AND TREATMENT OF TUMORS.\\neffects on the new cells or by effecting a change in the type of tissue-\\nproliferation.\\nInjection of Erysipelas Toxines. It has been known for a long\\ntime that an intercurrent attack of erysipelas frequently retarded the\\ngrowth of a sarcoma, and in exceptional cases resulted in a permanent\\ncure. Billroth and others have reported such cases. Since the dis-\\ncovery of the microbe of erysipelas by Fehleisen patients suffering\\nfrom inoperable malignant tumors have been inoculated with pure\\ncultures of the streptococcus of erysipelas. Some of the cases sub-\\njected to this treatment improved, others received no benefit, and in\\nsome the symptoms were aggravated and the treatment hastened the\\nfatal termination. Coley and Bull have recently made use of sterilized\\ncultures of the erysipelas microbe, and have obtained equally good,\\nif not better, results than were obtained with the active cultures. This\\ntreatment is certainly preferable to the employment of active cultures,\\nas it is not attended by the risks incident to an attack of erysipelas.\\nThese authors have found that the employment of the sterilized cult-\\nures was followed by better results in the treatment of sarcoma than\\nin that of carcinoma. It has also been ascertained that the culture\\nmade of the streptococcus of erysipelas and the bacillus prodigiosus\\nis more effective than the culture of the streptococcus alone. As in\\nthe case of Koch s lymph, the injections are followed by a rise in the\\ntemperature. The diluted sterilized culture as sold in the shops is used\\nin doses of from 5 to 30 minims. The treatment should be commenced\\nby injecting 5 minims every alternate day, increasing the dose gradu-\\nally. Koch s syringe (Fig. 43) should be employed for this purpose.\\nThe writer has given this treatment a fair trial in twelve cases, but so\\nfar no permanent beneficial results have been obtained.\\nFig. 43. Koch syringe.\\nThe author has given this treatment an extensive trial, with invari-\\nably negative results and Drs. L. A. Stimson, A. G. Gerster, and B. F.\\nCurtis, at a recent meeting of the New York Surgical Society, sub-\\nmitted the following report upon the use of erysipelas toxins in the\\ntreatment of malignant disease We believe that in the instances of\\napparent cure or marked improvement the correctness of the diagnosis\\nis open to doubt. We therefore submit: 1. That the danger to the\\npatient from this treatment is great. 2. Moreover, that the alleged\\nsuccesses are so few and doubtful in character that the most that can", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0138.jp2"}, "133": {"fulltext": "TREATMENT OF TUMORS.\\n119\\nbe fairly alleged for the treatment by toxins is that it may offer a very\\nslight chance of amelioration. 3. That valuable time has often been\\nlost in operable cases by postponing operation for the sake of giving\\nthe method of treatment a trial. 4. Finally, and most important, that\\nif the method is to be resorted to at all, it should be confined to the\\nabsolutely inoperable cases.\\nCauterization. The destruction of tumors by caustics and by the\\nactual cautery is one of the most ancient resources of the surgeon in\\nthe bloodless removal of tumors. The actual cautery was preferred\\nby the surgeons of ancient times, because it not only destroyed the\\ntumor quickly, but at the same time also acted as a hemostatic. The\\nuse of the actual cautery has had an extended application also as a\\nsupplement to the knife in effecting the destruction of remnants of\\ntumor-tissue and in arresting hemorrhage. The actual cautery is occa-\\nsionally used now in the removal of small surface carcinomata in\\npatients who show an unconquerable objection to the use of the knife,\\nand in the palliative treatment of inoperable ulcerating malignant\\ntumors. The instrument employed almost universally for this purpose\\nis Pacquelin s cautery (Fig. 44). The bulb- or knife-point is used most\\nfrequently in the treatment of malignant tumors, while the needle-point\\nis used almost exclusively in the treatment of angiomatous tumors.\\nThe employment of the potential cautery chemical caustics in differ-\\nent forms has found a more varied and extended application than that\\nof the actual cautery. It is to be regretted that this method of treat-\\nment has fallen almost entirely into the hands of charlatans. The\\nignoramus fears blood the public always has had, and always will\\nhave, faith in bloodless procedures hence the great popularity which\\nchemical caustics have en-\\njoyed in the treatment of\\ntumors. The war between\\ncaustics and the knife has\\nbeen a long and bitter one,\\nand it is by no means ended.\\nThe cause of caustics is de-\\nfended by a great army of ig-\\nnorant, irresponsible, money-\\nloving quacks, supported\\nand cheered by an admiring\\nmisled public. On the side\\nof the knife stands the hon-\\nest surgeon who holds out\\nonly guarded promises, confronted by patients suspicious of his skill\\nFig. 44. Pacquelin cautery.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0139.jp2"}, "134": {"fulltext": "120 PATHOLOGY AND TREATMENT OF TUMORS.\\nand in great dread of a bloody operation. The ultimate victory of the\\nknife must rest on earlier and more thorough operations. The quack\\nhas been educating the people to the effect that the caustic he uses de-\\nstroys only cancer-tissue, and he takes special pains to point out to his\\npatient that the remedy has not only succeeded in removing the cancer,\\nbut has also followed its roots. The patient, with the specimen care-\\nfully preserved in alcohol, returns to his home happy and hopeful, and\\nexhibits the specimen cancer, roots and all, with satisfaction and a cer-\\ntain feeling of pride as a signal triumph of quackery over regular\\nmedicine. In the face of such a state of things it is no wonder that\\nthe surgeon who has regard for his own reputation is slow in substi-\\ntuting caustics for the knife. Chemical caustics have had an exten-\\nsive trial at the hands of the regular profession. Their merits and\\ndisadvantages have been studied by competent and honest surgeons.\\nThey occupy at the present time a limited and special field in the\\ntreatment of tumors.\\nThe value of different caustics depends on the manner of their\\naction the more potent its action, the less the liability to hemorrhage\\nthe less the pain it inflicts, the more useful it is. The treatment of\\nsmall benign tumors by the application of caustics often results in a\\npermanent cure. In the treatment of carcinoma this is seldom the\\ncase. The difficulty encountered in this method of treatment is that\\none application is seldom sufficient to destroy all the tumor-tissue,\\nand that repeated applications cause so much suffering and distress\\nthat few patients will endure them long enough to effect a radical cure.\\nSome of the caustics which have been used may become absorbed in\\namount sufficient to produce poisoning, and on this account should\\nnever be used this is the case with arsenical preparations. When fluid\\ncaustics are employed the surrounding tissues should be protected\\ncarefully against their action. If the caustic is to be repeated, the\\nsecond application is postponed until the eschar has separated. Pain\\nis to be subdued by the application of cold and by hypodermic injec-\\ntions of morphine. In the selection of the caustic we must be guided\\nby the depth to which it is desirable to penetrate, as well as by the\\nlocation to which liquid caustics are adapted.\\nCaustic Potash. Caustic potash is a very energetic caustic. The\\nrapid liquefaction which it undergoes when applied to the tissues\\ndetracts somewhat from its advantages, and it must be watched care-\\nfully and the tissues beyond its desired range of action must be pro-\\ntected thoroughly. It cannot be employed safely in the treatment of\\ntumors located in cavities. Its hemostatic action is not reliable. This\\nsubstance is often mixed with caustic lime, the mixture constituting", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0140.jp2"}, "135": {"fulltext": "TREATMENT OF TUMORS. 121\\nthe famous Vienna paste, which is not much inferior to the caustic\\npotash as a caustic.\\nChloride of Zinc. This article, in the form of a paste known as\\nCanquoin s paste, has been used quite extensively as a caustic. To\\nincrease its action in paste form it is necessary that it should receive\\na certain amount of moisture, and it must therefore be applied under\\nthe skin. If the skin over the tumor is intact, it should be made per-\\nmeable to the caustic by macerating it for some time with a dilute\\nsolution of caustic potash or by making multiple superficial incisions.\\nIt is a reliable hemostatic, which fact is an additional recommendation\\nfor its employment in the removal of vascular tumors. The eschar it\\nproduces is very dry and corresponds in size to the cubic volume of the\\nmass of paste inserted. In a few days the eschar can readily be re-\\nmoved with the knife, when the cauterization is repeated. The caustic\\narrows of Maisonneuve are composed of a paste of flour and chloride\\nof zinc in the proportion of 3:1. Landolfi, a famous Italian cancer-\\ndoctor, used a mixture of chloride of zinc, chloride of gold, and chlo-\\nride of bromium.\\nArsenic. The arsenical preparations, especially the paste of Frere\\nCome, were popular for a long time, and proved useful in the removal of\\nsmall epiblastic carcinomata about the face and the lip. Arsenic is an\\nenergetic caustic, but its action is slow. Intoxication from the absorp-\\ntion of arsenic has repeatedly been observed. For some time arsenic\\nwas regarded as a specific in the treatment of carcinoma, but this delu-\\nsion no longer prevails, as it has been found that its beneficial action\\nwhen applied as a caustic depends entirely upon the depth to which\\ntissue is destroyed, as is the case with all other caustics.\\nChromic Acid. This acid inflicts less pain than any other liquid\\ncaustic, and has proved successful as a superficial caustic. It is used\\nin the form of crystals or as a concentrated solution.\\nNitric Acid. Of all the acids, nitric acid has been used most fre-\\nquently as a caustic in the treatment of tumors. The eschar is of a\\nyellowish color, and the resulting scar is small. Nitric acid is also\\na good hemostatic.\\nInstead of resorting to cauterization from without, French surgeons\\ndevised a method by which caustics are inserted into the tissues of the\\ntumor through punctures from different points, which method they\\ntermed linear cauterization. The first attempts in this direction were\\nmade in 1700 by Deshaies Gendrou. His method consisted in intro-\\nducing pieces of caustic paste under the base of the tumor, with the\\nexpectation that the deep cauterization from different points would\\neventually separate the tumor from the tissues, when it would be cast", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0141.jp2"}, "136": {"fulltext": "122\\nPATHOLOGY AND TREATMENT OF TUMORS.\\noff as a whole with the eschar. Under the name of cauterisation\\nen fleches Maisonneuve in 1857 developed this procedure. He in-\\nFig. 45. Cauterisation en rayons (after Maison-\\nneuve).\\nFig. 46. Cauterisation en faisceaux (after Maison-\\nneuve).\\nserted arrow-shaped pieces of chloride-of-zinc paste into the substance\\nof the tumor after puncturing it at different points with a bistoury.\\nHe described three methods of procedure First, the arrows are intro-\\nduced on the same level in such a way that their points meet in the\\ncentre of the tumor (Fig. 45) second, the arrows are inserted from the\\nsurface like posts driven in the ground (Fig. 46) third, an arrow was\\ninserted into the centre of the tumor, so that cauterization should pro-\\nceed from the centre toward the periphery cauterisation centrale\\n(Fig. 47)-\\nIn the removal of tumors of small size surface cauterization must\\nbe resorted to. If the tumor is large, Maisonneuve s procedures are\\npreferable. They are, however, not devoid of danger. It has hap-\\npened in the practice of Maisonneuve that the caustic destroyed the\\nwalls of large blood-vessels, and upon the separation\\nof the eschar troublesome and even fatal hemorrhage\\noccurred. The writer recollects a case of carcinoma\\nin the parotid region that was treated by a charlatan\\nby caustics. Before the patient left the institution\\nprofuse hemorrhage occurred after separation of the\\nlast eschar. The patient was informed that the cure\\nwas completed, and was advised to return to his\\nhome. Soon after he left the institution there oc-\\ncurred another hemorrhage, which nearly proved fatal.\\nGreatly debilitated and almost exsanguinated, he was\\nbrought to the Presbyterian Hospital, Chicago. The\\ndressings were saturated with blood. An anesthetic was administered,\\nthe dressings were removed, the neck was disinfected, and the common\\ncarotid artery was tied. Upon examination of the large surface partly\\nFig. 47. Cauterisation\\ncentrale (after Maison-\\nneuve).", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0142.jp2"}, "137": {"fulltext": "TREATMENT OF TUMORS.\\n123\\ncovered by granulations and partly by fungous carcinoma-tissue, a\\nlarge opening in the external carotid artery was found near the bifur-\\ncation of the common carotid. The surface was disinfected and the\\nopening in the vessel was tamponed with iodoform gauze. The hem-\\norrhage did not return, and the patient left the hospital in the course\\nof a week.\\nImmediate and complete removal of a tumor is accomplished by\\nthe employment of the ligature, the ecraseur, the galvano-caustic wire,\\nand the knife. The complete removal of a tumor is effected in the\\nsafest manner and most expeditiously by the use of the knife, but, as\\nall the procedures enumerated above are still endorsed by eminent\\nsurgeons, and as all of them are occasionally resorted to, they merit\\na brief description.\\nLigature. The ligature is an ancient surgical resource in the treat-\\nFig. 48. Maisonneuve s constrictor.\\nment of tumors. Ambrosius Pare and De Saliceto removed with it\\npolypoid growths from the nasal cavities and from the cervix of the\\nuterus. Mayor described this procedure, under the name of ligature\\nen masse, as a new discovery, improved the technique, and extended its\\nuse to different parts of the body. The ligature\\nwas used in two ways 1. It was tied so firmly\\nthat it strangulated all blood-vessels, producing\\nrapid necrosis of the tumor 2. It was tightened\\nfrom time to time, in order to cut its way more\\nslowly through the tissues. The single ligature\\nwas used in tying off pedunculated growths.\\nIts use was extended to the removal of tumors\\nwith a wide base, with the introduction of the\\ndouble and multiple ligatures. The ligatures\\nwere either tied on the surface of the skin or\\ninserted with needles around and under the\\nbase of the tumor. Whenever possible a ped-\\nicle was made artificially by making traction\\nupon the tumor before inserting and tying the\\nligatures, or by dissecting off the skin around\\nthe base of the tumor. The percutaneous ligature has been employed\\nFig. 49.\\n-Koderik s rosary instru-\\nment.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0143.jp2"}, "138": {"fulltext": "124\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nextensively in the treatment of angioma. Recently absorbable lig-\\natures of catgut and kangaroo tendon have been sustituted for the\\nsilk and metallic ligatures in the subcutaneous ligation of vascular\\ngrowths. Various instruments have been devised for the progress-\\nive constriction of the base of the tumor by the ligature. Maison-\\nneuve s (Fig. 48) is constructed upon the same plan as Chassaignac s\\necraseur. In Koderik s instrument (Fig. 49) the ligature is tightened at\\nintervals over a row of perforated shot. Manec contributed largely\\ntoward the perfection of the technique of the subcutaneous ligature.\\nHe devised a needle for this special purpose, the manner of use of\\nwhich is well shown in Figure 50. Fergusson s method (Fig. 51)\\nis simpler and does not require a needle of special construction. The\\ngreat objections to the use of the ligature are the pain it causes\\nand the liability to infection that attends its use. The ligature is used\\nat the present time only in exceptional cases of angioma. The aseptic\\nligature should be used, attended by all necessary antiseptic precautions.\\nFig. 50. Manec s method of percutaneous ligation of a tumor (after Manec).\\nGalvano-caustic Wire. Recognizing the disadvantages of the silk\\nand metallic ligatures in the removal of tumors, Middeldorpf in 1852", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0144.jp2"}, "139": {"fulltext": "TREATMENT OF TUMORS.\\n125\\nsubstituted for ligation the galvano-caustic wire. Like the ligature, it\\nhas been used in severing the tumor from the body by cutting its way\\nFergusson s percutaneous ligature (after Fergusson).\\nfrom the surface and by destroying the tumor-tissue subcutaneously.\\nThe latter method of application has proved very useful in the treat-\\nment of subcutaneous angioma, as the overlying skin is protected\\nagainst cauterization by insulating the platinum wire at the points of\\nentrance and exit. The galvano-caustic wire has been a great improve-\\nment over the ligature, as it completes its work almost as quickly as\\nthe knife and leaves a wound much less liable to infection. One great\\nobjection to the use of the galvano-cautery is the well-known fact that\\nthe apparatus is very liable to get out of order, often necessitating a\\nresort to other measures. With few exceptions it has been superseded\\nby the needle-point of the Pacquelin cautery.\\nBcrasement Lineaire. The removal of tumors by linear crushing\\nwas devised by Chassaignac. The parts included in the chain or wire\\nof the ecraseur are divided slowly and, if no large vessels are present,\\nbloodlessly. Chassaignac was an enthusiast in the use of his ecraseur\\nFig. 52. Chassaignac s chain ecraseur.\\n(Fig. 52). In his practice it almost displaced the knife. According to\\nChassaignac s own directions, the tissues should be divided very slowly,", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0145.jp2"}, "140": {"fulltext": "126 PATHOLOGY AND TREATMENT OF TUMORS.\\nfor the purpose of guarding more efficiently against hemorrhage. That\\nhemorrhage is not always prevented even by exercising the greatest\\ncaution is well known. The writer has seen profuse hemorrhage from\\nboth lingual arteries after amputation of the tongue by the ecraseur.\\nRhinologists and laryngologists have invented minute ecraseurs upon\\nwhich they rely almost exclusively in the removal of polypoid growths\\nfrom the nasal cavities and the larynx. The general surgeon at the\\npresent time seldom resorts to the ecraseur. Mr. Hutchinson prefers\\nFig. 53. Wire ecraseur.\\nit to the knife or the scissors in removing the tongue, but few surgeons\\ncould be induced to follow his example.\\nAvulsion. The removal of a pedunculated tumor by torsion is\\naccomplished by grasping the pedicle, as close to its attachment as pos-\\nsible, with a pair of strong forceps and twisting it around its axis until\\nthe tumor is torn from its bed. This has been a favorite method of\\nremoving polypoid growths of the nose and the uterus. If the tumor\\nis soft, the removal is often incomplete, and a return of the growth is\\nthe rule if the pedicle is large and firm, unnecessary damage is often\\ninflicted upon the organ to which the tumor is attached. Avulsion\\nshould give way to the galvano-caustic wire, to the ecraseur, or to\\nenucleation.\\nExtirpation. The general surgeon, with few exceptions, removes\\nall tumors by extirpation. This method of eradicating tumors has\\nprecision. The knife can be made to include any tissue that may pre-\\nsent a suspicious appearance, and it enables the surgeon to examine\\nthe tissues as he proceeds with the operation, and thus to outline more\\naccurately the limits of the tumor. The operation can be performed\\npainlessly by placing the patient under the influence of an anesthetic,\\nand the wound can be made to heal by primary intention. The con-\\ntrast between the speedy and painless removal of a tumor by excision\\nand the slow and painful destruction by caustics is great. The wound\\nleft after the use of caustics has to heal by a slow process of granula-\\ntion, and, as so often happens, incomplete removal transforms a subcu-\\ntaneous into an open ulcerating cancer, with all the risks and incon-\\nveniences incident to such a condition. Incomplete removal by caustics\\ninvariably results in -aggravation of all the local conditions, as the\\ninflammation which follows cauterization imparts a new stimulus to", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0146.jp2"}, "141": {"fulltext": "TREATMENT OF TUMORS. 127\\ntumor-growth. The risks of hemorrhage and infection are much greater\\nafter cauterization than after excision. The removal of benign tumors,\\ncarcinoma, and sarcoma by extirpation should be made the rule, and\\nthe use of caustics be reserved for exceptional cases of carcinoma.\\nThe idea that the results after extirpation of malignant tumors are\\nbetter if the wound suppurates and heals by granulation is wrong both\\nin theory and in practice. Inflammation is one of the most influential\\nfactors in effecting a speedy recurrence if the tumor has not been\\nremoved completely. In extirpation of tumors it should be the aim of\\nthe surgeon to secure healing of the wound by primary intention. If the\\nmargins of the wound cannot be brouglit into apposition by suturing,\\nowing to the removal of an extensive area of skin with the tumor, the\\nmargins should be approximated as far as possible by tension-sutures,\\nand the remaining surface be covered with a Wolfe skin-graft or with\\na mosaic of Thiersch skin-grafts. For the purpose of preventing wound-\\ncomplications, and with the view of securing speedy healing of the wound\\nand of obtaining an ideal functional and cosmetic result, it is absolutely\\nnecessary to resort to the strictest antiseptic precautions in the extirpation\\nof a tumor, irrespective of its size or its location.\\nThe instruments should be sterilized by boiling for at least ten\\nminutes in a 1 per cent, solution of carbonate of soda. Sterile liga-\\ntures, sutures, and gauze sponges should be used. The field of opera-\\ntion and the hands of the operator and of his assistants should be\\ndisinfected thoroughly by scrubbing with warm water and potash soap\\nfor at least five minutes, followed by washing in a 1 1000 solution of\\ncorrosive sublimate. If the tumor occupies any of the large cavities, the\\npatient must be prepared thoroughly for the operation by preliminary\\ntreatment continued for several days. The external incision should be\\namply large, to facilitate deep dissection. The danger of a wound is\\nno longer estimated by its size. The attempt to remove tumors\\nthrough small incisions is attended by greater risks of injury to\\nimportant structures than when the parts we wish to avoid are well\\nexposed by a large incision. The incision should be made in a loca-\\ntion and direction which will render the tumor most accessible and\\nwhich will not implicate important structures. It must be remem-\\nbered that tumors often displace important vessels and nerves, and on\\nthis account special care is necessary to avoid these structures when\\ndisplaced. In operating upon the extremities the incision should be\\nmade parallel with muscles. In extirpating tumors of the neck an\\nincision in the direction of the sterno-cleido-mastoid muscle is usually\\nmade. A transverse incision is preferred by some operators in the\\nremoval of tumors of the thyroid gland. Submaxillary growths should", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0147.jp2"}, "142": {"fulltext": "128 PATHOLOGY AND TREATMENT OF TUMORS.\\nbe approached through a slightly-curved incision below the border of\\nthe lower jaw. In amputations of the breast the incision is prolonged\\nbehind the border of the pectoralis major muscle to the apex of the\\naxilla. Tumors of the groin are laid bare by making an incision\\nparallel with and a little below Poupart s ligament, and joining it by\\na vertical incision over the femoral vessels extended to the apex of\\nScarpa s space. A slightly-curved incision affords more room than\\na straight one. If the skin or the mucous membrane over the tumor\\nis implicated, it is included between two elliptical incisions and is\\nremoved with the tumor. After a benign tumor has been reached,\\ncutting instruments are laid aside and the tumor is removed by enucle-\\nation, using for this purpose the finger, Kocher s director, or blunt-\\npointed scissors. Extirpation of osteoma and chondroma requires the\\nuse of the chisel or the saw. Some cysts have such firm attachments\\nthat enucleation is impracticable, in which event their removal is effected\\nby careful dissection. If the extirpation of a tumor requires a prelim-\\ninary myotomy, the muscle should be united by buried absorbable\\nsutures before the external wound is closed. If a nerve or a tendon\\nis accidentally or intentionally cut, it is united in a similar manner.\\nIf an important fascia has been divided, it is separately sutured. As\\nbenign growths are aseptic pathological conditions, the external wound\\ncan be closed throughout by sutures and sealed. The after-treatment\\nshould include rest of the part operated upon, which can be secured\\nby rest in bed, bandages, splints, etc. Operations for carcinoma and\\nsarcoma are attended by great difficulties, as with the tumors the sur-\\ngeon must include a zone of tissue surrounding them, and must usually\\nextend the operation far into apparently healthy tissue to reach and\\nremove the products of regional infection. Two great difficulties con-\\nfront the surgeon during the course of the operation. In the absence\\nof any limiting structures he is often in doubt concerning the amount of\\ntissue he should include with the tumor, and, again, to what extent he\\nshould invade the vicinity in his attempts to eradicate the disease. No\\ndefinite rules can be laid down to guide the surgeon in deciding these\\nmost important points of the operation. He must take pathological\\nanatomy as his guide. It is well known that sarcoma follows connec-\\ntive tissue, blood-vessels, nerve-sheaths, and muscles. The surgeon\\nmust therefore include as much tissue in the direction of these pathways\\nas is permissible with the importance of the structure involved. The\\namount of tissue to be included must necessarily vary with the character\\nof the tumor, its location, and the importance of the structures in its\\nvicinity. The farther the tumor is away from important vessels and\\nnerves, and the more tissue can be included, the better will be the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0148.jp2"}, "143": {"fulltext": "TREATMENT OF TUMORS. 129\\nresults. As a rough estimate the writer would say that the incisions\\nshould be made at least an inch away from the periphery of the tumor.\\nSarcoma of bone usually demands amputation, although recently suc-\\ncessful local operations have been made in cases of circumscribed\\nmyeloid sarcoma. If amputation is performed, the entire bone should\\nbe removed that is, amputation should be made through or above the\\nproximal joint. In the removal of a malignant tumor enucleation must\\nnever be attempted the tumor must be excised. Extirpation here means\\nthe removal not only of the tumor, but also of all infected tissues in its\\nvicinity or in the same region. The knife or the scissors must be used\\nfrom the beginning to the end of the operation. The extirpation of a\\ncarcinoma, unless the tumor involves a free surface and is recent and\\nlocalized, must be follozved by excision of the lymphatic glands of the\\nsame region, whether enlarged or not enlarged. The tumor and the string\\nof lymphatic glands should be removed in one continuous piece by\\nthorough and clean excision. It has been shown that carcinoma fre-\\nquently selects the connective tissue as pathways for local infection hence\\nas much of the connective tissue as possible in the vicinity of the tumor\\nshoidd be included in the excision. Muscles are often divided or removed\\nin operations for malignant tumors. Partial removal for malignant dis-\\nease of organs not essential to life is bad surgery. In operating for\\nmalignant disease parts and tissues must be removed regardless of the\\ncosmetic result. The surgeon who operates with a view of securing a\\ngood cosmetic result is very liable to perform an incomplete operation.\\nThe primary indication in the extirpatioii of a malignant tumor is to re-\\nmove all infected tissues the cosmetic result is of secondary consideration,\\nand can be improved immediately or later by plastic operation. After\\noperation it is advisable to watch the patient carefully, and in case of\\nrecurrence to repeat the operation. By following this course there is\\nno doubt that the patient is made more comfortable and life is pro-\\nlonged, and occasionally a radical cure is effected by repeated opera-\\ntions for local recurrence.\\nContraindications to radical operations for malignant disease are\\n1. Metastasis; 2. Extreme old age; 3. Regional infection beyond the\\nreach of complete removal of diseased tissue without imminent danger\\nto life 4. Very extensive local infection, as in cases of diffuse cancer\\nen cidrasse.\\nPalliative Treatment.\\nPalliative treatment is indicated in cases of inoperable malignant\\ntumors. It consists in protecting the tumor against irritation, and, in\\nopen ulcerating tumors, in partial removal, antiseptic applications, and", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0149.jp2"}, "144": {"fulltext": "130 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe use of anodynes to subdue pain. If the tumor is on the surface,\\nit should be protected against friction by the clothing by a compress\\nof aseptic absorbent cotton held in place by a bandage or by strips of\\nadhesive plaster. As soon as indications of ulceration appear, the sur-\\nface should be disinfected thoroughly and be protected by an antiseptic\\ndressing, so that when the tumor-tissue is exposed the ulcerated sur-\\nface will be protected against infection. If the ulcer or fungous mass\\nhas become infected, it is necessary to correct the fetor by the employ-\\nment of strong antiseptic applications. Chlorine-water, solution of per-\\nmanganate of potash, saturated solution of acetate of aluminum, and\\nsolution of chlorinated soda (Labarraque s solution) are most efficient\\nin correcting the putrefactive processes. A 10 per cent, solution of\\nchloride of zinc, carefully applied with a camel s-hair brush to the dried\\nsurface of the ulcer, is one of the best disinfectants. The writer has\\nfound a solution of hydrate of chloral (2 100) not only a good anti-\\nseptic, but also a local anodyne. The stronger antiseptics, creosote,\\ncarbolic acid, and corrosive sublimate, must be used with caution, as\\nthe prolonged use of even a weak solution might result in intoxication.\\nVegetable charcoal has been popular for a long time as a deodorizer.\\nGreat benefit often follows the removal of fungous granulations with\\na sharp spoon, followed by an energetic use of the actual cautery.\\nThis treatment is frequently resorted to with decided temporary im-\\nprovement, so far as the local conditions are concerned, in the palliative\\ntreatment of inoperable carcinoma of the uterus. Bleeding from the\\nulcerated surface, commonly of capillary origin, is best controlled by\\napplying a few layers of gauze saturated with liquor, ferri sesqui-\\nchlorati, over which an antiseptic tampon is applied, and the whole kept\\nin place with the dressing applied to the ulcer by broad strips of ad-\\nhesive plaster. If a large vessel is the source of hemorrhage, and can\\nbe tied neither in loco nor at a distance, the antiseptic tampon will have\\nto be relied upon. Very little is to be expected in the way of allevi-\\nating pain from local anodynes of these, cocaine has proved the most\\nuseful. A strong solution (10 per cent.) of cocaine applied to ulcerating\\ncarcinomata of the cavity of the mouth has done much to relieve pain\\nand dysphagia. Arnott derived great benefit from cold applications.\\nThe cold coil or the ice-bag deserves a trial as a local anesthetic. Sub-\\ncutaneous injections of morphia have to be relied upon to allay pain\\nand to procure sleep. The smallest dose possible should be com-\\nmenced with the dose must be increased rapidly as the pain increases\\nin severity and the patient becomes habituated to the use of the drug.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0150.jp2"}, "145": {"fulltext": "XII. CLASSIFICATION OF TUMORS.\\nA rational, systematic classification of tumors is to the surgeon\\nwhat the analytical key is to the botanist. A uniform system of classi-\\nfication of tumors is one of the great wants of modern pathology, and\\nall attempts in this direction have proved failures. New classifications\\nare being introduced from time to time, but each of them invariably\\nrepresents the individual author s own views regarding the origin and\\nnature of tumors. A classification which will be intelligible to the\\nstudent and of practical utility to the surgeon must be based on the\\nhistogenesis and the clinical aspects of tumors. As the histologist\\ntraces the normal tissue to its embryonic origin, so the pathologist must\\nfollow the tumor-cells to the embryonic matrix which produced them,\\nin order to trace tumors to their primary histogenetic origin and to\\nclassify them upon a histological basis. The botanist includes in the\\nsame class wholesome and poisonous plants from their morphological\\nresemblance, and the pathologist groups together tumors which have\\na common embryonic origin but in making a classification he must\\nmake a subdivision according to their clinical aspects, which means\\ntheir relation to the surrounding tissues and the organism. To Virchow\\nbelongs the honor of having attempted the first systematic classifica-\\ntion of tumors on a histological basis.\\nVirchow s Classification.\\n1. Histioid;\\n2. Organoid\\n3. Granulomata;\\n4. Teratoid\\n5. Combination tumors\\n6. Extravasation- and exudation-tumors\\n7. Retention-cysts.\\nAmong the histioid tumors he included all tumors composed of one\\nkind of cells.\\nThe class of organoid tumors he made to include all tumors com-\\nposed of several kinds of tissue-elements with a definite typical arrange-\\nment of the component parts.\\n131", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0151.jp2"}, "146": {"fulltext": "132 PATHOLOGY AND TREATMENT OF TUMORS.\\nAmong the infective swellings he included carcinoma and sarcoma,\\ncalling this group granulomata. Teratoma was the term applied\\nto tumors composed of a system of organs arranged in an imperfect\\nmanner, of course, and representing different parts of the body, and\\nsometimes a perfect body, such as dermoid cysts and fcetus in fcetii.\\nCombination tumors, as the term implies, are tumors composed\\nof different kinds of tumor-tissue representing two or more histioid\\ntumors, such as adeno-chondroma, myofibroma, etc.\\nThe extravasation- and exudation-tumors include swellings con-\\ntaining blood, serum, or inflammatory products.\\nA pure histioid tumor, according to Klebs, could be found only in\\na very small epithelioma and a small sarcoma. In large tumors it is\\nrepresented by angioma.\\nThe term organoid as applied to tumors is incorrect and mislead-\\ning, because even the most perfectly-developed adenoma, as well as all\\nthe rest of the tumors, lacks physiological function.\\nCompound tumors occur in consequence of degenerative changes\\nor of change in the type of tissue-growth in a primary simple tumor.\\nThe granulomata and the extravasation- and exudation-swellings,\\nwhich should no longer be classified with tumors, will be eliminated\\nfrom our classification.\\nRetention-cysts are not tumors, but have so much in common with\\ntumors, and occupy such a conspicuous place in the differential diag-\\nnosis, and require so frequently the same treatment as tumors, that\\nthey will be treated under a separate head in this book.\\nCohnheim s Classification.\\nFibroma\\nLipoma\\nMyxoma\\nChondroma\\ni. Connective-tissue type. Osteoma;\\nAngioma\\nLymphangioma\\nLymphoma\\nSarcoma.\\nEpithelioma\\nOnychoma\\nStruma\\nCystoma\\nI Adenoma\\nv Carcinoma.\\n2. Epithelial type.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0152.jp2"}, "147": {"fulltext": "CLASSIFICATION OF TUMORS.\\n135\\n3. Myomata.\\n1. Archiblastic neoplasms.\\nf Myoma laevi-cellulare\\nMyoma stri-cellulare.\\nT f Neuroma\\n4. Neuromata.\\n5. Teratomata. (Virchow).\\nThe classification of tumors as prepared by a committee of the\\nCollege of Physicians and Surgeons of London is very defective, as\\namong tumors it includes swellings the product of other pathological\\nconditions.\\nWilliams s Classification.\\nLowly organized\\nc Squamous\\nEpithelioma. Cylindrical;\\nGlandular.\\nHighly organized\\nAdenoma\\nCystoma (neoplastic)\\nPapilloma.\\nLowly organized\\nSarcoma\\nMyxoma.\\nHighly organized\\nFibroma\\nLipoma\\nChondroma\\nOsteoma.\\nWilliams and Klebs classify tumors into archiblastic and parablastic,\\nin accordance with the division by His of tissue in the embryo. For\\nthe sake of simplifying the location of tumors anatomically in the diag-\\nnosis, as well as in pointing out the differences of structure and func-\\ntion of the cells of the epiblast and hypoblast, we shall retain the\\ndistinction between epiblastic and hypoblastic tumors.\\nVirchow from a practical standpoint divided all tumors again into\\n1. Homologous 2. Heterologous terms which have been used wrongly\\nas synonymous with the designation benign and malignant. All\\nmalignant tumors are heterologous, but not all heterologous tumors arc\\nmalignant. According to Virchow, a heterologous growth is a tumor\\nwhich in its histological structure deviates from the type of tissue from\\nwhich it grows, while a homologous tumor is one which reproduces\\nthe type of tissue of the part or organ in which the tumor is located.\\nThe innocent tumors histologically very closely resemble normal tissue\\n2. Parablastic neoplasms.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0153.jp2"}, "148": {"fulltext": "134 PATHOLOGY AND TREATMENT OF TUMORS.\\nno such resemblance can be seen in the malignant tumors. The former\\nare homologous, the latter heterologous but there are instances where\\nan innocent tumor is heterologous (chondroma), and malignant tumors\\npresent a homologous appearance during the earliest stages of their\\ndevelopment. A familiar illustration of what is meant by the term\\nhomologous is furnished by a myofibroma of the uterus, because it\\ncontains all the tissue-elements of that part of the uterine wall with\\nwhich it is in contact. A chondroma in any of the glands as the paro-\\ntid, mammary, and testicle represents a benign heterologous tumor,\\nbecause cartilage is not a normal histological constituent of these\\nglands. According to Cohnheim, all chondromata are heterologous\\ntumors, as they never spring from cartilage where it normally exists,\\nbut occur in bone and soft tissues where cartilage has no legitimate\\nphysiological existence. Using the term heterologous in a strictly\\npractical sense, the only tumors that are destructive are those which\\nare heterologous in their origin and location. The homologous tumors\\nmay become destructive only by accident. Heterotopic tumors are\\nheterologous tumors. Heteroplasty is another term introduced by\\nVirchow, and in its strictest sense it takes in the malignant tumors.\\nAccording to the views of this author as to the origin of malignant\\ntumors, in cases of sarcoma and carcinoma during the earliest stages\\nwe meet with indifferent cells which, according to the nature of the\\ninitiative, assume an epithelial or connective-tissue type. It must be\\nremembered that Virchow entertained the belief that carcinoma and\\nsarcoma have a common origin in connective tissue, and that during\\na later stage the new products differ as their cellular elements reach\\nvarious degrees of development.\\nRobin and Waldeyer showed conclusively that epithelial tumors are\\nnever developed from a connective-tissue matrix. Lancereaux, Klebs,\\nand others have excluded from the mesoblastic tumors endothelioma,\\nas being a separate type closely resembling epiblastic and hypoblastic\\ntumors. Lancereaux described endothelial tumors of the lymphatics\\nof the peritoneum Robin, of the arachnoid and peritoneum Gaucher,\\nof the spleen from the endothelia of blood-vessels and lymphatic\\nglands Monod and Arthraud, of the retina from the vascular endo-\\nthelia.\\nSutton claims that the same relation exists between sarcoma and\\nendothelioma as between carcinoma and epithelioma. We shall include\\nendothelioma among the malignant mesoblastic tumors, and thus\\nadhere strictly to the classification made in accordance with the division\\nof embryonic tissue into the three germinal layers. We shall also\\nendeavor to show that the endothelial cells are capable of being trans-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0154.jp2"}, "149": {"fulltext": "CLASSIFICATION OF TUMORS. 135\\nformed into ordinary connective tissue, and vice versa, and that their\\nclose histological and pathological relationship to the connective-tissue\\ntumors would, a priori, tend to prove that they are subject to tumor-\\nformation of the same type as the common connective tissue of similar\\nhistogenetic origin. From a practical standpoint, the division of tumors\\naccording to their clinical aspects manifested by their relations to the\\nadjacent tissues and to the organism has always been, and always will\\nbe, of the greatest importance to the surgeon. Clinically, tumors have\\nbeen divided into\u00e2\u0080\u0094 1. Benign; 2. Malignant; 3. Suspicious. We have\\nexplained elsewhere why the third class should be abolished. A tumor\\nis either benign or malignant. The tumors classified heretofore as sus-\\npicious are tumors which from their structure or location present con-\\nditions not favorable for thorough removal by the usual operations\\nmade for the removal of benign tumors. Such tumors as chondroma\\nand myxoma, about which there has always lingered a suspicion as to\\ntheir benign nature, from a practical standpoint have been regarded\\nas innocent growths, and incomplete removal is responsible for many\\nrelapses after operation. The sudden change in the clinical behavior of\\ntumors which have been pursuing a benign course for perhaps a long time\\nis no evidence of a semi-malignant nature of the tumor, but is an evidence\\nthat a benign tumor has undergone transition into a malignant stage, or\\nthat the tumor was malignant from its incipiency, and has passed from\\na latent into an active condition. All the embryonic germinal layers\\nfurnish matrices for benign and for malignant tumors. The clinical type\\nof the tumor depends upon the stage of arrest of development of the cells\\ncomposing the matrix derived from the embryo or from embryonic cells\\nof post-natal origin.\\nThe cells composing the tumor-matrix produce a tumor that is either\\nbenign or malignant. We shall speak of benign and malignant tumors\\nof the epiblast and hypoblast and the mesoblast. A benign tumor is\\none which never extends beyond the germinal layer in which it had its\\norigin, while a malignant tumor extends to and involves tissues derived\\nfrom germinal layers other than the one from which it had its origin.\\nThe extension of a tumor to adjacent tissues irrespective of their structure\\nor their embryonic oi r igin has been regarded for a long time as the most\\nreliable clinical proof of the malignant nature of the tumor.\\nWe shall classify tumors with special reference to their origin from\\nthe different germinal layers the epiblast, the hypoblast, and the meso-\\nblast and to the stage of arrest of development of the cells composing\\nthe tumor-matrix. The lowly-organized tumor-tissue will represent the\\nmalignant tumors, and tumors composed of highly-organized cells will\\ninclude all benign growths. In the description of the different varieties", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0155.jp2"}, "150": {"fulltext": "136\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nof tumors the benign tumors will be considered first, as the tissues of\\nwhich they are composed bear a closer resemblance to normal tissue\\nthan do the tissues of malignant tumors, and hence the deviation from\\nthe laws governing normal growth and nutrition is less marked.\\nAuthor s Classification.\\nf Papilloma\\nI. Epiblastic and hypoblastic J Adenoma;\\ntumors.\\n2. Mesoblastic tumors.\\nI Cystoma\\nL Carcinoma.\\nFibroma\\nLipoma\\nMyxoma\\nChondroma\\nOsteoma\\nAngioma\\nLymphangioma\\nLymphoma\\nyr Lsevi-cellulare\\n1 Stri-cellulare\\nat f Neuroma,-]\\nNeuromata, J Amyelmic;\\nGlioma (Klebs);\\nSarcoma.\\nTeratomata.\\nEpiblastic, hypoblastic, and\\nmesoblastic tumors.\\nSwellings caused by reten-\\ntion of physiological se- f Retention-cysts.\\ncretion. J", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0156.jp2"}, "151": {"fulltext": "XIII. PAPILLOMA AND ONYCHOMA.\\nPapilloma.\\nA papilloma is a non-malignant epithelial tumor of the cutaneous or\\nmucous surface. The essential part of the tumor is composed of epithe-\\nlial cells the framework is furnished by the connective tissue under-\\nneath the epithelial proliferation. The tumor-tissue proper is outside\\nthe limits of the vascular area, being separated from it by the mem-\\nbrana propria. The tissues of the epiblast and the hypoblast possess\\nno independent organ-producing power, as their blood-supply is derived\\nfrom the mesoblast. Epithelial cells in the normal mesoblast have no\\npower to proliferate, hence in cases in which we find them multiply-\\ning here the mesoblast has undergone changes. The epithelial cells\\nreceive their nourishment from the blood-plasma and the leucocytes.\\nAs the stroma of an epithelial tumor is derived from the mesoblast, an\\nepithelioma is a mixed tumor, in which, however, in accordance with the\\nlaw of the legitimate succession of cells, the epithelial cells are derived\\nfrom the epiblast or the hypoblast, and the connective tissue from the\\nmesoblast. The development of new tissue from these sources is usu-\\nally unequal sometimes the product of one, and sometimes that of the\\nother, predominates. The unequal representation of the two different\\ntissue-elements, epithelial cells and connective tissue, in this form of\\ntumor has given rise to a great deal of confusion in classification. As\\npapillary formations are found in many tumors not belonging to this\\nvariety, and as in many specimens fibrous tissue predominates, Virchow\\nobjected to papilloma as a separate variety of tumors. Rokitansky\\nalso treated papilloma as a variety of fibroma. Virchow proposed\\nthe name fibroma papillare. However, in most tumors which deserve\\nthe designation papilloma the epithelial elements predominate and\\nimpart character to the tumor the reticulum, if it predominates, being\\nan accidental product. It is the intention of the writer to show, as far\\nas possible, in connection with every variety of tumors, the counter-\\npart in the normal tissues of the body. A papilloma of the skin under\\nlow power presents in a hypertrophic condition all the tissues of which\\nthe skin is composed.\\nHistology and Pathology. Papilloma of the skin, as shown in\\nFigures 54 and 55, represents the same papillary structure as the skin,\\n137", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0157.jp2"}, "152": {"fulltext": "138\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nthe number of papillae depending on the size of the tumor. In papil-\\nloma of the hypoblast the villi correspond with the papillae of the\\nepiblastic papilloma. The connective tissue and the vessels occupy\\nthe centre of the papillae (Fig. 55, a), and present, on vertical section\\nof the tumor, finger-like projections conical in shape, the base corre-\\nsponding with the base of the tumor, and the apex with the summit\\nof each papilla. The epiblastic papilloma is covered by stratified layers\\nof squamous epithelial cells. The new cells are produced near the\\nvascular territory (Fig. 55, b). As the cells become older they lose the\\nliquid part of their contents by exposure on the surface and by more\\nFig. 54. Section of human skin (after Piersol) a, stratum corneum b, stratum Iucidum; c, stratum\\ngranulosum; d, stratum Malpighii e, f, papillary and reticular layers of corium g, stratum of adipose tis-\\nsue h, i, spiral and straight portions of duct of sweat-gland k, coiled portion of sweat-gland vascular\\nloops occupying papillae of corium.\\ndistant removal from the vascular supply, forming the horny layer of the\\npapilloma (Fig. 55, c). The papilloma of the hypoblast is composed of\\na connective-tissue stroma, usually softer and more vascular than that\\nof epiblastic papilloma, and of cells corresponding in type to the cells\\nof the mucous membrane in which the tumor is located. The pave-\\nments of cells which constitute the essential part of the tumor are made\\nup of cylindrical cells. As hypoblastic tumors are constantly exposed\\nto maceration by the contents of the hollow organs in which they are\\nlocated, the epithelial cells become cedematous and are very liable to\\nundergo myxomatous degeneration. Even by excluding the papillo-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0158.jp2"}, "153": {"fulltext": "PAPILLOMA AND ONYCHOMA. 1 39\\nmata of inflammatory origin, we have, so far as the texture of the\\ntumor is concerned, two varieties (i) hard and (2) soft. The density\\nof a papilloma depends on the amount and character of the stroma and\\nthe location of the tumor. If the stroma is abundant and compact,\\nr ?M\\nI\\n\u00e2\u0096\u00a07.\\nFig. 55.\u00e2\u0080\u0094 Papilloma of skin X 50 (Surgical Clinic, Rush Medical College, Chicago) a, connective tissue;\\nb, embryonic epithelial cells c, old squamous epithelial cells.\\nand if the tumor is not exposed to maceration by constant moisture,\\nthe tumor is firm on the contrary, if the stroma is scanty, if the con-\\nnective-tissue fibres are loosely arranged and vascular, and if the\\nepithelial cells, by constantly imbibing moisture from their environ-\\nment, become \u00c2\u00a9edematous, the tumor is soft. The former conditions\\nare most frequently presented by tumors of the skin and of mucous\\nmembranes derived from the epiblast, and the latter condition by tumors\\nof mucous membranes lining hollow viscera and paved with columnar\\nepithelium. In some instances a papilloma is covered by columnar\\nepithelia if the tumor occupies a location surrounded by squamous\\nepithelia. Hard papillomata are found most frequently in the skin and\\nin the mucous membrane of the lip, mouth, soft palate, nose, larynx,\\nurethra, vagina, and cervix uteri. The soft variety is found most fre-\\nquently in the mucous membrane of the intestinal canal and oi~ the\\nbladder. If a number of papillomatous tumors develop simultaneously", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0159.jp2"}, "154": {"fulltext": "140 PATHOLOGY AND TREATMENT OF TUMORS.\\nor in succession in the same neighborhood, they form tumor-masses\\nof greater or less circumference with a mushroom-like surface. The\\npapillary excrescences are often branched, producing the so-called\\ndendritic vegetations. This condition is often found upon mucous\\nsurfaces. If the papilloma is not subjected to injury and is otherwise\\nsurrounded by favorable conditions for rapid growth, it often elongates\\ninto a delicate filamentous tumor, as is frequently seen in the bladder.\\nThe connective-tissue core conveys vessels and nerves to each papil-\\nlary growth, the vessels forming loops as in the papillae of normal\\nskin and in the villi of the intestinal mucous membrane. In papillary\\ngrowths in joints the vessels are absent. In benign epithelial tumors\\nof the skin we often find epithelial cells in concentric layers arranged\\nin pearl-like masses, a proof of the independent proliferation of the\\nepithelial cells. A papilloma never attains great size, large tumors of\\nthis kind being met with only as a result of the confluence of a number\\nof tumors. By the aggregation of numerous tumors, masses the size\\nof a fist are observed in the rectum and upon the prepuce and the labia\\nmajora. An individual tumor seldom exceeds the size of a cherry. The\\ngrowth of a true papilloma is always very slow, papilloma manifesting\\nin this respect much less activity than infective papillomatous growths.\\nAmong the degenerative processes which most frequently affect papil-\\nlomatous tumors are cretefaction, myxomatous degeneration, and ulcer-\\nation. Cretefaction often arrests the further growth of a papilloma of\\nthe skin. Myxomatous degeneration most frequently attacks tumors\\nof hypoblastic origin. Ulceration is the result either of mechanical\\nirritation or of infection with pathogenic microbes through an abrasion\\nor a fissure of the surface of the tumor. If in a pedunculated papil-\\nloma the principal artery becomes thrombosed, either in consequence\\nof an injury, such as twisting of the pedicle or traction, or as one of\\nthe results of an accidental inflammation, gangrene of the tumor is\\nproduced, usually resulting in a permanent cure. Psammoma is very\\nprone to undergo calcification which limits tumor-growth a fortunate\\noccurrence, considering the importance of the locality occupied by such\\ntumors.\\nTransformation into Malignant Tumors. Of all tumors, papillo-\\nmata are most liable to undergo malignant transformation.. The irrita-\\ntion to which such tumors are frequently exposed by their location upon\\na surface will account satisfactorily for this well-established clinical fact\\nThis transition is observed most frequently in tumors which occupy local-\\nities most exposed to irritation. We seldom hear of a papilloma of the\\ncavity of the mouth undergoing such a transformation, while carcinoma\\nfrequently originates in a papilloma of the lip. Papilloma constitutes", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0160.jp2"}, "155": {"fulltext": "PAPILLOMA AND ONYCHOMA. 141\\na more frequent starting-point of a carcinoma than of a sarcoma. The\\ndeepest stratum of epithelial cells is composed of young cells which\\nare in touch with the membrana propria, which, so long as the tumor\\nremains benign, constitutes an impermeable partition between the essen-\\ntial tumor-elements and its stroma, the subcutaneous or submucous\\nconnective tissue. If, in consequence of prolonged irritation or other\\nexciting causes, this partition is damaged, the embryonic cells have\\naccess to the vascular part of the tumor, and, once there, the trans-\\nformation from a papilloma into a carcinoma takes place. If, on the\\ncontrary, fetal rests or post-natal embryonic cells in the connective-\\ntissue part of the tumor become environed by causes favoring tumor-\\ngrowth, the papilloma is transformed into a sarcoma. Such a trans-\\nformation was observed by Simon in a papillary growth of a joint.\\nSarcoma of the skin has occasionally a similar origin.\\nTopography. Papilloma is met with in various parts of the body,\\nbut some parts are more predisposed to it than others. It is most fre-\\nquent in localities most exposed to irritation. We shall not include\\npapilloma of an infective origin as warts, condylomata, and molluscum\\ncontagiosum, all of which are inflammatory swellings and not true\\ntumors in the discussion of the topographical distribution of papil-\\nloma. Warts (verruca) come and disappear mysteriously. They increase\\nin size much more rapidly than papilloma, and they often disappear\\nspontaneously. Condyloma, another papillomatous inflammatory swell-\\ning resembling in its structure papilloma, almost always appears mul-\\ntiple in places where skin and mucous membrane meet and are bathed\\nwith infective discharges, usually of a gonorrheal origin. The vulva,\\nthe prepuce, and the anal region are the parts most frequently affected\\nby condyloma. The removal of the primary causes usually results in\\na speedy cure. Molluscum (Bateman) or epithelioma contagiosum\\n(Virchow) is now generally recognized as an inflammatory swelling.\\nIts contagiousness is the best possible evidence that it is not a tumor.\\nHaab succeeded in producing it artificially in animals by inoculation.\\nAustrian and English dermatologists have traced its starting-point to\\nsebaceous glands. The papillary growths of non-infective origin, the\\ntrue benign epithelial tumors, do not disappear spontaneously their\\ngrowth is limited by an inherent limitation of tissue-proliferation or by\\ndegenerative changes. These tumors have a very wide distribution,\\nand the more important localities inhabited by them, and the different\\nclinical varieties, will now be discussed.\\nSkin. Papilloma of the skin occurs in two principal forms: 1.\\nCornu cutaneum 2. Fibrous papilloma. In the former variety the\\ntumor is composed almost exclusively of epiblastic tissue in the latter", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0161.jp2"}, "156": {"fulltext": "142\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nthe connective tissue derived from the mesoblast is present in varying\\nproportions.\\nCornn Cutaneum. The cutaneous horn represents a form of pap-\\nilloma in which the tumor is composed almost exclusively of desic-\\ncated epithelial cells corresponding with the horny layer of the skin.\\nThe old cells, instead of becoming desquamated, remain attached to\\nthe tumor-matrix, forming projections varying in length from half an\\ninch to twelve or more inches. Such horns are found most frequently\\non the scalp, temple, forehead, eyelid, nose, lip, cheek, shoulder, arm,\\nelbow, thigh, leg, knee, toe, axilla, thorax, buttock, loin, penis (Fig. 56),\\n^iMs w$^^^^\\nFig. 56. Cornu cutaneum of penis (after Pick).\\nand scrotum. The matrix of such tumors is very vascular. Horny\\ntumors of the skin can readily be enucleated, and they seldom return\\nafter removal. A post-natal matrix for cutaneous horns is furnished\\nmost frequently by scars. Cruveilhier described a specimen of cornu\\ncutaneum which originated from a scar following a burn of the forearm,\\nthe tumor reaching such an enormous size that amputation became\\nnecessary (Fig. 57). The tumors in this case were multiple.\\nThat desiccation is not the sole cause in the production and fixation\\nof such an enormous mass of epithelial cells is shown by the fact that\\npapillomata of a similar structure are occasionally found in dermoid", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0162.jp2"}, "157": {"fulltext": "PAPILLOMA AND ONYCHOMA. 143\\nand sebaceous cysts. The matrix of a cutaneous horn undoubtedly\\nnot only possesses the inherent capacity of producing epithelial cells\\nvery rapidly, but also furnishes the cement-substance which fixes the\\nold epithelial cells, thus preventing their removal by desquamation.\\nThere is no reason why papillomata should not develop as secondary\\nformations in epithelial tumors of either a benign or a malignant type.\\nFig. 57. Cornua cutanea from the scar of a burn (after Cruveilhier).\\nNot infrequently we find in the interior of an adenoma, a cystoma, or a\\ncarcinoma papillary growths which resemble in every respect the surface\\npapillomata, and which impart to the tumor additional pathological\\nand clinical characteristics. Papillomatous cysts of the ovary (Fig. 58)\\nare regarded with special interest by the surgeon. A semi-malignant\\nnature was assigned to them long ago. There can be no doubt that\\nin many instances such tumors are malignant from the beginning,\\nbut in other instances the papillomata are benign and remain so. The\\ndesquamated epithelial cells furnish here a part of the contents of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0163.jp2"}, "158": {"fulltext": "144\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ncysts (Fig. 58, d). As in surface tumors, the epithelial cells are strati-\\nfied. Tumors of large size are formed by the aggregation and coales-\\ncence of numerous smaller tumors.\\nThe fibrous papUlomata of the skin occupy most frequently the region\\nFig. 58. Papillomatous cyst of ovary; X no (Surgical Clinic, Rush Medical College, Chicago) a, in-\\nterpapillary space; b, stroma; c, epithelial lining; d, amorphous, non-staining detritus with a few detached\\nepithelial cells e, proliferating areas.\\nof the face, scalp, and hands they are of slow growth and never\\nattain large size.\\nRespiratory Organs. The larynx is the most frequent seat of papil-\\nlomata. Morgagni s pockets are their favorite locations. They appear\\nas isolated affections or as multiple tumors closely aggregated, giving\\nto the mass a cauliflower-like appearance. The symptoms will vary ac-\\ncording to the size and the location of the tumor. Hoarseness, cough\\nharassing in character, and difficult breathing alternating with tempo-\\nrary attacks of dyspnea, are some of the leading clinical features. Not\\ninfrequently, papilloma of the larynx undergoes transformation into car-\\ncinoma, as was probably the case in the instance referred to in the sec-\\ntion treating of the Transformation of Benign into Malignant Tumors.\\nDigestive Tract. The mucous membrane of the cavity of the mouth\\nis derived from the epiblast and is frequently the seat of papilloma.\\nThe favorite localities are the mucous membrane of the cheek, the\\nprolabium of the lip, the tongue, the soft palate, and the pharynx. The\\nnaso-pharyngeal space is frequently studded with papillomatous vegeta-\\ntions. The stomach is almost exempt from this affection. The fre-\\nquency with which the mucous membrane of the intestinal canal is\\naffected increases in a downward direction. Papillomata are rare in the\\nintestines, while in the rectum they are most frequent, and are either", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0164.jp2"}, "159": {"fulltext": "PAPILLOMA AND ONYCHOMA.\\n145\\nFig. 59. Papilloma of the rectum (alter Lucke)\\na, submucous connective tissue b, papillae, some\\nof them branching, covered by columnar epithelia.\\nsessile or pedunculated, constituting a frequent form of polypus of this\\norgan. The writer has repeatedly seen the mucous membrane of the\\nlower part of the rectum studded with papillary tumors varying in size\\nfrom a hempseed to a cherry (Fig.\\n59). The symptoms which attend this\\naffection of the rectum are hemor-\\nrhage, usually slight, tenesmus, and\\na glairy discharge.\\nUrinary Organs. The urinary\\ntract is very often the seat of papil-\\nloma, and no part of it is exempt.\\nPapillomata are frequently located in\\nthe urethra, and especially around the\\nmargin of the meatus in the female.\\nIn this locality they are often multi-\\nple, and they are a source of great\\ndistress to the patient. The tumors\\nare very vascular, are extremely sen-\\nsitive to touch, and are the source of\\ngreat pain during micturition. Papil-\\nlomata of the male urethra are more\\nfrequent than was formerly supposed, and their presence can now be\\nascertained and their removal be facilitated by the use of the urethro-\\nscope. They simulate, and have usually been mistaken for, stricture.\\nPapilloma of the bladder is a frequent affection of this organ. The\\nconnective tissue is usually abundant and carries with it one or more\\nvessels of considerable size. The main stem of the tumor usually gives\\noff branches which in turn again become branched, giving to the tumor\\nan arborescent structure (Fig. 60). As the connective-tissue core of the\\ntumor is often covered by only one layer of epithelial cells, and the ulti-\\nmate branches are often exceedingly delicate, it is easy to understand that\\nsuch tumors frequently give rise to hemorrhage. If the principal artery\\nof such a tumor is eroded or torn, the hemorrhage may become alarm-\\ning and even fatal, Sometimes small fragments of such a tumor are\\nvoided with the urine or are removed in the eye of the catheter, afford-\\ning the surgeon an opportunity to make a correct diagnosis, by the aid\\nof the microscope, in what was before an obscure case. The cysto-\\nscope renders valuable assistance in ascertaining not only the existence,\\nbut also the exact location and character, of the tumor. The liability\\nof such growths to become transformed into malignant tumors is well\\nknown and generally recognized. A very interesting case of papil-\\nlomatous tumors of the pelvis of the kidney is reported by Murchison\\n10", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0165.jp2"}, "160": {"fulltext": "146 PATHOLOGY AND TREATMENT OF TUMORS.\\nand quoted by Sutton. The pelves of both kidneys were similarly\\naffected, and the bladder contained two similar tumors, one on each\\nside near the ureteral orifice. Sutton believes that in this case the\\ntumors in the bladder were secondary, and were caused by the implan-\\ntation of tumor-cells from the primary tumors upon the mucous mem-\\nbrane of the bladder. While this mode of origin is possible, it is more\\nlikely that the tumors developed from so many different tumor-matrices\\nindependently of one another. Multiple papilloma of the same surface\\nor organ is not of rare occurrence.\\nFig. 60. Papilloma of the bladder (after Perls).\\nFemale Organs of Generation. The external genitals, the uterus,\\nand all its appendages represent conditions favorable to the origin\\nand development of papillomatous tumors. We shall, of course, ex-\\nclude infective papillary swellings, which are of such frequent occur-\\nrence upon the external genitals of gonorrheal patients and syphilitics.\\nThe labia (Figs. 61, 62) and the fringes of the hymen are frequently\\nthe starting-points of such growths. The tumors may be either single", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0166.jp2"}, "161": {"fulltext": "PAPILLOMA AND ONYCHOMA.\\nH?\\nFig. 6i.\\n-Papilloma of right greater labium (after Winckel) a, minor labium; b, dilated meatus of the\\nurethra c, papilloma.\\nor multiple, sessile or pedunculated. In the absence of irritating dis-\\ncharges they occasion but little inconvenience, and they are usually\\naccidentally discovered in examinations for\\nother affections.\\nThe so-called erosions of the mucous\\nmembrane of the cervix uteri present under\\nlow power the typical structure of a papil-\\nloma. Many of the small polypoid growths\\nof the cervical canal are papillary tumors.\\nThe uterine mucous membrane is often the\\nseat of multiple papillary tumors which may\\nproduce profuse menstruation and other\\nsymptoms simulating chronic endometritis or\\nmalignant disease (Fig. 63). Papilloma of\\nthe Fallopian tubes has been described by\\nHennig in 1876. Doran first described a\\ntrue papilloma of the tube in 1879, whilst\\nSutton is of the opinion that this tumor is an\\nadenoma. Landau, Kaltenbach, and Eberth,\\nhowever, support the papilloma theory, as\\nthey find that in its earliest stage the growth i\\nFig. 62. Papillomata of lesser\\nlabium (after Winckel) a, clitoris;\\norifice of urethra c, papillomata\\nd, fimbriated hymen.\\npapillary elevation or", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0167.jp2"}, "162": {"fulltext": "148\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nvillus, and not a glandular structure. On the other hand, it is quite\\npossible that the tumor described by Sutton is a distinct affection from\\npapilloma, and is developed, if his theory be correct, from his normal\\ntubal glands if incorrect, from Recklinghausen s Wolffian relics. The\\nsame theory may explain the occurrence of tubular cells found by\\nDoran in primary tubal carcinoma.\\nr.. f V A g\\nr*\u00c2\u00ab\u00c2\u00aba\\nW\\nFig. 63. Papillary excrescences of the mucous membrane of the cervix uteri, vertical section; X 22\\n(after Karg and Schmorl). The papillae, as well as the remnants of glandular tissue, are covered by cylin-\\ndrical epithelia. This section was taken some distance from a carcinoma, and two of the papillae at b are\\ninfiltrated with epithelial cells, indicating the beginning of carcinomatous degeneration.\\nPapillomata may develop upon the surface of the ovary, but more\\nfrequently from the wall of glandular cysts (Fig. 58). Papillary tumors\\nupon the surface of the ovary have been observed by Gusserow, Klebs,\\nBirch-Hirschfeld, and Winckel. The intraglandular papilloma of the\\novary will be described more fully in connection with proliferating\\npapillary cysts of the ovary.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0168.jp2"}, "163": {"fulltext": "PAPILLOMA AND ONYCHOMA. 149\\nBrain. The brain is developed from the epiblast, but papillary\\ntumors of this organ are exceedingly rare. The choroid plexuses are\\nfringed with tufts of epithelium-covered villi which occasionally become\\nthe seat of papillary tumors. Douty describes a case of this kind in\\nwhich the tumor attained the size of a bantam s egg. The patient was a\\nboy seventeen years old, and the tumor produced focal symptoms which\\nenabled the medical attendant to localize the tumor accurately during\\nlife. Sutton is of the opinion that psammoma is an epithelial tumor,\\nbut the majority of pathologists assign to it an endothelial origin, and\\nit will be discussed more fully in connection with epiblastic tumors.\\nDiagnosis. The greatest difficulty encountered in the diagnosis of\\npapilloma is to differentiate from it inflammatory papillary swellings\\nand carcinoma. Inflammatory swellings usually grow rapidly and\\nappear as a multiple affection. The microbic cause can often be ascer-\\ntained. The swellings frequently present signs and symptoms of in-\\nflammation which are lacking in papilloma. The difficulty would be\\ngreatly increased if a papilloma were at the same time in a condition\\nof inflammation. Inflammatory papillary swellings may occur at any\\ntime of life, the only essential cause being the presence of pathogenic\\nmicrobes in quantity sufficient to produce either a subacute or a chronic\\ninflammatory process. Papilloma is most frequent in adults and in\\npersons past middle life. Age is an important factor in the differential\\ndiagnosis between papilloma and carcinoma. Carcinoma affects most\\nfrequently persons past middle life. A papillary carcinoma almost with-\\nout exception is indurated at its base a condition absent in papilloma.\\nIn doubtful cases the microscope will decide the diagnosis. The part\\nof the tumor that it is most important to subject to microscopic ex-\\namination is the base. If sections from this part of the tumor show\\nno epithelial cells on the vascular side of the membrana propria, the\\ntumor is benign the presence of even a limited number of epithelial\\ncells in the subcutaneous or submucous connective tissue is a positive\\nevidence of malignancy. Papillomata of the meninges of the brain\\nand of other inaccessible organs which produce no symptoms cannot,\\nof course, be recognized during life if they produce symptoms, these\\nmust be studied carefully and be referred, if possible, to their proper\\nsource. Papillomata of the larynx, urethra, bladder, uterus, and rectum\\nmust be seen before they can be recognized, and for this purpose the\\ndifferent instruments that render them accessible to sight must be em-\\nployed.\\nPrognosis. Papillomata never attain a large size, consequently they\\nonly become a source of danger to life if, by causing compression o\\\\ an\\nimportant organ or by blocking an important passage, the function oi~", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0169.jp2"}, "164": {"fulltext": "150 PATHOLOGY AND TREATMENT OF TUMORS.\\nan organ is impaired or abolished. A papillary tumor at the base of\\nthe brain may result in fatal cerebral compression. A papilloma of the\\nlarynx may be caught in the rima glottidis, and produce death from\\nsuffocation. Another element of danger is hemorrhage. A papilloma\\nof the bladder has often been the source of serious and even fatal\\nhemorrhage. The liability of a papilloma to undergo transformation\\ninto a malignant tumor must also be taken into consideration, and\\nshould be regarded as a forcible argument in favor of early operative\\ntreatment.\\nTreatment. The only treatment of a papilloma is a radical opera-\\ntion. The tumors being usually small, they can be destroyed by the\\nenergetic use of the needle or the knife-point of the Pacquelin cautery,\\nor be removed by excision. The cauterization or excision should in-\\nclude the entire tumor-matrix if this is not done, a recurrence will\\nalmost surely follow the operation. Incomplete removal of a papilloma\\nwill also favor transformation of the balance of tumor-tissue into a\\nmalignant tumor. Laryngeal papillomata can be removed with a\\nsnare, aided by the use of the laryngoscope, or by laryngotomy.\\nLaryngo-fissure is the preferable method if there is any question\\nconcerning the benign nature of the tumor. Small papillomata of\\nthe uterine cavity and the cervical canal can be removed with a sharp\\nspoon followed by the use of the Pacquelin cautery (cervix) or of\\na safe caustic (uterine canal). Papillomata of the urethra require in\\ntheir removal the urethroscope. When the tumor has been thor-\\noughly exposed to sight it can be removed by torsion or by linear\\ncrushing. Papillomata of the bladder can be rendered sufficiently\\naccessible to operative removal only by a suprapubic incision. The\\nTrendelenburg posture will greatly facilitate the operation. The tumor\\nis removed either by torsion, by the wire ecraseur, or, if broad and flat,\\nby scraping it away with a sharp spoon or a finger-nail. If the bed\\nof the tumor can be exposed sufficiently well to sight and touch, it\\nshould be cauterized lightly with the actual cautery for the purpose\\nof arresting hemorrhage as well as to destroy remnants of the tumor,\\nwhich, if left, would give rise to a speedy recurrence.\\nOnychoma.\\nVirchow described a papillary tumor of the matrix of nails under\\nthe name of onychogry pilosis (Fig. 64), and distinguished it from an inflam-\\nmatory hyperplasia occupying the same locality, which he called onycho-\\nmycosis. A papillary tumor of that part of the cutaneous surface occu-\\npied by the nails resembles in structure and in physical appearance the\\ncornu cutaneum. Such a tumor is composed almost exclusively of the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0170.jp2"}, "165": {"fulltext": "PAPILLOMA AND ONYCHOMA.\\n151\\nproduct of epithelial proliferation, and it has a vascular base. A true\\nnail-horn usually appears clinically as a single tumor, while the inflam-\\nmatory swelling, onychogryphosis, is a multiple affection attacking at the\\nsame time or in succession a number or all of the nails of both hands.\\nFig. 64. Onychogryphosis of toes natural size (after Ziesing).\\nThe inflammatory form of onychoma is extremely common in the toes\\nof bedridden patients, especially old women and those who are filthy.\\nThe true onychoma occurs in persons in perfect health and under the\\nbest sanitary and hygienic conditions. The nail often reaches several\\ninches in length and becomes curved, resembling a ram s horn. The\\nwriter removed a nail of this kind which was three inches in length.\\nA recurrence of the tumor can be prevented with certainty only by\\nextirpation of the whole matrix of the nail.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0171.jp2"}, "166": {"fulltext": "XIV. ADENOMA.\\nAdenoma is a benign epithelial tumor which in structure resembles\\nthe glandular tissue of the organ in which the tumor is located. Ade-\\nnoma is the second variety of benign tumors of the epiblast and the\\nhypoblast. The relation of the epithelial cells to the basement membrane\\nis the reverse of that of papilloma that is, the basement membrane is on\\nthe outside of the parenchyma of the tumor, instead of on the inside, as\\nis the case in papilloma. In papilloma of the cutaneous a?td mucous\\nsurfaces the cellular elements of the tumor often become detached and\\npermanently lose their connection with the tumor in adenoma the cells\\nare confined in hollow spaces bounded by the basement membrane and\\nthey or the imabsorbable products of their regressive metamorphoses\\nremain permanently as a part of the tumor. These differences in the\\nanatomical structure of the tumor will go far to explain why a papil-\\nloma never attains a large size, and why the size to which a rapidly-\\nproliferating adenoma may attain is unlimited. In reference to the\\nrelation of the tumor-cells to the subcutaneous or submucous connec-\\ntive tissue, there exists a great analogy between papilloma, epithe-\\nlioma, adenoma, and glandular carcinoma. An adenoma, as its name\\nimplies, is a glandular tumor. Broca included under the term ade-\\nnoma all circumscribed glandular swellings. Cornil and Ranvier\\nembraced in this class only glandular tumors composed of new gland-\\nular tissue. In the strictest etiological and pathological sense the term\\nshould be limited to glandular tumors containing adenomatous tis-\\nsue produced from a tumor-matrix independently of the pre-existing\\nglandular tissue. As adenoma is present in all the glandular organs,\\nthe cells of which it is composed resemble the type of cells of the\\ngland or duct in which the tumor is located. Glandular tumors, how-\\never, are found in localities where glands do not normally exist. In\\nsuch instances the tumor develops either from a matrix of embryonic\\ncells displaced and isolated during fetal life the so-called rests or\\nfrom a matrix of embryonic cells in a supernumerary or accessory\\ngland. Such accessory glands are found in the vicinity of nearly all\\nthe glandular organs, notably the thyroid, pancreas, spleen, liver, kid-\\nneys, and mammary gland. Adenomata are found quite often in the\\n152", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0172.jp2"}, "167": {"fulltext": "ADENOMA.\\n*53\\naxillary space unconnected with the mammary gland. A fetal matrix\\nin the vicinity of the umbilicus, derived from the intestinal tract, may\\ngive rise to adenomata representing intes-\\ntinal glands. Tumors of this kind were ob-\\nserved by Kustner and Heukelem, and were\\nfreely supplied with unstriped muscular fibres.\\nGlandular tumors springing from a post-natal\\nmatrix of embryonic cells are necessarily\\nconfined to normal or accessory glands.\\nThe histological similarity between an\\nadenoma and the normal tissues in which\\nsuch a tumor may be located is well shown\\nin Figures 65 and 66. The difference be-\\ntween an adenoma and normal gland-tissue,\\nfrom a physiological standpoint, is best shown by tumors of glands\\nin continuous physiological activity, such as the liver and the kidneys,\\nfrom the absence of gland-ducts and the presence of an atypical in\\nplace of a typical circulation.\\nFig. 65. Transverse section of\\nfollicles of large intestine of dog the\\nindividual tubules are separated by the\\nfibrous stroma of the mucosa (after\\nPiersol).\\nFig. 66. Polypus (adenoma) of rectum, showing the glands of the tumor; X 35\u00c2\u00b0 (after D.J. Hamilton):\\na, gland lined by columnar epithelium b, stroma of the tumor.\\nHistology and Pathology.- The histogenesis of adenoma has been\\nreferred either to a congenital matrix of embryonic cells in glandular\\norgans, accessory glands, or displaced islets of embryonic cells (hetero-\\ntopic), or to embryonic cells of post-natal origin in glands and acces-\\nsory glands. Like the papilloma, it receives its stroma and its blood-\\nsupply from the mesoblast. The glandular part of a tumor remains\\nin an adenoma permanently. The most important distinctive feature\\nbetween a localized or diffuse hyperplasia of a gland and an adenoma", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0173.jp2"}, "168": {"fulltext": "i54\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nis the absence of function in the latter in common with all other tumors.\\nThe absence of ducts prevents the escape of the products of cell-pro-\\nliferation, frequently resulting in the formation of cysts the contents\\nof which vary according to the nature of the degenerative processes\\nwhich occur in the cells of the parenchyma of the tumor. Tumors in\\nthe interior of internal organs, as a rule, attain greater size than tumors\\nof the cutaneous or the mucous surfaces. Adenoma of the breast\\nseldom exceeds the size of a walnut. The essential structure of an\\nFig. 67. Adenoma of mammary gland X 50 (after Karg and Schmorl) a, epithelial cells lining gland-space\\nb, glandular space c, stroma.\\nadenoma is the stroma of fibrous or myxomatous connective tissue\\ncontaining newly-formed glands of either the acinous or the tubular\\nvariety. A central space between the epithelial cells can invariably be\\nfound, representing the glandular spaces in normal glands.\\nMost of the myxomatous polypoid growths are glandular tumors.\\nAdenoma containing tubular glands presents on section under the\\nmicroscope the appearance of tubular glands. The cells are arranged\\nin a single layer or in stratified layers the centre of each tubule shows\\na space toward which the unattached parts of the cells converge.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0174.jp2"}, "169": {"fulltext": "ADENOMA.\\n155\\nAdenoma composed of acinous glandular tissue shows on section\\nunder the microscope spaces lined by flat epithelial cells (Fig. 67). The\\nstroma varies in amount if abundant, the tumor is hard if scanty, soft.\\nThe blood-vessels follow the stroma and supply each tubule or acinus\\nof the tumor with an irregular network of capillary vessels. The cells\\nof an adenoma are subject to fatty, mucoid, and colloid degeneration.\\nThe stroma frequently undergoes myxomatous degeneration. The\\nprogressive accumulation of the degenerated products of cell-prolifera-\\ntion leads to cyst-formation. Such cysts vary in size from micro-\\nscopical spaces to cavities which contain many quarts of fluid. The\\nlargest cysts are found in, or in the vicinity of, the ovary. The fetal\\nremains of ducts in the vicinity of the ovary give rise to the formation\\nof adenoma containing tubular structures the vegetative power of\\nwhich is much greater than that of the Graafian follicles. The liability\\nof an adenoma to become transformed into a glandular carcinoma is\\nperhaps greater than that of papilloma. In fact, according to D. J.\\nHamilton, carcinoma is preceded by an adenomatous stage (Fig. 68),\\nan opinion advanced years ago by Gouley of New York. The earliest\\nevidences that such an occurrence has taken place are a more active\\nmultiplication of epithelial cells\\nand their migration through the\\nbasement membrane into the con-\\nnective tissue outside the limits\\nof the tumor (Fig. 68, b).\\nEtiolog-y. The essential\\ncause, the matrix of embryonic\\ncells, has been referred to in the\\nintroductory remarks of this sec-\\ntion. Of the exciting causes,\\ntrauma, irritation, and inflamma-\\ntion are the most influential.\\nAdenomata are found most fre-\\nquently in organs the seat of pe-\\nriodical congestion, such as the\\nmammary and prostate glands,\\nthe uterus, and the ovaries. They\\nare common also in mucous pas-\\nsages the seat of catarrhal affec-\\ntions, such as the nasal cavities\\nand the rectum. Adenoma is met\\nwith most frequently in the young and in persons not beyond middle\\nlife. The greater frequency of adenoma of the ovary as compared\\nFig. 6S.\u00e2\u0080\u0094 Development of a cancer of the mamma\\na set of adenomatous acini becoming cancerous X 35o\\n(after D.J. Hamilton): a, an adenomatous swelling\\nof an acinus b, the cells of a similar swelling which\\nhave broken out and are invading the surrounding\\nstroma; c, part which is cancerous.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0175.jp2"}, "170": {"fulltext": "156\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwith that of the testicle is explained by Klebs upon the ground that in\\nthe testicle the structures retain their fetal arrangements, while in the\\nFig. 69. Isolated sebaceous adenomata (after Demme).\\novary they are transformed into isolated structures, the Graafian folli-\\ncles. During the rearrangement of the structures of the ovary in the\\nFig. 70. Sebaceous adenoma from the skin of the left side of the neck upon the summit of the separate\\nnodules the dilated outlets of the ducts can be seen (after Demme).\\nembryo tubular remnants not utilized in the formation of the Graafian\\nfollicles are set aside, and remain as fetal rests, from which later the\\nlarge adenomatous cysts take their origin.\\nTopography. The topographical distribution of adenomata fur-\\nnishes an interesting proof of the importance of exciting causes in the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0176.jp2"}, "171": {"fulltext": "ADENOMA. 157\\nproduction of tumor-growth. We shall find that benign glandular\\ntumors frequent localities and organs the seat of prolonged vascular\\nfluxions and exposed to intercurrent affections which are calculated to\\ndiminish the physiological resistance of the tissues.\\nSkin. Adenoma of the skin is represented by the two kinds of\\nglands found in this structure, the sebaceous and the sudoriparous\\nglands. Retention-cysts of these glands are, of course, excluded from\\npresent consideration. True adenomata of the skin are very rare.\\nAdenoma Sebaceum. Sebaceous glands found in other tumors, such\\nas dermoid cysts, are not tumors, but hyperplastic glands. Lucke\\nremoved an ulcerating sebaceous tumor from the nose of a man eighty\\nyears old. He suspected that the tumor was a carcinoma, but micro-\\nscopic examination showed only convolutions of sebaceous glands and\\ninterglandular connective tissue no trace of carcinoma. The tumors\\nwhen small assume the shape of sebaceous glands. In larger tumors\\nthe glandular tubules form a convoluted mass. Demme described a\\nlarge sebaceous adenoma of the skin of the scrotum. The few cases\\nof sebaceous adenoma that have been reported appear to show that this\\ntumor is found almost exclusively in the aged, and that the face and\\nthe scrotum are its favorite localities. Anatomically, this tumor is dis-\\ntinguished from a retention-cyst by the presence of numerous tubules\\ninstead of one cavity, as is the case in retention-cysts (Figs. 69, 70).\\nAdenoma Sudoriparum. Sudoriparous adenoma was first described\\nby Verneuil. Virchow s doubts regarding the existence of such a tumor\\nhave not been confirmed by later investigations. Lotzbeck observed a\\ncase in which the tumor was congenital. In Thierfelder s case the\\ntumor occupied the diploe, but communicated with the skin, in which\\nit undoubtedly had its origin. The growth of the tumor takes place\\nfrom the deeper part of the tubule, which elongates and becomes more\\nconvoluted than normal sweat-glands (Fig. 71). According to Verneuil\\nand Demarquay, these tumors may reach the size of a fist, and may\\nmanifest a great tendency to ulceration they have been mistaken for\\nangioma. The growth of the tumor is slow. Sweat-gland adeno-\\nmata have been observed most frequently upon the skin of the face.\\nDemarquay saw such a tumor the size of an egg in the axillary space;\\nVerneuil, one upon the sternum and one upon the back.\\nDigestive Tract. Adenomata of the cavity of the mouth are rare.\\nIn the stomach adenoma occupies most frequently the pyloric part, and\\nmay attain the size of a hen s egg and cause pyloric obstruction. It is\\nmore frequent in the intestinal mucous membrane, and is often the\\ndirect cause of invagination. The mucous membrane of the rectum is\\nmore frequently affected by adenoma than is the remaining part of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0177.jp2"}, "172": {"fulltext": "158\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwhole intestinal tract. The majority of cases of polypus in this local-\\nity have an adenomatous structure. Port has recently collected 13\\ncases of multiple adenoma of the intestinal tract which terminated in\\ncarcinoma. The patients ranged in age from 10 to 30 years. In a\\nnumber of the cases more than one member of the family was similarly\\naffected. The prognosis is grave, even in the event an operation is\\nperformed, as out of the 13 cases 9 died. Only in 4 cases did the\\nFlG. 71.\u00e2\u0080\u0094 Sudoriparous adenoma from skin of frontal region of a woman transverse section of tubule,\\nX 650 (after Liicke) a, hair-follicle b, adipose tissue c, sweat-glands in longitudinal section; d, d the\\nsame in transverse section.\\noperation result in relief for a considerable length of time. In Helfe-\\nrich s case the pyloric end of the stomach was the seat of a similar\\naffection, and the disease led to extensive glandular metastasis. Nearly\\nall the adenomata of the mucous membrane lining the gastro-intestinal\\ncanal present in section under the microscope a tubulated appearance.\\nAdenoma of the rectum (Fig. 72) is more frequent in children than in\\nadults. The tumor increases slowly in size, and in the course of time", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0178.jp2"}, "173": {"fulltext": "ADENOMA.\\nJ 59\\nbecomes pedunculated. Adenomata in this locality usually vary in\\nsize from that of a cherry to that of a walnut. At the base of the tumor\\nor pedicle the mucous membrane of the tumor is continuous with that\\nof the rectum. The symptoms are the same as in papilloma.\\nNasal Cavities. Many of the polypoid growths of the nasal cavi-\\nties are adenomata. Billroth was the first to discover gland-follicles\\nFig. 72. Adenoma of the rectum X 48 (after Karg and Schmorl). The tumor is composed of glandular\\nspaces and, between them, a stroma infiltrated by small cells. The structure of the tubules corresponds with\\nthat of the normal glands of the rectum. The glandular spaces are lined with columnar cells with basal\\nnuclei surrounded by the membrana propria. Between the columnar cells here and there can be seen goblet-\\ncells (c). Some of the glands are enlarged and are supplied with lateral buds others are transformed into\\nlarger hollow spaces (a). At b dilated blood-vessels are seen in the stroma.\\nin the myxomatous polypus of the nose. The connective tissue sur-\\nrounding the adenomatous growth and the epithelial cells of the mu-\\ncous membrane covering the tumors are in a hyperplastic condition,\\ncaused by an increased blood-supply. Adenoma of the nasal mucous\\nmembrane often appears as a multiple affection. Catarrhal inflamma-\\ntion often precedes, and frequently attends, adenoma of the nose.\\nUterus and its Appendages. The uterus is the organ most frequently", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0179.jp2"}, "174": {"fulltext": "i6o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\naffected by adenoma. The development of the tumors in this locality-\\nis usually preceded by catarrhal inflammation. The inflammation evi-\\ndently acts as an exciting cause in diminishing the physiological resist-\\nFig. 73. Adenoma of the posterior wall of the uterus (after Winckel).\\nance of the tissue in the vicinity of the embryonic matrix. The fungous\\nvegetations which so often cover the cervix uteri and its canal the\\nso-called erosions are either papillomata (see Fig. 63) or adenomata.\\nFig. 74. Uterine cavity entirely filled with adenomatous vegetations (after Winckel).\\nIn the uterine cavity adenoma is found as a single tumor or in the form\\nof diffuse vegetations covering the entire surface. Adenoma of the\\nuterine cavity (Figs. 73, 74) or of the cervix seldom increases beyond\\nthe size of a walnut. The tumor appears first as a small nodule,\\npushes the mucous membrane before it, and, if it increases to the", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0180.jp2"}, "175": {"fulltext": "ADENOMA. 161\\nsize of a cherry, becomes pedunculated. Multiple adenomata of the\\nuterine mucous membrane usually remain sessile. Menorrhagia, a pro-\\nfuse glairy discharge, and dysmenorrhea are some of the most promi-\\nnent symptoms which point to the existence of adenomata of the\\nmucous membrane lining the uterus.\\nAdenoma of the Fallopian tubes is a very rare affection. Ascites\\nis sometimes produced by tumors in this locality, as the increased\\nsecretion provoked by the tumor escapes into the peritoneal cavity.\\nAdenoma of the ovary, according to Waldeyer, Thierfelder, and\\nKlebs, does not originate from the Graafian follicles so frequently\\nas was formerly believed. In the majority of cases the tumor starts\\nfrom an embryonic tubular matrix, a remnant of Pfliiger s ducts.\\nGlandular tumors of the ovary appear as globular, nodular tumors of\\nwidely different form and size. Some of these tumors become so large\\nthat they exceed the weight of the patient. They develop beneath the\\ncolumnar epithelial cells of the surface of the ovary, within a strong\\nlayer of connective tissue in which are imbedded the blood-vessels.\\nIn the centre of this vascular connective-tissue layer a small space\\nlined with cylindrical cells marks the beginning of the adenoma and\\nthe incipient formation of a cyst. Waldeyer claimed that the glandular\\nspaces are lined by only one layer of epithelial cells, while Rindfleisch,\\nBottcher, and others found several layers. Into a space thus formed\\nother tubules project and open, forming secondary cysts. If the walls\\nof the secondary cysts, by distention and growth, come in contact, the\\njoint septum formed breaks down and a communication between the\\ncysts is established. Coalescence of many cysts in this manner may\\nresult in the formation of enormous spaces. Cruveilhier and Virchow\\nfound in the jelly-like, structureless contents of such cysts blood-\\nvessels, the remnants of the broken-down septa. For this kind of\\nglandular cysts Waldeyer proposed the name myxomatous cysts.\\nIn typical adenoma of the ovary the cysts do not reach such great\\nsize. Constant friction on the surface of the tumor destroys the epithe-\\nlial layer and leads to adhesions, which in cases of glandular cysts are\\noften very extensive and firm. From the cyst-wall form buds covered\\nby cylindrical epithelium, projecting into the cyst and presenting the\\nappearance of placental villi (see Fig. 58). These papillary intracystic\\ngrowths carry with them large vessels and take a very active part in the\\nproliferation of tumor-tissue. By perforation of the cyst-wall these\\npapillary excrescences reach the peritoneal cavity, and undoubtedly\\nhave much to do with the production of ascites, which so often attends\\nthis form of ovarian tumor. The small cysts contain a jelly-like, homo-\\ngeneous substance. The larger the cyst the more liquid its contents,\\nit", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0181.jp2"}, "176": {"fulltext": "162\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nWaldeyer and Spiegelberg found in all cysts of the ovary paral-\\nbumin.\\nThyroid Gland. The thyroid is one of the ductless glands. It is\\nonly recently that its physiological importance has been ascertained\\nd :fmitely. Clinical observation and experimental research have demon-\\nstrated that the complete destruction of the gland by disease or its\\nremoval by extirpation results in myxedema and cretinism. It is a\\ncompound tubular gland, whose excretory duct, the thyro-glossal duct,\\nin the early stages of the organ connects the tubules with the mucous\\nsurface, where its opening corresponds to the foramen caecum. It is\\nalong this tract that remnants of the gland are occasionally found, as\\nwell as accessory glands in the vicinity of the organ, which may become\\nthe seat of adenomata resembling the structure of the thyroid gland.\\nThis gland in its normal condition contains the product of one of the\\nretrograde tissue-metamorphoses colloid material. It would appear\\nthat this tendency of the cells to degen-\\neration into colloid material in a normal\\ncondition would naturally predispose\\nadenomata of this organ to the forma-\\ntion of cysts. Virchow divided the\\nbenign tumors of the thyroid gland\\ninto (i) Struma hyperplastica (2)\\nstruma gelatinosa (3) struma cystica.\\nThis classification is no longer tenable,\\nas the gelatinous and cystic varieties\\nrepresent only an advanced stage of\\nadenoma.\\nThe ordinary bronchocele, mias-\\nmatic struma, is not a true tumor, but\\nan infective swelling caused by an unknown microbe. Enlargement of\\nthe- gland from this cause is an endemic affection. The true glandular\\ntumor of the thyroid is produced, like other tumors, from a matrix\\nof embryonic cells. It is in this gland that the essential cause of\\ntumor-formation has been actually demonstrated. Wolfler has found,\\nin the substance of the gland, cell aggregations which did not appear to\\nbelong to the gland-structure and which he regarded as remnants of\\nembryonic tissue. From these develop the adenomata. He formulates\\nadenomata as epithelial new formations which develop from embryonal\\ngland-matrices with atypical vascularization. Wolfler has shown that\\nthe true benign tumor of the thyroid gland is an adenoma. The\\ngreater prevalence of adenomata in districts inhabited by miasmatic\\nstruma is an important proof of the part taken by the surrounding\\nFig. 75. Section of thyroid body exhibiting\\ndetail of acini, which are cut in various direc-\\ntions (after Piersol) c, colloid material distend-\\ning the larger acini i, interacinous connective\\ntissue; v, blood-vessels.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0182.jp2"}, "177": {"fulltext": "ADENOMA.\\nl6 3\\ntissues in tumor-formation. The physiological resistance of the tissues\\nis diminished by the infective process, and matrices of embryonic cells\\nwhich have remained in a latent state until then assume active tissue-\\nproliferation and produce a true glandular tumor.\\nThe difference between an infective swelling of the thyroid gland and\\na true tumor has already been pointed out. A miasmatic swelling\\nyields to the internal and external use of iodine preparations a true\\ntumor is not affected by this treatment. Early treatment of a miasmatic\\nstruma is a prophylactic measure against tumor-formation as it restores\\nthe physiological resistance impaired by the microbes which produced the\\nstruma. The glandular tumors are always imbedded in the substance\\nof the gland or in the miasmatic struma, and are encapsulated. Fre-\\nquently they are multiple. Small recent cysts always contain a colloid\\nsubstance. Multilocular cysts are formed in the same manner as in\\ncystic adenoma of the ovary, by coalescence of two or more cysts. In\\nFig. 76. Enormous tumor of the thyroid gland (after Bruns).\\nold cysts the contents become more liquid, and are often changed other-\\nwise by hemorrhage into the cyst and by the formation of numerous\\ncholesterin-crystals. Other forms of regressive metamorphosis are", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0183.jp2"}, "178": {"fulltext": "1 64 PATHOLOGY AND TREATMENT OF TUMORS.\\namyloid, cheesy, and fatty degeneration and calcification. The tumors\\noften attain great size. Rose has shown that death from sudden suffo-\\ncation is caused by atrophy and softening of the tracheal rings resulting\\nfrom pressure of the tumor. The trachea in such cases has been found\\nflattened, resembling a sabre-sheath. Pressure-atrophy and flattening\\nof the trachea do not take place in proportion to the size of the tumor.\\nA small tumor, not larger than a hen s egg, of the middle lobe of the\\ngland will do more damage to the trachea than will a large tumor, such\\nas that shown in Figure 76. When a tumor has attained this size\\npressure-symptoms are often relieved by the weight of the tumor\\nmaking traction away from the trachea. Retro-sternal tumors give rise\\nto the most distressing symptoms, as the outward growth of the tumor\\nis opposed by the unyielding sternum. Retro-tracheal tumors or\\ntumors encircling the trachea are also the source of great suffering, and\\ndemand operative treatment. It is generally known that adenoma of\\nthe thyroid gland shows no tendency to increase in size after the patient\\nhas reached his fiftieth year. Numerous cases of congenital tumors of\\nthe thyroid gland have been recorded. They are most likely to occur\\nin localities where bronchocele is endemic.\\nIf, in a person past middle life, a struma that has been stationary\\nfor years suddenly and without any special provocation commences to\\nincrease in size, it is very probable that the tumor has undergone\\ntransformation into a carcinoma or a sarcoma. Malignant disease of\\nthe thyroid gland is more likely to originate in a pre-existing tumor\\nthan in a normal gland. Tumors of the thyroid gland always receive\\na rich blood-supply. The gland is so abundantly supplied with blood\\nfrom the four thyroid arteries that excessive vascularization of the\\ntumor invariably occurs. The veins of the capsule of the gland, if\\nthe tumor is large or multiple, often attain the size of the little finger\\nthe superficial veins in such instances are also enormously dilated (see\\nFig. 76).\\nThe differential diagnosis in tumors of the thyroid gland has for its\\nobject to distinguish between infective swelling, adenoma, cyst, carci-\\nnoma, and sarcoma. A miasmatic bronchocele presents itself as a\\nsmooth swelling involving usually the entire gland. It is endemic in\\ncertain districts in some countries (Switzerland and Austria), and it\\nappears usually during childhood or at the age of puberty. A few\\nweeks treatment with preparations of iodine will make an impression\\non the swelling. Adenoma commences as a small nodule in the sub-\\nstance of the gland, and follows the movements of the gland during\\ndeglutition. Adenoma is often multiple from the beginning, or addi-\\ntional nodules appear in different parts of the gland in succession.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0184.jp2"}, "179": {"fulltext": "ADENOMA. 165\\nSarcoma and carcinoma develop in preference in a gland affected pre-\\nviously by infective swelling or by adenoma, and occur, as a rule, in\\nadults and in persons of advanced age. The malignant tumors grow\\nrapidly in size, and soon render the tumor immovable by extension to\\nthe surrounding tissues. Cysts frequently mark an advanced stage\\nof an adenoma. Unless the cyst-wall is very tense, fluctuation can be\\nelicited without difficulty. If any doubt exists, an exploratory puncture\\nwill furnish the desired information. A miasmatic swelling or an ade-\\nnoma of the thyroid gland is prone to become the seat of microbic infec-\\ntion during an intercurrent infective disease. Tavel studied this subject\\nvery exhaustively from a bacteriological aspect, and reported a number\\nof cases of strumitis in which he found in the inflamed tumors microbes\\nsimilar to those which caused the general infective disease, notably\\ntyphoid fever.\\nTreatment. Owing to the importance of the operative treatment\\nof tumors of the thyroid gland, this subject will be discussed separately.\\nThe most efficient treatment of miasmatic bronchocele is by the internal\\nand external use of iodine. The parenchymatous injections of iodine\\nso extensively used by Lucke are no longer popular. It has been fol-\\nlowed by disastrous results in a number of instances. Paralysis of the\\nrecurrent laryngeal nerve, great swelling, and suppuration are some of\\nthe immediate complications occasionally caused by this method of\\ntreatment. The late Professor Gunn used parenchymatous injections\\nof a 5 per cent, solution of carbolic acid, repeated once or twice a week,\\nwith great success, and this method has remained in constant use in\\nthe clinic of Rush Medical College, and is yielding excellent results.\\nIt is perfectly safe, almost painless, and the carbolic acid appears to\\nneutralize the primary microbic cause. The iodine treatment is em-\\nployed at the same time. The injection should be made into different\\nparts of the tumor, and should be repeated at least twice a week.\\nExtirpation of the thyroid gland for tumor is a comparatively recent\\noperation. J. Collins Warren of Boston extirpated one lobe of the thy-\\nroid gland, after preliminary ligation of the common carotid artery on\\nthe same side. He believed that the operation was impracticable with-\\nout resorting first to tying of the common carotid artery. Green prac-\\ntised rapid removal of the tumor, and ligated the bleeding vessels later.\\nRose tied each vessel before cutting, proceeding very slowly. The\\nwriter in 1878 witnessed one of his operations, which lasted for four\\nhours. The operative technique of strumectomy has been perfected\\nchiefly by the teachers of surgery in the universities of Switzerland\\nBillroth, Lucke, Julliard, Reverdin, Socin, and Kocher men who\\nwere frequently called upon by patients from localities in which", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0185.jp2"}, "180": {"fulltext": "166 PATHOLOGY AND TREATMENT OF TUMORS.\\nbronchocele prevailed as an endemic affection. Kocher was the first\\nto call the attention of the profession to the evil results following\\ncomplete removal of the thyroid gland. He observed, in a number of\\ncases in which he removed with the tumor the entire gland, a condition\\nwhich he termed cachexia strumipriva, which resembled what was later\\ndiscovered to be myxedema. This subject then received careful ex-\\nperimental investigations which corroborated Kocher s observations.\\nZesas found in his experiments on dogs that if only a part of the gland\\nis extirpated the remaining part undergoes compensatory hypertrophy\\nand that complete removal of the gland resulted sooner or later in the\\ndeath of the animal. Similar experiments with the same results were\\nmade by Bardeleben and Horsley. The experiments have taught sur-\\ngeons that complete extirpation of the thyroid gland except for malig-\\nnant disease is an unjustifiable operation. A part of the gland must be\\nallowed to remain in order to prevent the probable occurrence of serious\\nremote complications.\\nPartial extirpation of the thyroid gland is still in use in the removal\\nof benign growths, and complete strumectomy is absolutely necessary\\nin the extirpation of malignant tumors. The external incisions selected\\nfor this purpose must be made in accordance with the size and location\\nof the tumor. An incision along the margin of the sterno-cleido-\\nmastoid muscle will secure good access for the removal of tumors or\\nfor extirpation of the lateral lobes. A median incision will reach tumors\\nof the isthmus most directly. In large tumors or in tumors involving\\nboth lobes a transverse incision over the most prominent part of the\\ntumor, with the concavity directed upward, is preferable. So far as pos-\\nsible, the vessels should be ligated or be secured with pressure-forceps\\nbefore being cut. This ligation is especially necessary when the thyroid\\narteries are reached. The isthmus of the gland is included in a ligature\\nen masse. The operation should be performed slowly and carefully, and\\nall tissues should be identified before being cut, to avoid injury to the\\nrecurrent branch of the pneumogastric nerve. Accidental section of\\nthis nerve is followed by paralysis of the vocal cords on the same side,\\nwhich paralysis will in all probability remain as a permanent disability.\\nExtirpation of parts of the thyroid gland has largely given way to\\nenucleation, an operation devised by Socin and strongly endorsed by\\nJulliard. It is the ideal operation, as it leaves the gland-tissue intact.\\nThis operation is not limited to the removal of small growths, as the\\nenormous tumor depicted in Figure 76 was successfully removed by\\nthe same procedure. All glandular and cystic tumors of the thyroid\\ngland are enclosed by a thick connective-tissue capsule which can be sep-\\narated from the surrounding tissues with ease and without much heritor-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0188.jp2"}, "181": {"fulltext": "ADENOMA. 167\\nrhagc. The great secret in the successful removal of glandular and\\ncystic tumors of the thyroid gland is to find the exact place, between cap-\\nsule and tissues, at which to commence the enucleation. The dissection\\ndown to the capside must be made with the utmost care, and no attempts\\nat enucleation should be made until the proper place is found. As soon\\nas the capsule is reached the knife must be laid aside and the tumor\\nbe enucleated by the use of the finger or of blunt instruments. The\\nparenchymatous hemorrhage generally yields to pressure and hot water,\\nor, in case it is not controlled in this way, to the aseptic tampon. If\\nthe aseptic tampon is not used, the mantle of thyroid tissue which was\\ncut in exposing the tumor should be sutured with absorbable material\\nseparately before closing the external wound. If the tampon is em-\\nployed, it is removed at the end of the first day and the wound is closed\\nby secondary sutures. If more than one tumor is found, all the tumors\\ncan be removed through the same external incision by approaching\\nthem through separate incisions through the capsule or veil of gland-\\ntissue which invariably covers them. The great advantages of enucle-\\nation over extirpation are greater ease of operation, less liability to\\ntroublesome hemorrhage, less deformity, and, lastly, that it does not\\ndeprive the patient of any normal gland-tissue, which has been found\\nof such enormous importance in the preservation of health.\\nWolfler revived the operation of ligating the thyroid arteries in the\\ntreatment of tumors of the thyroid gland. This operation, of course,\\ncan attain what is claimed for it only in parenchymatous tumors. Cysts\\nshould invariably be enucleated unless calcification of the capsule has\\nso far advanced as to render this procedure impracticable. Adenomata\\nshould be dealt with in the same manner unless the capsule of the\\ntumor has become firmly attached to its surrounding tissues by an\\nantecedent inflammation. Extirpation should be limited to tumors that\\ncannot be enucleated, and it should never include the entire gland except\\nin the removal of malignant tumors.\\nMammary Gland. The benign tumor most frequently met with in\\nthe mammary gland is the adenoma. Until quite recently it was gen-\\nerally conceded that the firm tumors of the mammary gland were in\\nthe majority of cases fibromata. Careful study under the microscope\\nof sections from such tumors has shown that glandular elements\\nare absent only in exceptional cases, and consequently that most of\\nthe benign tumors of the gland are not fibromata, but adenomata.\\nSchimmelbusch has shown that the tumors of the breast heretofore\\ndesignated as fibromata are in reality tumors in which the adeno-\\nmatous structures predominate an opinion strongly supported by\\nHaeckel. In order to realize the true nature and structure of such", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0189.jp2"}, "182": {"fulltext": "i68\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ntumors it is absolutely necessary to examine sections from different\\nparts of the tumor. Some sections from the same specimen will often\\nshow epithelial cells almost exclusively, while other sections exhibit\\nonly fibrous tissue. The presence of epithelial cells in different parts\\nof the tumor, however, leaves the impression that they take the essen-\\ntial part in the production of the tumor. Billroth denied that epi-\\nthelial cells took any part in the origin and growth of tumors of the\\nbreast, which he designated as fibroid tumors. The adenoid structure\\nis well marked in the tissues of young tumors, while in old tumors\\nthe epithelial cells are found arranged in an irregular manner in the\\niff P W \\\\\\\\f ///--w^.SA.\\n^-6\\nFig. 77. Adenoma of mamma (after Haeckel) a, fibrous tissue; b, epithelial cells. (Zeiss, Obj. A., Oc. 2.)\\nconnective-tissue spaces. Figure J J shows that the connective tissue\\nhas separated the acini, but the glandular appearance is well preserved.\\nThe fibrous tissue is increased by active proliferation of the interacinous\\nconnective tissue, and the new elements impart to the tissues a grayish-\\nred or yellowish color instead of the pearly-white color of old connec-\\ntive tissue. At some points in the older portions of the tumor the\\nfibrous tissue is pale and firm, at others\\ncedematous or myxomatous.\\nIt is a question whether pure fibromata\\never occur in the mammary gland. Un-\\nmixed adenomata are also exceedingly rare.\\nHaeckel had an opportunity to remove and\\nexamine a pure adenoma of the breast, and\\nhe gives the accompanying illustration (Fig.\\n78) to explain its histological structure. The\\ntubules were lined by at least twenty strata\\nof epithelial cells.\\nThe writer removed a tumor the size of a\\nhazelnut from the breast of a young lady, and from its firmness\\nFig. 78. Pure adenoma of the\\nmammary gland (after Haeckel).\\n(Zeiss, Obj. D., Oc. 2.)", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0190.jp2"}, "183": {"fulltext": "ADENOMA.\\n169\\nwas led to believe the tumor to be a fibroma. The macroscopical\\nappearance of a section of the tumor showed wavy bundles of connec-\\ntive tissue, thus confirming the opinion formed. Under the microscope\\nthe tumor revealed itself as a genuine adenoma. The microscopic ap-\\npearance of the tumor-tissue and the relative proportion of glandular\\nand connective tissue are shown in the accompanying illustration (Fig.\\n79). It will be seen from this illustration that, although the tumor had\\nexisted for several years, the tubules are lined by a number of layers\\nof epithelial cells and that the glandular spaces are small. We have\\ny\\nSPSBr\\nW*\\n-v: ?S.,\\nC :y\\nFig. 79.\u00e2\u0080\u0094 Adenoma of breast X 115, reduced one-fifth (Surgical Clinic, Rush Medical College, Chicago) a,\\nshrinkage due to hardening b, proliferating ducts c, fibrous tissue.\\nreason to believe that during the future growth of such a tumor the\\nstroma would increase more than the parenchyma, and so render\\nthe fibrous structure more apparent. Adenomata without cyst-forma-\\ntion never attain a large size. Usually they range\\nin size from that of a pea to that of a walnut\\n99 per cent, of them occur in females. Adeno-\\nmata occupy more frequently the superficial and\\nperipheral than the deep and central parts of\\nthe gland. They are often multiple in one breast,\\nseldom in both breasts. They often cause great\\npain and are quite tender on pressure. These\\nsymptoms are much less prominent in the early\\nhistory of carcinoma of the breast. Adenoma of the breast (Fig. 80)\\nis always well encapsulated. Adhesion to the skin and retraction are\\nFig. 80. Adenoma of the\\nbreast, showing capsule (after\\nAstley Cooper).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0191.jp2"}, "184": {"fulltext": "170 PATHOLOGY AND TREATMENT OF TUMORS.\\ntherefore never observed. The existence of a well-defined capsule is\\nof great assistance to the surgeon in doubtful cases after he has exposed\\nthe tumor to make a positive diagnosis of its non-malignant nature. A\\nsection of the tumor (Fig. 81), if the fibrous tissue predominates, very\\nmuch resembles in its naked-eye appearances fibroma of the uterus.\\nThe surface of the section appears as though the tumor were composed\\nof separate parts, each of which indicates a different centre of growth.\\nCystic adenoma often attains great size. The contents of the cysts are\\nvariable. Colloid degeneration seldom takes place. The serous fluid is\\nFig. 8i. Large adenoma of breast, cut surface resembling fibroma of the uterus (after Astley Cooper).\\noften stained a dark color, owing to the presence of blood and cholesterin-\\ncrystals. The writer has found cystic degeneration most frequent in\\nwomen advanced in years. In the diagnosis it is important to remem-\\nber that carcinoma seldom, if ever, occurs in the breast as a multiple\\naffection, while this is frequently the case in adenoma. Retraction of\\nthe nipple and the skin may follow inflammatory affections of the\\nbreast, but is never present in uncomplicated adenoma, and is of fre-\\nquent occurrence in carcinoma. Adenoma resembles more closely\\nsarcoma than carcinoma. Sarcoma, however, grows much more rapidly\\nthan carcinoma, and is usually attended by dilatation of the superficial\\nveins. Adenoma and sarcoma occur frequently in young adults, while\\ncarcinoma is seldom met with in women less than thirty-five years", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0192.jp2"}, "185": {"fulltext": "ADENOMA. 171\\nof age. The prognosis must always be guarded, as adenoma of the\\nbreast undergoes transformation into malignant tumors carcinoma and\\nsarcoma perhaps more frequently than any other benign tumor. Early\\noperative removal should be recommended, as an operation brings\\nmental as well as physical relief, and protects the patient against the\\npossibility of the occurrence of malignant disease caused by the transi-\\ntion of a benign into a malignant tumor.\\nProstate Gland. The prostate is a glandular organ and part of\\nthe genital apparatus. It was until recently supposed that the en-\\nlargement of this gland in men past fifty years of age was a tumor\\nresembling myofibroma of the uterus. This idea, in the light of recent\\ninvestigations, has been abandoned, and the enlargement is now regarded\\nas a glandular swelling or tumor. White of Philadelphia ascertained\\nby his experiments on dogs that castration resulted almost uniformly\\nin great diminution in the size of the prostate. Surgeons have made\\nuse of the knowledge thus gained, and in a few instances have resorted\\nto castration for the relief of enlargement of the prostate gland. Ramm\\nof Christiana reports two cases in which this operation afforded perma-\\nnent relief and was followed by progressive diminution in the size of the\\ngland. Harrison of London reports a case of hypertrophy of the pros-\\ntate greatly benefited by subcutaneous section of the spermatic cord on\\nboth sides. The patient begged to have castration performed, and as\\na compromise Harrison made subcutaneous section of both cords.\\nShould future operations produce similar results, they would prove\\nthat in the majority of cases enlargement of the senile prostate is not\\na tumor, but a swelling. The writer is firmly convinced that in most in-\\nstances this is the case. There is, however, a tumor of the prostate\\nthat is glandular in structure and that appears as a single or a multiple\\naffection involving any or all of the lobes of the gland. The general\\nenlargement of the gland consists of a hyperplasia of the glandular\\nand connective-tissue part of the gland the isolated nodules are ade-\\nnomata. Adenomata are found almost exclusively in hyperplasic glands,\\nin this respect bearing a strong resemblance to adenomata of the thy-\\nroid gland. The hyperplasia of the organ occurs as one of the many\\npathological conditions incident to old age, in the production of true\\ntumors taking the same part as the miasmatic struma. The prostate,\\nlike the uterus and the thyroid gland, is an organ in which and around\\nwhich complicated developmental changes take place consequently\\nthere is here, as in the other organs mentioned, great liability of the\\ndeposition of unutilized embryonic cells which later become the essen-\\ntial tumor-matrix. So long as the physiological resistance of the tis-\\nsues around the matrices remains unimpaired, tumor-growth does not", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0193.jp2"}, "186": {"fulltext": "172 PATHOLOGY AND TREATMENT OF TUMORS.\\ntake place, but when this resistance becomes diminished by senile debil-\\nity, and particularly by the changes which the prostate undergoes\\nduring advanced age, the embryonic cells assume active tissue-prolifer-\\nation which results in the formation of a tumor. Billroth asserted that\\nhe never observed an adenoma in the prostate gland, and he attributed\\nthe senile enlargement to dilatation of the acini and hyperplasia of the\\nepithelial cells. It took a long time for pathologists to make a distinc-\\ntion between hyperplasia of the thyroid gland and the adenomata, and\\nthe same confusion has prevailed in regard to the two entirely different\\nkinds of enlargement of the prostate gland. The extirpation of the\\nhyperplasic prostate in toto has not yielded encouraging results, and\\nwill never become a feasible surgical procedure on the contrary, enu-\\ncleation of adenomata of this organ from the perineum through Zucker-\\nkandl s incision or through the bladder above the pubes has a promis-\\ning future.\\nLachrymal Gland. Adenoma of the lachrymal gland has been\\nstudied by P. Becker and others. It appears as a lobulated, nodular\\ntumor of moderate size, and it is very liable to undergo hyaline degen-\\neration. The tumor increases in size very slowly, and the formation\\nof small cysts is of frequent occurrence. Enucleation of the tumor\\nshould be done in preference to extirpation of the whole gland.\\nParotid Gland. According to C. O. Weber, the parotid gland is very\\nrarely the seat of adenoma. Billroth maintained that adenoma of this\\norgan, when it does exist, is only a part of a compound tumor. It cannot\\nbe denied that compound tumors of the parotid gland, such as adeno-\\nchondroma, adeno-cystoma, and adeno-carcinoma and adeno-sarcoma,\\nare frequently met with in the examination of tumors of this organ.\\nPure adenoma of the parotid gland has, however, been found, and it\\nresembles in structure similar tumors of the thyroid gland. Glandular\\ntumors occur most frequently in young adults. Cystic degeneration\\noften takes place at different points, large cavities being formed by the\\ncoalescence of smaller cysts. The cyst-wall, lined by epithelial cells,\\noften projects into the cysts at different points in the form of papillary\\nexcrescences. The tumor is well encapsulated, and it can be enucleated\\nvery readily without serious damage to the gland. The incision should\\nbe made with special reference to the location and direction of Sten-\\nson s duct and the branches of the facial nerve. A thin veil of gland-\\ntissue has to be divided before the capsule of the tumor is reached, and\\nthe operation occasionally results in the formation of a temporary\\nsalivary fistula.\\nTesticle. The relative proportion of true tumors of the testicle to\\ninflammatory swellings is unusually small. Adenoma of the testicle", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0194.jp2"}, "187": {"fulltext": "ADENOMA. 173\\nhas only recently been described. Liicke called attention to its\\nexistence in connection with cystic disease of the testicle. Eve has\\nexamined a large number of cysts, including adeno-cystoma, sarco-\\nmata, myxomata, and carcinomata they were lined with columnar,\\nstratified, or ciliated epithelium some were papillomatous, and car-\\ntilage and unstriated muscular fibres were occasionally present in\\nthe stroma. The adeno-myxomata were characterized by slit-like\\ntubes or solid rods of gland-tissue surrounded by a zone of trans-\\nparent tissue. Eve and Sutton believe that the majority of gland-\\nular tumors of the testicle originate in the remnant of the Wolffian\\nbody lying between the globus major of the epididymis and the\\ntesticle proper. This remnant of the Wolffian body is known as\\nthe paradidymis.\\nAdenoma of the testicle is characterized by the existence of numer-\\nous small cysts. The cyst-spaces are lined with columnar or stratified\\nepithelium. If the tumor attains large size, it causes atrophy of the\\ntesticle by pressure. The tumors are encapsulated, but in the few cases\\nthat have come under the observation of the writer their enucleation\\nhas been found quite difficult. The tumors varied in size from a\\nhickory-nut to a walnut, and on section presented a honeycomb appear-\\nance, owing to the presence of numerous cysts, the largest of which\\ndid not exceed the size of a hempseed.\\nThe differential diagnosis of adenoma of the testicle must take into\\nconsideration tuberculosis, gumma, carcinoma, sarcoma, and circum-\\nscribed hydrocele of the tunica vaginalis. In the removal by enucleation\\ngreat care is required in preventing injury to the cord and the testicle.\\nLiver. Adenoma of the liver during the last year or two has\\nbecome a more interesting topic to the surgeon from the fact that in\\nseveral cases tumors of this kind have been removed successfully by\\nexcision. Keen and Von Bergmann have each reported a successful\\ncase. The earliest communications on adenoma of the liver were made\\nby Hoffmann and Lancereaux. Gruber, Wagner, and others have\\nfound detached portions of liver-tissue, often very numerous, in the\\nperitoneal folds supporting the liver and in the portal fissure these\\nfragments may be a possible source of cysts and tumors. Friedreich\\nfound in the liver itself groups of cells which did not appear to form\\npart of the parenchyma, as they were isolated from it by a capsule.\\nThese embryonic remnants are undoubtedly the matrices from which\\nadenomata originate. Isolated tumors may be no larger than a marble\\nlarger tumors are formed by a collection of multiple tumors. In some\\nparts of the tumor the seat of active proliferation, metaplastic condi-\\ntions of the parenchyma-cells are developed, as in a case reported by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0195.jp2"}, "188": {"fulltext": "174 PATHOLOGY AND TREATMENT OF TUMORS.\\nRindfleisch-Griesinger the nodules in the acini of this specimen were\\nFig. 82. Adenoma of the liver (after Paul) a, section of blind duct filled with green fluid: b, liver-cells;\\nc, connective tissue.\\nmade up of columnar epithelial cells. Small adenomata, consisting of\\ncylinders lined by columnar epithelium and imbedded in fibrous tissue,\\nFig. 83. Papillary adenoma of kidney X 250 (after Karg and Schmorl) hollow spaces lined by cylindrical\\ncells stroma scanty and moderately cellular papillary proliferations project into the glandular spaces.\\noccur (Fig. 82). The acini may be solid and hard, or they may consist\\nof large cells and may resemble the acini of the pancreas. A slow-", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0196.jp2"}, "189": {"fulltext": "ADENOMA.\\n175\\ngrowing tumor in the substance of the liver in a non-syphilitic subject\\nwould indicate the necessity of making a careful investigation with a\\nview of determining the propriety of an abdominal section to make\\na positive diagnosis, and, if the tumor is found to be an adenoma, to\\nattempt its removal In the cases thus far operated upon a positive diag-\\nnosis was made only after the tumor was rendered accessible to direct\\nexamination by abdominal section.\\nKidney. The frequency with which the kidney is now subjected to\\noperative treatment adds renewed interest to everything pertaining to the\\npathology of the numerous affections of this organ that have recently\\nbeen brought within the reach of successful surgery. Very little is\\nknown of benign tumors of this organ. Occasionally small cystic\\nadenomata are found, some of which are undoubtedly derived from\\nretention-cysts, but it is also probable that Wolffian-body rests may be\\na cause. Shattock maintains, with good reason, that remnants from the\\nmesonephros (Wolffian body) and the metanephros (true kidney) often\\nserve as matrices for tumor-\\nformation. The papilloma-\\ntous projections into the cysts\\nof renal adenomata as well as\\nthe cyst- wall are covered with\\ncolumnar epithelium which\\nbears no resemblance to the\\nepithelial cells lining the\\nuriniferous tubules (Fig. 83).\\nAdenomatous tumors of\\nthe kidney sometimes reach a\\nconsiderable size in case the\\ncysts are large and numerous,\\nas in Mr. Edmunds case (Fig.\\n84). The kidney represented\\nin Figure 84 was successfully\\nremoved by Mr. Edmunds\\nfrom a girl eighteen years old.\\nSuch a tumor might easily\\nbe mistaken for a sarcoma.\\nDiagnosis. The differen-\\ntial diagnosis between ade-\\n11 Fig. 84. Adenoma of the kidney (after Edmunds).\\nnoma and other glandular\\naffections is of great practical importance, often is exceedingly difficult\\nowing to the location of the organ affected, and is frequently rendered\\nmore perplexing by misleading statements on the part of the patient.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0197.jp2"}, "190": {"fulltext": "176 PATHOLOGY AND TREATMENT OF TUMORS.\\nChronic infective swellings, tuberculosis, and gumma are most likely\\nto be mistaken for adenoma. Mistakes of this kind have sometimes\\nbeen made by careful and competent surgeons. Search for additional\\nevidences of the primary cause of infection will frequently furnish valu-\\nable information. In gumma of the testicle the presence of other less\\napparent tertiary lesions and the existence of tuberculosis in other\\norgans are points upon which the surgeon often rests his diagnosis in\\ndifferentiating between an adenoma and an infective swelling. The\\ncentral part of an infective swelling frequently degenerates and liquefies,\\nstill further complicating the diagnosis between a cystic adenoma and\\nan infective swelling. An exploratory puncture is often of great value\\nin ascertaining the character of the contents of a doubtful swelling.\\nPrimary tuberculosis does not often attack the organs which are the\\nfavorite seat of adenoma. Tuberculosis of the mammary, thyroid, and\\nprostate glands is a comparatively rare affection. Carcinoma of a\\ngland differs from adenoma by the absence of any attempts at encap-\\nsulation of the tumor and by the presence of regional dissemination\\nthrough the lymphatics. Metastasis never attends adenoma. Cohnheim\\nclaimed to have found metastasis in a case of adeno-myxoma of the\\nthyroid gland. The tumor perforated a vein-wall, and fragments were\\ndetached and reached the pulmonary vessels, where the secondary\\ntumors were found. It is more than probable that in this case, the only\\none of the kind on record, the tumor was malignant, the strongest\\nproof of this being the manner in which the tumor reached the lumen\\nof the vein. Sarcoma in its earlier stages resembles adenoma, but its\\nmore rapid growth and the local and often general infection are the\\nmost important points upon which to base a correct diagnosis.\\nPrognosis. Adenoma without cyst-formation never grows beyond\\ncertain limits, so that it seldom interferes with important functions by\\nits presence. Adeno-cystoma of the ovary often reaches an immense\\nsize. Adenoma of the middle lobe of the prostate and of the isthmus\\nof the thyroid gland of moderate size gives rise to serious symptoms\\nof obstruction. With the exception of adenoma of the prostate, gland-\\nular tumors seldom originate in persons advanced in years, and usually\\nthey become stationary at the age of fifty. Adenoma not infrequently\\nundergoes transformation into carcinoma or sarcoma. Malignant\\ntumors of the thyroid gland frequently have such an origin. The\\ntransition into carcinoma is observed oftener than a resulting sarcoma.\\nTreatment. Most of the adenomata can be removed successfully\\nby enucleation. In adenoma of the breast the surgeon is often in doubt\\nas to whether the tumor is benign or malignant when the operation is\\nundertaken. A positive diagnosis can be made after the tumor has", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0198.jp2"}, "191": {"fulltext": "ADENOMA. 177\\nbeen reached. If the tumor is an adenoma, it is supplied with a perfect\\ncapsule, and can be shelled out from its bed without any difficulty if it\\nis a carcinoma, all evidences at limitation of the growth are absent, the\\ntumor infiltrates the surrounding tissues, and the operation is incomplete\\nunless the entire breast and all of the axillary glands are removed. If\\nany doubt exists in the mind of the operator in cases of glandular\\ntumors of the breast, the patient should be informed beforehand that\\nconditions might be revealed by the operation which would necessitate\\nremoval of the entire breast. In the enucleation of benign tumors of\\nthe breast the incision should be made in the direction of the milk-\\nducts, and the capsule of the gland should be sutured separately after\\nthe removal of the tumor.\\nAdenomata of the uterus and cervix are usually removed by the use\\nof the sharp curette. Preliminary rapid dilatation of the cervical canal\\nand thorough disinfection of the parts are essential in effecting com-\\nplete removal of the diseased tissue and in preventing septic infection.\\nTamponade of the uterine cavity with iodoform gauze and rest in bed\\nfor at least a week will add to the beneficial effects of the operation and\\nwill minimize the liability to complications.\\nCystic adenoma of the kidney does not justify nephrectomy, as the\\nopposite organ is frequently found similarly affected. If the kidney has\\nbeen exposed by a lumbar incision and the nature of the tumor has\\nbeen determined, enucleation or partial nephrectomy is preferable to\\ncomplete removal of the organ.\\nAdenoma of the liver may become an object of operative treatment\\nif the abdomen has been opened for the purpose of determining the\\nnature of an obscure tumor of that organ. The hemorrhage after\\nremoval of the tumor by enucleation or excision should be arrested by\\nthe employment of the aseptic tampon, which is brought out at the\\nupper angle of the wound, by the application of the actual cautery, or\\nby suturing Glisson s capsule, as advised by Von Bergmann.\\n12", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0199.jp2"}, "192": {"fulltext": "XV. CYSTOMA.\\nThe term cystoma in this book will be used in the most restricted\\nhistogenetic sense, and will be applied only to those cysts in which both\\ncyst-wall and contents are formed anew and independently of pre-existing\\ngland-structures. A sharp etiological distinction must be made between\\na cyst, in the ordinary sense in which this word has been used, and\\na cystic tumor or cystoma. The word cyst has been used very\\nindiscriminately to indicate the existence in a closed cavity of various\\nsolid and liquid contents. It has been, and is still, used to designate\\nthe existence of the products of extravasation, inflammation, and re-\\ntained secretions in a closed cavity. We shall limit the term cystoma,\\ncystic tumor, to cystic formations in which the cyst-wall is produced\\nfrom a matrix of embryonic cells, and the contents are the products of\\ntissue-proliferation of the cells lining the cyst-wall. Used in such a\\nlimited sense, a cystic tumor is a hollow tumor, the interior of the cyst-\\nwall being lined by epithelial or endothelial cells. The cells lining the\\ncyst-wall are the essential tumor-cells. Retention-cysts and cysts\\ncaused by extravasation or inflammation will be excluded from this\\nsection. The epithelial lining of the cyst-wall is derived either from the\\nepiblast or the hypoblast or is composed of endothelial cells. We have\\nalready described adeno-cystoma and proliferating adeno-cystoma in the\\nsection on Adenoma. In adeno-cystoma the glandular structure of the\\ntumor predominates, the cystic part being accidental and usually limited.\\nProliferating cysts may attain great size, but the glandular part pre-\\ndominates permanently. The epithelial cells correspond in shape and\\nstructure to that part of the epiblast or the hypoblast from which the\\nmatrix is derived. In cysts representing mucous membrane and ducts\\nthe cells are usually columnar in cysts of epiblastic origin the cells are\\nflat, corresponding to the pavement epithelium of the skin (Fig. 85).\\nCysts composed exclusively of mesoblastic tissue are lined by endothe-\\nlial cells. Heterotopic cysts are cysts lined with epithelial cells and entirely\\ndisconnected with tissues or organs of epiblastic or hypoblastic origin.\\nMesoblastic cysts are never heterotopic, as connective tissue can be\\ntransformed into endothelial cells and endothelial cells into connective\\ntissue, and connective tissue is present in the body everywhere.\\n178", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0200.jp2"}, "193": {"fulltext": "CYSTOMA. 179\\nSterile cysts are cysts in which the epithelial or endothelial lining has\\ndisappeared by degeneration of its cells (Fig. 85, d).\\nGrowth of a cyst will continue so long as the cells lining the interior\\nof the cyst-wall continue to proliferate. When the cells are destroyed\\nby degeneration or otherwise the contents of the cyst cease to increase,\\nand the cyst remains stationary or diminishes in size. In Figure 85\\nthe cystic spaces at b and c, being lined by proliferating epithelial cells,\\na _=_ _.. \u00e2\u0080\u0094^~*r~\\nFig. 85. Adeno-cystoma of thyroid gland X 5\u00c2\u00b0, reduced one-third (Surgical Clinic, Rush Medical\\nCollege, Chicago): a, stroma; b, acinus filled with colloid material and lined by epithelial cells c, epithelial\\nlining; a?, acinus from which all epithelial cells have disappeared, constituting a sterile cyst.\\nwould increase in size by the addition of new colloid material to the\\ncontents of the cyst, while the space at d would remain stationary in\\nsize, because all the epithelial cells have been destroyed by degenera-\\ntion, and with the destruction of the epithelial cells the cyst has been\\ndeprived of any further source of colloid material. The framework of\\nthe cyst-wall to which the epithelial or endothelial cells are attached\\nis composed of connective tissue. The connective tissue in a true\\ncystoma is derived from the pre-existing connective tissue, which at\\nfirst is condensed by compression caused by the gradual enlargement\\nof the cyst, and later becomes increased in thickness by the production\\nof new connective tissue. The cyst-wall may be exceedingly thin and\\ndelicate if it contains only a small amount of connective tissue, or in\\nthe course of time it may become enormously thickened by the pro-\\nduction of new connective tissue. If the cyst is surrounded by tissue\\non all sides, this tissue gradually becomes more and more isolated\\nfrom the external surface of the cyst-wall, so that finally only the\\nvascular connections remain a condition exceedingly favorable for the\\nremoval of the cyst by enucleation. The cyst-wall may also become", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0201.jp2"}, "194": {"fulltext": "180 PATHOLOGY AND TREATMENT OF TUMORS.\\nfirmly attached to the surrounding structures by inflammatory adhe-\\nsions, as is so often the case in ovarian cysts and in cysts in other parts\\nof the body subjected to partial extirpation or to other inadequate\\nmethods of treatment.\\nThe cyst-contents will vary according to the type of the cells which\\nproduced them. Cysts lined by epiblastic epithelial cells usually\\ncontain the products of fatty degeneration, an atheromatous material,\\nor, if the fatty degeneration has progressed still further, pure oil.\\nCysts lined by columnar epithelial cells analogous to those found\\nin the gastro-intestinal canal usually contain mucus. Cysts of the\\nthyroid gland contain most frequently colloid material, or, if the col-\\nloid material has disappeared by liquefaction, a serous fluid. Meso-\\nblastic cysts generally contain a serous fluid. The cyst-contents are\\nmodified by hemorrhage into the cyst and by the addition of choles-\\nterin-crystals a frequent occurrence, especially in cysts of an epiblastic\\norigin. A simple, single cyst is called a monolocular cyst. A cyst in\\nwhich we find different compartments from the beginning, or produced\\nlater by coalescence of several cyst-walls or by proliferation from the\\ncyst-wall, is called a multilocular cyst. The cyst-wall often undergoes\\ncalcareous degeneration, and sometimes ossification, particularly in cases\\nin which the epithelial lining has been destroyed by degeneration.\\nEtiolog-y. Cystoma very frequently appears as a congenital affec-\\ntion. The tumor-matrix proliferates during intra-uterine life, and at\\nthe time of birth the activity of proliferation can be calculated by the\\namount of contents of the cyst. Congenital cystic tumors of the neck\\nare of frequent occurrence. Although cystic tumors may occur at any\\ntime after birth, they are met with most frequently at the age of puberty.\\nSublingual epiblastic tumors make their appearance most frequently at\\nthis time of life. The great physiological activity of the organs derived\\nfrom the epiblast plays an important part in stimulating a latent matrix\\nto active tissue-proliferation, and if this matrix is of such a structure\\nor nature that its product is not arranged in glandular form, cystic\\ndilatation of its primary central space will follow. The growth of the\\ncyst will depend on the amount of essential tumor-elements and the\\nactivity of their proliferation. Other exciting causes are trauma and\\nprolonged irritation and inflammation in the immediate vicinity of the\\ntumor-matrix.\\nDiagnosis. A cystic tumor usually grows more rapidly and attains\\na larger size than a papilloma or an adenoma. A central hollow space\\nis present from the very beginning, and does not appear later, as is\\nthe case in adeno-cystoma. If the cyst-wall is not too tense or thick,\\nfluctuation can be elicited by careful palpation. If the cyst-wall is thin", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0202.jp2"}, "195": {"fulltext": "CYSTOMA. 181\\nand near the surface, the tumor is translucent if it contains clear serum.\\nIn uncomplicated cases of hydrocele of the neck the tumor is trans-\\nlucent. An exploratory puncture will often prove of great value, not\\nonly in showing the cystic nature of the tumor, but also in demon-\\nstrating the nature of its contents. This diagnostic resource must be\\nemployed with caution in the examination of abdominal tumors if the\\nfree peritoneal cavity cannot be avoided. Exploratory puncture through\\nthe free peritoneal cavity is ordinarily attended by more danger than\\nan exploratory incision. In locating the tumor an effort should be\\nmade to ascertain its primary anatomical starting-point and to bring it\\nin connection with the organ in which it originated. If the cyst occu-\\npies the pelvis, it should be ascertained whether it is connected with\\nthe ovary, the Fallopian tube, or the uterus. If it occupies the abdom-\\ninal cavity and is not connected with the pelvic viscera, the relation of\\nthe tumor to the different abdominal organs must be studied with care\\nto determine the organ with which the tumor is connected or to which\\nit has become attached. Inflation of the stomach and the intestinal\\ncanal will often prove an invaluable diagnostic aid in such cases.\\nPrognosis. Cystoma is a benign tumor. A proliferating cyst of\\nthe ovary may perforate the cyst-wall and invade the peritoneal cavity,\\nbut aside from this a cystic tumor does not extend beyond the limits\\nof the organ primarily affected. Cystoma, if in close contact with im-\\nportant organs, may give rise to dangerous complications by causing\\nharmful pressure. Cysts of the neck and of the pelvis may become a\\nsource of danger from pressure. Large cysts of the abdominal cavity\\nultimately interfere with digestion and respiration and become a source\\nof danger from their size. Adhesions between pelvic and abdominal\\ntumors and the surrounding organs may become a cause of intestinal\\nobstruction. Infection of a cystic tumor with pyogenic microbes may\\nresult in suppuration and sepsis. Torsion of the pedicle of a cystic\\ntumor of the pelvis or of the abdomen has often resulted in gangrene,\\nseptic peritonitis, and death. Malignant transformation is not as often\\nobserved in cystoma as in papilloma and adenoma.\\nTopography. Cystic tumors are met with most frequently in\\norgans and parts of the body in which during intra-uterine life the\\nmost complicated tissue-changes occur. The favorite localities are the\\novaries, the base of the tongue, the neck, and the region of the orbits.\\nTraumatic Epithelial Cysts. The accidental or intentional dis-\\nplacement of a small island of skin into the mesoblastic tissues brings\\nabout a condition closely resembling the relations of an epiblastic tumor-\\nmatrix to the surrounding tissues. A few cases have been reported in\\nwhich epithelial cysts had such an origin. The difference between such", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0203.jp2"}, "196": {"fulltext": "i8a\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nan artificial matrix and a genuine tumor-matrix is the limited prod-\\nuct of the epithelial proliferation. Kaufmann studied the behavior of\\nattached buried epithelial cells by resorting to a procedure which he\\nterms enkatarrhophy He selected for this purpose the cock s comb.\\nBy two elliptical incisions an island of skin was circumscribed it was\\nthen buried by suturing over it the margins of the wound. In some\\nof the successful cases the result was followed until the 210th day.\\nExamination of the specimens obtained at variable periods after the\\noperation showed that at the margins of the buried skin the epithelial\\ncells proliferated, resulting in the formation of a cyst-wall lined\\nthroughout by epithelial cells. The cysts formed in this manner con-\\ntained a material which resembled the contents of an atheromatous\\nWmBmMk\\nFig. 86 Traumatic epithelial cyst of finger (after Garre) a, skin b, subcutaneous tissue c, epithelial cyst.\\ncyst. The growth of the cysts continued until they reached a certain\\nlimited size, when it ceased and the cysts remained stationary.\\nGarre recently reported two cases of traumatic epithelial cysts of\\nthe fingers. In both cases the injury which preceded the cyst-forma-\\ntion was a punctured wound. The cyst developed soon after the injury.\\nIn one case the cyst was 12 millimeters in length and 7 to 8 millimeters\\nin width. A section through the centre of the tumor showed a central\\ncavity (Fig. 86). The implanted fragment of skin could readily be\\nidentified by its characteristic anatomical structure. The epithelial cells\\nat the margins produced new cells which converted the piece of skin\\ninto a globular mass well supplied with blood-vessels. The cyst con-\\ntained exclusively epidermic cells arranged in wavy stratified layers.\\nIn the other case the cyst had reached the size of a hempseed and\\nshowed a similar structure. The opinion of Chavasse that such cysts", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0204.jp2"}, "197": {"fulltext": "CYSTOMA.\\n183\\nFig. 87. Manner of production of traumatic epithe-\\nal cyst (after Garre) a, skin b, subcutaneous tissue\\ndislocated fragment of skin.\\nE- b\\nare produced by the sweat-glands contained in the implanted skin is\\ncontradicted by Garre. The process of cyst-formation as explained by\\nGarre can readily be understood by a glance at Figures 87, 88, and\\n89. He did not find any evidences of the formation of a cyst-wall as\\ndescribed by Kaufmann.\\nReverdin believes that epithelial cysts can originate from the dis-\\nplacement of detached mature epithelial cells into the mesoblastic\\ntissues. Garre s second case was\\none in point. In this case only\\ncells were forced into the subcu-\\ntaneous tissue before the point\\nof a needle, and from them a\\nglobular mass of epithelial cells\\ndeveloped, but no trace of a\\ncyst-wall could be found. Rizet\\nreported a case in which the\\nepithelial cells that originated\\nfrom a displaced fragment of skin\\nbecame the seat of a calcareous\\ndegeneration. In other instances\\nthe cells have frequently been\\neliminated by suppurative inflam-\\nmation.\\nTatum observed on the scar of\\na scalp wound an atheroma-cyst\\nwhich undoubtedly was caused\\nby a dislocated particle of skin.\\nA conclusion of the greatest eti-\\nological moment that can be\\ndrawn from the experiments of\\nKaufmann and the clinical ob-\\nservations of Garre and others\\nis this, that a dislocated fragment of skin does not possess the same\\nintrinsic capacity of continued progressive tissue-proliferation as an epi-\\nblastic tumor-matrix. Epithelial cysts of a similar origin are found\\nmore frequently in the scars following burns than after trauma. Epi-\\nthelial pearls in scar-tissue, the product of buried epithelial cells, are\\nnot of rare occurrence. Traumatic epithelial cysts must be removed\\nby thorough extirpation, otherwise a recurrence will almost surely take\\nplace.\\nDeep-seated Atheroma. A retention-cyst of the sebaceous glands\\nresembles a true atheroma so perfectly in the structure of the cyst-wall\\nFig. 88. Beginning of healing of the skin-defect\\nand commencing proliferation from the margins of the\\nimplanted skin (after Garre).\\nFig. 89. Wound entirely healed, and the buried\\nskin-graft enlarged by proliferation from the surface\\nand margins of the graft (after Garre).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0205.jp2"}, "198": {"fulltext": "1 84\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nand in its contents that we must distinguish between them etiologically\\nand clinically according to their location. Retention-cysts of the seba-\\nceous glands result from obstruction to the escape of the secretions,\\nand always retain their relations with the skin. They are superficial,\\nbeing covered only by the skin. The deep-seated atheroma has no con-\\nnection with the glandular apparatus of the skin, and it always originates\\nfrom a displaced matrix of embryonic epiblastic cells. It should be dis-\\ntinguished from a dermoid cyst by the character of its contents. An\\natheroma contains only epithelial cells as its characteristic morphologi-\\ncal cellular element, while the cyst-wall of a dermoid cyst represents\\nskin with its appendages in the simplest cases, and in more complicated\\ncases systems of organs in various degrees of perfection. The displace-\\nment of the matrix of an atheroma occurred at a time prior to the differ-\\nentiation of the epiblastic cells into the organs representing the appendages\\nof the skin, while the matrix of a dermoid cyst points to a later displace-\\nment of the matrix. Atheroma is met with most frequently in the\\novaries, in the region of the orbits, especially the superciliary arch, and\\nat the base of the tongue. In all these localities it is most frequent\\nat the age of puberty. In the superciliary region it occurs occasion-\\nally as a congenital affection. In this locality it seldom exceeds\\nthe size of a walnut, while tumors at the base of the tongue the size\\nof a cocoanut are not uncommon. Superciliary atheromata frequently\\n_ contain pure oil which will ignite\\nand burn like ordinary lamp-oil.\\nWhen this stage of degeneration\\nis reached further growth is gen-\\nerally arrested. In the majority\\nL of cases the tumor contains a\\nsubstance resembling in every\\nrespect the contents of a reten-\\n/fi? tion-cyst ofthe sebaceous glands.\\nThe granular detritus is com-\\nposed of epithelial cells which\\nhave undergone fatty degenera-\\ntion suspended in a serous fluid\\nin varying proportions. Cho-\\nlesterin-crystals are often very\\nabundant in old cysts. Cysts\\nat the base of the tongue pro-\\nject toward the cavity of the\\nmouth, and when they have reached a certain size they form a swelling\\nin the submaxillary region, causing great disfigurement, and by press-\\nt\\nFig. 90. Sublingual dermoid cystomj", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0206.jp2"}, "199": {"fulltext": "CYSTOMA.\\n185\\nure against the tongue interfering with speech and often also with deg-\\nlutition (Fig. 90). The differential diagnosis between such a tumor and\\na branchial cyst is often difficult, and sometimes can be made only by\\nresorting to an exploratory puncture. A branchial cyst usually con-\\ntains either mucus or a serous fluid an atheroma contains the product\\nof fatty degeneration of epithelial cells.\\nAn atheroma may occur in almost any part of the body, and in the\\ndifferential diagnosis of cysts in unusual localities this fact should be\\ntaken into consideration. The cyst-wall of an uncomplicated atheroma\\nis loosely attached, and can readily be removed by enucleation.\\nMucous Cysts. Cystic tumors with mucoid contents are compara-\\ntively rare if we exclude from this category retention-cysts with similar\\ncontents. They are analogous to atheroma in their etiology, except\\nthat the matrices are derived from the hypoblast and that the interior of\\nthe cyst-wall is lined by columnar epithelium. In place of atheroma-\\ntous material the cysts contain mucus, which in old cysts is usually\\ntransformed in the course of time into a serous fluid. If the cyst is\\nderived from a matrix representing squamous or ciliated epithelia, it\\nis lined by cells representing the part or organ from which the epi-\\nblastic or hypoblastic matrix was derived. Frequent locations of these\\ncysts are the orifice of the cervical canal of the uterus and the mucous\\nmembrane of the lips, mouth, phar-\\nynx, and intestinal canal. Mucous\\ncysts seldom attain the size of a\\nwalnut, as, owing to the delicate\\nstructure of the cyst-wall, rupture\\ntakes place usually before the tu-\\nmor reaches this size. The epithe-\\nlial cells are generally arranged in\\na single layer, and are not stratified\\nas in epiblastic epithelial cysts an\\nadditional cause for the early rup-\\nture of these cysts that so fre-\\nquently takes place. Many of the\\nso-called hydatid cysts are mu-\\ncous cysts, the mucoid substance\\nhaving become transformed into a\\ntransparent serous fluid. Among\\nthe morphological elements in the\\ncontents of a mucous cyst are epi-\\nthelial cells, free nuclei, cholesterin-\\ncrystals, colloid masses, and sometimes concretions. The mucous cysts\\n91\\nCongenital cervical cyst extending into\\nthe axilla (after T. Smith).\\n^m", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0207.jp2"}, "200": {"fulltext": "1 86 PATHOLOGY AND TREATMENT OF TUMORS.\\nare usually globular in shape owing to the fragility of the cyst-wall,\\nthey seldom become pedunculated. Extirpation and the complete\\ndestruction of the epithelial lining of the cyst by cauterization are the\\nonly two operative procedures which can be relied upon in preventing\\na recurrence. With very few exceptions, enucleation is impractical,\\nowing to the great fragility of the cyst-wall.\\nCysts lined by ciliated epithelial cells always have their origin from\\nan embryonic matrix derived from parts and organs supplied with\\nciliated epithelium in the fetal state. Cysts of this kind have been\\nfound in the brain, the external ear, the liver, and the testicles.\\nMesoblastic Cysts. Cysts composed exclusively of tissue of meso-\\nblastic origin are found most frequently in the region of the neck, where\\nthey have been described by the German authors as hygroma and\\nby the English surgeons as hydrocele of the neck. This form of\\ncyst is always of congenital origin it occupies the deep tissues of the\\nneck in front of the large vessels, and often extends from the hyoid\\nbone down to the clavicle and even as far as the axillary space (Fig.\\n91). Congenital cysts of the neck often shrivel soon after birth and\\ndisappear spontaneously; at other times they increase rapidly in size.\\nIn a few instances they reappeared later in life, such a case being\\nreported by Birkett. They are usually unilocular, but sometimes\\nthey are divided in part or completely into a number of compart-\\nments with similar contents. If the cyst is large and contains a\\nclear serous fluid, it is translucent. The histology of these cysts has\\nnot been investigated sufficiently. The very fact that in the majority\\nof cases they disappear spontaneously is sufficient proof that epi-\\nthelial cells do not enter into their construction. Some authors have\\nsuggested that these spaces are ectatic lymph-spaces. If the cyst per-\\nsists, the wall of the space would be sure to become lined by endothe-\\nlial cells, as under such circumstances the connective-tissue cells on the\\nsurface would become transformed into endothelial cells. Such trans-\\nformation of connective-tissue cells into endothelial cells is frequently\\nobserved in the formation of accidental bursae and in the formation of\\nfalse joints in ununited fracture. The attempt to remove such cysts\\nby extirpation is attended by danger, and often has to be abandoned\\nbefore the completion of the operation. The injection of irritating\\nsolutions has also been followed by disastrous consequences. Repeated\\nevacuation by tapping, followed by the injection of a 5 per cent, solu-\\ntion of carbolic acid under strictest antiseptic precautions, is the safest\\nand most efficient method of treatment. Cysts developing from an\\nembryonic mesoblastic matrix after birth are formed in the same way\\nas epithelial cysts. The central space in the matrix becomes lined by", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0208.jp2"}, "201": {"fulltext": "CYSTOMA. 187\\nendothelial cells serous contents accumulate and distend the space.\\nThe spontaneous disappearance of endothelial cysts is of frequent\\noccurrence, as the endothelial cells may at any time revert into their\\nformer condition, and the cyst-contents are more amenable to absorp-\\ntion than are the products of epithelial cells. If the cyst is emptied by\\nabsorption of its contents and the endothelial cells lining the cyst-wall\\nare brought in contact, permanent obliteration of the space will follow.\\nThyroid Gland. A true cyst of the thyroid gland commences as\\nsuch. The formation of the cyst is not preceded by any considerable\\nproduction of glandular tissue. The glandular tissue is scanty. In\\nM k\\nFig. 92. Adenocystoma of thyroid gland; X 85 (Surgical Clinic, Rush Medical College, Chicago):\\na, a, stroma; b, follicles of gland slightly enlarged c, colloid cyst d, two colloid cysts separated by a thin\\nseptum.\\ncystic degeneration of an adenoma of the thyroid gland cyst-formation\\ntakes place usually at different points, and the glandular part of the\\ntumor predominates (Fig. 92). The cysts enlarge by the breaking\\ndown of the thin compartments between smaller cysts, and the cystic\\nnature of the tumor becomes clinically apparent only after the larger\\npart of the glandular structure has been destroyed by degeneration.\\nIn a true cystoma the cavity is formed by expansion of the epithelial\\ncells from a central point of the tumor-matrix, and the tumor is more\\nH", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0209.jp2"}, "202": {"fulltext": "1 88 PATHOLOGY AND TREATMENT OF TUMORS.\\nfrequently unilocular than multilocular. Of course, a number of cysts\\nmay form simultaneously and coalesce into one common cavity, but\\nthis occurrence is rare as compared with adeno-cystoma. A cystoma\\nof the thyroid gland can usually be recognized without difficulty, but\\nif any doubt exists, this can be set aside effectually by an exploratory\\npuncture. Enucleation is the proper treatment for cystic tumor of the\\nthyroid. If this operation cannot be done on account either of calcareous\\ndegeneration of the cyst-wall or of firm adhesions with the surround-\\ning tissues, a partial thyroidectomy is indicated. Laying open of the\\ncyst freely by incision, followed by vigorous application of the actual\\ncautery so as thoroughly to destroy the cellular lining of the interior\\nof the cyst-wall, will also effect a radical cure, but this treatment\\nconsumes more time and will leave a more unsightly scar than either\\nenucleation or extirpation.\\nThe writer has recently treated successfully a cyst of the thyroid\\ngland the size of a hen s egg by a single tapping, followed by the\\ninjection of 2 drams of a 10 per cent, emulsion of iodoform in\\nglycerin.\\nMammary Gland. Retention-cysts and adeno-cystoma of the mam-\\nmary gland occur much more frequently than true cysts. In both\\ninstances the cysts are frequently multiple, and seldom do they attain\\ngreat size. Bryant divides cysts of the mammary gland into three\\nvarieties I Cystic degenerations of the breast, met with in the aged as\\nwell as in glands which have long ceased to be active involution-\\ncysts, as they are called 2. Cystic tumors of the gland, single or\\nmultiple, of glandular, duct-, or connective-tissue formation, without\\nintracystic growths 3. Cystic tumors of the breast, of whatever kind,\\nin which papillomatous, adenomatous, sarcomatous, or carcinomatous\\nintracystic growths are present.\\nA true cystic tumor commences, like all true cystomata, in the centre\\nof a matrix of embryonic epithelial cells, the epithelial cells becoming\\nattached to the surrounding connective tissue, which becomes the\\nstroma of the tumor. The products of epithelial proliferation accumu-\\nlate in the central space and form the contents of the cyst. Serum, or\\nserum altered by the presence of blood or cholesterin-crystals, is usu-\\nally found as the characteristic contents of such a cyst. The tumor\\ngrows slowly in size, displaces the surrounding tissues, and often\\nreaches an enormous size. Paget refers to a case in which the tumor\\ncontained nine pounds of serous fluid. He remarks, very correctly,\\nthat tumors which contain the simplest fluids and which have the\\nsimplest walls are apt to grow to the largest size. Thickening of cyst-\\nwalls and, much more, their calcification are here, as elsewhere, signs", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0210.jp2"}, "203": {"fulltext": "CYSTOMA.\\n189\\nof degeneracy and of loss of productive power. A true cystoma of\\nthe mammary gland is characterized clinically by its progressive growth,\\nits simple contents, and the thinness of the cyst-wall.\\nAnother form of cyst of the mammary gland is described as pro-\\nliferous cyst, in which, from the cyst-wall, papillary excrescences\\nproject into the cyst, resembling the same kind of cyst in the ovary.\\nThis kind of cyst, however, more frequently occurs associated with\\nadenoma or sarcoma of the breast than as a distinct anatomical variety\\nof cystoma.\\nEnucleation is the proper treatment of cystic tumors of the breast\\nif this operation does not succeed on account of firm adhesions or of\\ndegeneration of the cyst-wall, the excision of a small zone of gland-\\ntissue with the cyst will ensure a radical cure.\\nOvary. As cysts of the ovary have so many different histogenetic\\nsources from which they take their origin, and as the different localities\\ncorrespond with so many structures of different embryonic origin, the\\nstudent must familiarize himself with the development of the ovary in\\nthe embryo in order to enable him to trace the different kinds of cysts\\nto their proper embryonic matrices (Fig. 93).\\naa\\nFig. 93. Schema of tubo-ovarian apparatus, to show the various points of origin of cystic growths\\n(after Doran) aa, multilocular glandular cyst, developed in a, ovarian parenchyma c, papillary cyst, devel-\\noped in b, tissue of the hilum of the ovary; d, unilocular cyst of the broad ligament, free from the parova-\\nrium, k; e, unilocular cyst of the broad ligament, situated just above the Fallopian tube, but not united to\\nit f, similar cyst nearjf, utero-ovarian ligament h, hydatid of Morgagni, which is never the starting-point\\nof a large cyst i, cyst developed at the expense of the horizontal canal of the parovarium cyst devel-\\noped at the expense of the vertical tube (according to Doran, these are the papillary cysts of the broad liga-\\nment) in, n, course of the obliterated canal of Gartner papillary cysts may be developed at any portion\\nof this canal (Coblenz), and these cysts may be the origin of papillary cysts connected with the uterus,\\nThe size of the cyst will depend on the vegetative capacity of the cells\\nof the tumor-matrix. The nature of the contents of ovarian cysts is\\ndetermined by the histological character of the tumor-cells and by the\\ntype of degenerative changes which these cells undergo. The hydatids", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0211.jp2"}, "204": {"fulltext": "190 PATHOLOGY AND TREATMENT OF TUMORS.\\nof Morgagni consist of an exceedingly delicate cell-wall and a trans-\\nFig. 94. Cystic disease of the ovaries serous and myxomatous multiple follicular cysts (after Pozzi)\\na, a small myxomatous cysts b, b large myxomatous cysts e, e follicular cysts with fluid contents c,\\ng, g 1 follicular cysts with caseous contents o,f,f, ovarian tissue containing small follicular cysts.\\nparent clear serum as contents, and they seldom exceed the size of an\\nFig. 95. Papillary cyst starting from the hilus of the ovary (aftor Doran). On the 1-eft lower extreme\\nof the picture is the ovary, which is almost intact. The cyst is developed within the broad ligament, which\\nis opened so that we may see above a portion of the Fallopian tube. An opening has been made in the cyst-\\nwall to show the papillary vegetations within.\\nordinary marble. They are usually pedunculated, and are discovered\\nonly in opening the abdomen for other indications.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0212.jp2"}, "205": {"fulltext": "CYSTOMA.\\nI 9 I\\nThe multiple cysts with serous contents that characterize the cystic\\novary as described by Rokitansky hardly ever exceed in size a cherry-\\nstone (Fig. 94).\\nOvarian cysts of this variety are always complicated by sclerosis\\nof the interstitial tissue. In a very instructive paper on ovarian papillo-\\nma Coblenz gives an accurate histogenetic account of this variety of\\novarian cysts. The author comes to the conclusion that the Pfliiger-\\nWaldeyer epithelial sacs, as well as the medullary tubules of Kolliker,\\nmay give rise to the formation of cysts, but that from the former the\\nglandular, and from the latter the papillary, variety are produced. At\\nany rate, the papillary cysts are genetically and anatomically analogous\\nto the papillary formation of the mucous membranes, whether they are\\nin the interior of cysts or whether they spring from the surface of the\\novary. In the latter case the tumor may have developed from the sur-\\nface of the ovaiy or may have reached this locality from the interior of\\na cyst. Proliferous cysts spring either from the surface of the ovary\\nor from rests of fetal tubules in the ovary (Fig. 95). The cystic spaces\\nare usually small, and the proliferating masses in their interior are large.\\nPapillary growths on the surface of the ovary, and similar vegeta-\\ntions reaching the surface after perforation of a proliferous cyst, spread\\nFig. 96. Papillary tumor of ovary covering the whole of both broad ligaments (after Pozzi).\\nto the surrounding parts, often imbedding ovary, tube, ligament, and\\nuterus (Fig. 96). The histological structure of a papuliferous tumor\\nof the ovary is well shown in Figure 97.\\nProliferous cysts of the ovary are more likely to return after opera-\\ntion than are any of the other benign tumors. If the tumor develops\\nfrom the surface of the ovary, or if the operation is postponed after a\\nproliferous cyst has been perforated, fragments of the tumor frequently\\nremain, and it is from these fragments that the recurrence takes place.\\nRecurring tumors have no pedicle and are usually extensively adherent,\\n\u00e2\u0096\u00a0M", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0213.jp2"}, "206": {"fulltext": "193\\nPATHOLOGY AND TREATMENT OF TUMORS.\\n1\\nS;\\ni\\no\\nu\\n8", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0214.jp2"}, "207": {"fulltext": "CYSTOMA.\\nJ 93\\nrendering their removal difficult and sometimes impossible. If the\\ntumor-tissue comes in contact with the peritoneal surface, ascites sets\\nin, still further complicating the case.\\nL\\nFig. 99. Adeno-cystoma of right ovary (after Winckel). In the anterior wall of the large cyst a number\\nof small prominences indicate the location of smaller cysts.\\nGlandular cysts of the ovary always occur as a multiple affection\\n(Fig. 98). By breaking down of the septa the cavities enlarge (Fig.\\n99). The contents undergo various regressive changes and vary\\nFig. 100. Follicular cysts of ovary (after Barnes).\\ngreatly in different cysts of the same tumor. Some cysts contain a\\njelly-like, amorphous mass, others a clear serum, and still others a\\nserous fluid stained by the admixture of blood.\\n13\\nM", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0215.jp2"}, "208": {"fulltext": "i94\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe origin of simple cysts of the ovary has been the subject of care-\\nful investigation, but has not definitely been settled. The so-called fol-\\nlicular cysts are dilated Graafian follicles. All the histological elements\\nof a normal follicle are found in such cysts. The cysts are numerous\\nand are separated by septa of connective tissue (Fig. ioo). The spaces\\nare lined by columnar epithelium, and ova have been found in their\\ninterior by Ritchie, Webb, Tait, and Rokitansky. The cysts contain\\nusually clear serum occasionally the serum is of a yellowish color,\\nand sometimes it is otherwise stained by the admixture of blood.\\nSometimes the epithelial cells undergo myxomatous degeneration\\n(Fig. 101).\\nHydrops of the follicles of the ovary is usually a symmetrical affec-\\ntion occurring in both ovaries at the same time. Follicular cysts of the\\novary seldom result in the formation of large tumors. It was formerly\\nbelieved that most of the simple ovarian tumors resulted from disten-\\ntion of pre-existing Graafian follicles by proliferation of the epithelial\\nlining. That this is not the case is now generally admitted, but that\\noccasionally an ovarian cyst may have such an origin cannot be denied.\\nFig. ioi.\u00e2\u0080\u0094 Follicular cyst of ovary with myxomatous degeneration; X 5\u00c2\u00b0 (after Pozzi) A, A, loose myxo-\\nmatous tissue toward the interior of the cyst B, B, dense myxomatous tissue toward the external surface.\\nIf in a Graafian follicle a matrix of embryonic epithelial cells should", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0216.jp2"}, "209": {"fulltext": "CYSTOMA\\n195\\nexist, we can readily understand that the follicle would become the\\ncyst-wall, while the matrix would furnish the contents. Neumann ex-\\namined a monolocular ovarian cyst which contained four liters of fluid,\\nand found that the cyst had developed from a Graafian follicle. The\\ndeposit which formed in the fluid after standing for some time contained\\nepithelial cells of the membrana granulosa and innumerable ova with\\na distinct zona pellucida. Neumann estimated the number of ova at\\nmany thousands. The majority of simple ovarian cysts undoubtedly\\noriginate from embryonic tubular rests.\\nCysts of the corpus luteum were ascribed by Rokitansky to preg-\\nnancy, but Gottschalk found them also in nullipara. The contents of a\\nFig. 102. Corpus luteum X 350.\\ncorpus luteum of the ovary without cystic degeneration are shown in\\nFigure 102, which shows the epithelial cells of the follicle and rem-\\nnants of the blood-clot. Cystic degeneration of a follicle may lead to\\nthe formation of cysts as large as an apple. Nagel has seen them as\\nlarge as an adult s head. Cysts of the corpus luteum (Figs. 103, 104),\\nas well as follicular cysts, are not cystic tumors, but are retention-\\ncysts.\\nThe parovarium (Fig. 93, k) is frequently the seat of cyst-formation.\\n^^m", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0217.jp2"}, "210": {"fulltext": "196\\nPATHOLOGY AND TREATMENT OF TUMORS,\\nThis structure is an embryonic remnant, and consequently it frequently\\ncontains the essential tumor-matrix. Cysts of the parovarium (Fig.\\n105) are also called cysts of Rosenmiiller s organ, because their\\norigin in the broad ligament, in which they are situated, corresponds\\nto the seat of these embryonic remains. Verneuil, De Sinety, and\\nFig. 103. Cyst of the corpus luteum natural size (after Nagel).\\nDoran believe that these cysts are developed in the connective tissue\\nindependently of the parovarium. Supernumerary ovaries must also\\nbe remembered as a possible source of such cysts.\\nAccording to the structure of the cyst-wall and the character of\\nFig. 104.\u00e2\u0080\u0094 Cyst of the corpus luteum; X 50 (after Nagel) a, connective tissue of the internal surface,\\nepithelium removed; b, yellow layer of corpus luteum c, normal tissue of the ovary near the hilum.\\nthe contents, cysts originating from the parovarium or in its immediate\\nvicinity are divided into I. Hyaline cysts 2. Papillary cysts 3. Der-\\nmoid cysts. Cysts developing from this locality do not reach a large\\nsize, and they contain a serous fluid. Their removal is attended by\\ndifficulty, owing to the absence of a pedicle.\\nMorgagni s hydatids (Fig. 106) are small, translucent, pedunculated", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0218.jp2"}, "211": {"fulltext": "CYSTOMA. 197\\ncysts attached to the fimbriated extremity of the Fallopian tubes.\\nAccording to Waldeyer, these cysts are caused by partial distraction\\nof Miiller s canal by fixation of a part of this structure to the diaphrag-\\nmatic band of the primary kidney. These cysts are perfectly harmless,\\nand never exceed in size a hazelnut.\\nIntraligamentous cysts of the broad ligament often attain the size\\nof a fetal head, contain a clear serous fluid, and are lined by squamous,\\nciliated, or columnar epithelial cells, according to the origin of the\\ntumor-matrix. In diagnosis they are often mistaken for ovarian cysts\\nand for the different varieties of retention-cysts of the Fallopian tube.\\nFig. 105. Unilocular parovarian cyst of the broad\\nligament (after Doran). To the left and above is the\\nincised ovary, which is seen to be free. The elongated\\nFallopian tube is spread over the surface of the cyst. Fig. 106.\u00e2\u0080\u0094 Morgagni s hydatid (after Winckel).\\nTheir removal by enucleation is one of the most difficult of all pelvic\\noperations. Tapping these cysts is not attended by much risk, and the\\noperation has occasionally resulted in a permanent cure.\\nTreatment. The proper treatment of an ovarian cyst, irrespective of\\nits origin and size, is removal by abdominal section. If no contraindi-\\ncations exist, the operation should be performed as soon as the diagno-\\nsis can be made. Under strict antiseptic precautions the abdomen is\\nopened to the requisite extent through the linea alba. After removal\\nof the contents of the cyst by tapping the tumor is drawn forward into\\nthe wound and its pedicle is ligated after transfixion by a double liga-\\nture of silk, and the cyst is severed at a safe distance from the liga-\\ntures, in order to prevent hemorrhage from slipping of the ligatures.\\nThe stump should be dusted lightly with iodoform, after which it is\\nreturned into the abdomen and the external incision is closed in the\\nusual manner. If the adhesions are firm, it is advisable to leave the\\nperitoneal covering attached to the adherent organs to prevent visceral", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0219.jp2"}, "212": {"fulltext": "198 PATHOLOGY AND TREATMENT OF TUMORS.\\ninjuries. In aseptic cases drainage may usually be dispensed with\\nunless made necessary by hemorrhage, when a Mikulicz drain should\\nbe employed. In closing the abdominal incision the peritoneum and\\nthe fascia of recti muscles should be sutured separately. The silk-worm\\ngut should embrace all tissues except peritoneum.\\nVagina. Kossmann attempts to prove that Gartner s ducts are\\nidentical with Wolff s ducts that, therefore, where they remain they\\nopen into the sinus urogenitalis between the urethral orifice and the\\nintroitus vaginae that as a rule they usually obliterate, but that in\\nsome mammalians, and abnormally in man, the obliteration of a part\\nmay not take place, and that, therefore, we may in the human female\\nfind their remnants in the anterior vaginal wall down toward the\\nurethral orifice. Nagel, on the other hand, seems to prove by his and\\nother excellent researches that Wolff s ducts have no part in the devel-\\nopment of the vagina, which proceeds from the lowest points of the\\nunited Miiller s ducts. Islets of epithelial cells, which subsequently\\nbecome hollow and constitute the beginning of cyst-formation, have\\nbeen seen by Ackeren and Schueller in early embryonic life. Vaginal\\ncysts, except those resulting from retention of secretions, arise from\\nembryonic remnants of the distal part of Gartner s duct. The writer\\nhas removed two such cysts, as large as a hen s egg, filled with mucus.\\nThese cysts are lined with stratified epithelium. Their enucleation from\\nthe vagina is not attended by any special difficulty.\\nTesticle. Cysts of the testicle were described by Astley Cooper as\\nhydatids, and Curling included them under the general term cystic\\ndisease of the testis. Cystic tumors of the testicle are cysts which are\\ndeveloped independently of pre-existing glandular structures, in con-\\ntradistinction to spermatocele, which forms in consequence of a\\nmechanical obstruction interfering with the escape of the physiological\\nsecretion of this organ. From the category of cystoma of the tes-\\nticle must also be excluded the different varieties of hydrocele. The\\nWolffian body enters largely into the composition of the testicle, and\\nis without doubt the source of many cystic formations simple exam-\\nples are the cysts of the organ of Giraldes. The hydatids of Mor-\\ngagni and other rests of Midler s duct are possible starting-points\\nof cysts. The cyst-wall is composed of an abundant new growth\\nof connective tissue lined by columnar, ciliated, or rarely by strati-\\nfied epithelium. How far the simple stratified cysts are derived\\nfrom adult spermatic tubes, how far from spermatic tube-rests which\\nhave failed to unite with Wolffian-duct tubes, it would be difficult to\\ndecide. That some of the sperm-containing cysts owe their origin to\\nthese rests seems very probable indeed, Paget suggested that in these", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0220.jp2"}, "213": {"fulltext": "CYSTOMA.\\n199\\ncysts spermatozoa were secreted by the lining membrane. Not long\\nago the writer removed a cystoma of the testicle, and found in the\\ncontents of the cyst numerous spermatozoa and a few epithelial cells.\\nThe tumor was perfectly encapsulated, with no connection whatever\\nwith the glandular apparatus of the testicle, and was enucleated with\\nease. Occasionally, cystic tumors of the testicle are multilocular.\\nEnucleation is the proper treatment. During the operation the\\nsame precautions must be observed as in the removal of adenomata\\nof this organ, to prevent injury to the spermatic cord or the testicle.\\nAfter enucleation the visceral layer of the tunica vaginalis should be\\nsutured by a buried row of catgut sutures.\\nBye. The iris and the cornea are the most common localities of\\ncysts of the eyeball. In the iris they occur most frequently upon the\\nanterior surface as sessile or pedunculated cysts containing a serous\\nfluid or a sebaceous material. Mr. Hulke collected 21 cases of cysts\\nof the iris, and found that in 17 cases the cyst-formation was pre-\\nceded by an injury. He suggests that some of these cysts originated\\nfrom portions of Descemet s membrane that may have been torn from\\nthe cornea and implanted on the iris.\\nCorneal cysts (Figs. 107, 108) are caused most frequently by implanta-\\ntion of corneal tissue resulting from\\noperations or injuries. This cause\\nof cyst-formation has been studied\\ncarefully by Treacher Collins.\\nFig. 107.\u00e2\u0080\u0094 Large implantation-cyst of the cor-\\nnea following an injury (after Collins).\\nFig. 108. Section of the cyst in Figure 107\\n(highly magnified), showing the laminated epithelium\\n(after Collins).\\nThe cysts of the cornea following an injury are produced in the\\nsame manner as the traumatic epithelial cysts described in the begin-\\nning of this section. They arise from transplantation of conjunctival\\nepithelium into the deep tissues of the cornea.\\nCysts of the Vitello -intestinal Duct. The profession is greatly\\nindebted to J. Bland Sutton for a more thorough understanding of\\ncysts of the vitello-intestinal duct and cysts of the urachus. His\\ninvestigations have done the most toward enabling surgeons to refer", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0221.jp2"}, "214": {"fulltext": "200 PATHOLOGY AND TREATMENT OF TUMORS.\\nhitherto obscure cysts in these localities to their origin from remnants\\nof embryonic life. Cysts of the vitello-intestinal duct connected with\\nthe umbilicus of babes and young children, and varying in size from a\\npea to a cherry, are of frequent occurrence. They are usually pedun-\\nculated, and are composed of unstriped muscle-fibre, mucous mem-\\nbrane, Lieberkuhn s follicles, and columnar epithelium collected in a\\nmass. These cysts may enlarge, rupture spontaneously, and leave a\\nsinus from which escapes a watery discharge. In rare cases that part\\nof the vitello-intestinal duct connected with the ileum becomes the seat\\nof cyst-formation. Such a case was reported by Roth. Occasionally\\nthe entire duct remains patent, when part of the intestinal contents\\nescape from its opening at the umbilicus. Sutton has traced imper-\\nforate ileum to the vitello-intestinal duct.\\nAllantoic (Urachus) Cysts. The urinary bladder of man presents\\nat its apex an impervious cord, known as the urachus, which passes to\\nthe umbilicus. The duct is obliterated at birth, and in the adult lies in\\nthe subperitoneal tissue in the middle line of the anterior abdominal\\nwall. If the urachus does not become obliterated in any part of its\\ncourse, it becomes dilated, and the cyst is found outside the peritoneum\\nand in close relation with the bladder. The whole of the intra-abdom-\\ninal part of the urachus may remain patent and form a large urinary\\nbladder. Shattock observed such a case. If the entire urachus remains\\nopen, urine escapes at the umbilicus. Tait reported a case in which he\\nfound a large cyst of the urachus beneath the abdominal wall. The\\nsurgical treatment of such cases is not well settled, and must be deter-\\nmined largely by the size and location of the cyst.\\nCysts of the vitello-intestinal duct and the urachus are not cysto-\\nmata, but are retention-cysts resulting from faulty development.\\nBone. True cystoma of bone is exceedingly rare. Engel describes\\nthe case of a female fifty-five years of age, the mother of six. healthy\\nchildren, who died of an acute affection and who had never exhibited\\nsymptoms indicative of any bone-lesion. At the post-mortem the\\nentire skeleton was found occupied by cysts varying in size from that\\nof a pea to three inches in diameter. The cysts contained a clear or a\\nbloody serum. The cyst-walls consisted of a layer of connective tissue.\\nIn a few cases isolated cysts of considerable size have been found in\\ndifferent bones.\\nBone-cysts developing from a displaced matrix of embryonic epithe-\\nlial cells are most frequently met with in the maxillary bones.\\nSingle cysts of the jaws are usually developed in connection with\\ndisplaced or diseased teeth, and consequently are met with most fre-\\nquently in young persons.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0222.jp2"}, "215": {"fulltext": "CYSTOMA. 20I\\nMalassez has made careful researches concerning the origin of cysts\\nof the jaws, which have led him to the conclusion that they start from\\nwhat he calls debris paradentaires epitheliaux, which he was able to\\ndemonstrate in embryos as well as in the adult. Such epithelial nests\\nare formed during intrauterine life by the mucous membrane covering\\nthe alveolar margin projecting into the tissues, where by constriction\\nN-\\nP ifr^r;^\\nl\\\\#?A^\\nr v V\\\\\\\\\\\\ ^*m^f$* r h -~c\\n*m^ S*\\nJM\\nck ,i.r \u00e2\u0080\u009e,*v\\nm\\nt\\nf t\\nJ jfJJ!*%i*?$X*i*r*;#X l t !k .\u00e2\u0096\u00a0.jF** M\\nm\\\\ 2SW c S v f i\\n44^ a\\nV. i i v ,V s V*\\n-t~^ s^\\ni? SB w- fi: t#^Sr Pk\\nFig. 109.\u00e2\u0080\u0094 Multilocular cystoma of the lower jaw vertical section through tumor, X 176 (after Becker)\\nC, cylindrical cells P, polygonal cells PI, flattened polygonal cells S, stellate cells V, vacuoles Cy, cyst\\nPk, pearl-globe (Kugel) K, granular contents of cyst Ca, capillary from stroma into alveolus Ck, colloid\\nmass Si, stroma.\\nat the surface isolation takes place, forming the tooth-germs, and from\\nwhich buds may form, which serve later as the starting-point of\\ncystoma. Allgayer and Grasse are of the same opinion. Such cysts\\nare lined with epithelial cells, and contain usually a viscid yellowish\\nfluid.\\nMultilocular cysts of the jaws (Fig. 109) are a great rarity. Re-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0223.jp2"}, "216": {"fulltext": "202 PATHOLOGY AND TREATMENT OF TUMORS.\\ncently two such cases from the clinic at Bonn were described by Becker.\\nThis author found in literature sixteen additional cases. The lower\\njaw is more frequently the seat of this tumor. From this fact alone\\nit is evident that displaced dental germs are not the cause of these\\ncysts, as most authors claim. In the upper jaw such cysts may rup-\\nture into the antrum of Highmore. They are found more frequently\\nin the region of the molar and bicuspid than in that of the other teeth.\\nThe youngest patient was twelve years, the oldest seventy-two years\\nof age. The growth, which commences during childhood and puberty,\\nis slow. Trauma and inflammatory affections are the exciting causes.\\nAccording to the location of the matrix the cyst will project either\\nfrom the outer or the inner side of the jaw.\\nThe crackling sensation (bruit de parchemin) as a diagnostic sign\\nin the examination of multilocular tumors of the jaw was described by\\nRunge in 1775, and later by Dupuytren. Fluctuation appears when the\\nbony wall has been absorbed, and is consequently a later sign. Ulcer-\\nation of the gums does not take place. Such tumors often attain an\\nenormous size. Falkson and Bryk describe a case in which the tumor\\nweighed one and a half kilograms and reached from the zygomatic arch\\nto the sternum. On section through the tumor a system of hollow spaces\\nwas disclosed. Some of the cysts communicated with others. The\\nsepta are usually membranous. These cysts contain a viscid fluid some-\\ntimes mixed with blood. The size of the cysts varies from minute\\nspaces to that of a hen s egg. The inner surface of the cysts is smooth.\\nIn the study of these cysts three stages are apparent 1. Cellular cords\\n2. Alveoli 3. Cysts.", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0224.jp2"}, "217": {"fulltext": "XVI. CARCINOMA.\\nThe subject of carcinoma is one of immense etiological and clinical\\ninterest. The etiology has been investigated and discussed for cen-\\nturies, and, although great progress has been made in tracing the histo-\\ngenetic origin of carcinoma to its proper source, the explanation of the\\nreal cause awaits discovery. The etiology has recently received renewed\\ninterest from the bacteriological researches that have been made to prove\\nthe microbic origin of carcinoma. As we shall see farther on, no posi-\\ntive proof has been furnished so far that carcinoma is a microbic disease.\\nThe clinical interest of carcinoma arises from the prevalence of this\\naffection and the inadequacy of the present surgical resources to cope\\nwith it successfully. To what fearful extent carcinoma figures as a cause\\nof death can be learned from the fact that in England and Wales during\\nten years (1860-1870), 2,379,622 persons above the age of twenty died,\\nand that this number includes 81,699 deaths from carcinoma, the deaths\\nfrom this cause constituting to all others a ratio of 1 29. There can\\nbe but little doubt that this disease is on the increase. The dread of\\ncarcinoma is almost universal. Its terrors have been described in prose\\nand in poetry. Shakespeare alludes to it in Hamlet And is t not to\\nbe damned, to let this canker of our nature come in further evil\\nNot only the profession, but also the public, is aware of the great\\nshortcomings of surgery in its treatment. The impression prevails\\namong the people that it is incurable. The great mass of the people\\nhave abandoned all hope of the receipt of permanent benefit from the\\nrecognized surgical craft for this affection, and seek aid from so-called\\ncancer specialists that exist everywhere and fatten on the credulity\\nof an army of despondent, almost desperate, cancer patients. This sad\\ncondition of affairs, and with it the remunerative occupation of this\\nhorde of pretenders, will cease to exist when the discovery of the real\\ncause of carcinoma is made and when successful therapeutic measures\\nare established upon such basis. The writer has great confidence in\\nfuture investigations in this direction. A great number of tireless,\\nhonest investigators are at work, and the prophesied results will be\\nrealized in time.\\nDefinition. Carcinoma is an atypical proliferation of epithelial cells\\nfrom a matrix of embryonic cells of congenital or post-natal origin.\\n203", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0225.jp2"}, "218": {"fulltext": "204 PATHOLOGY AND TREATMENT OF TUMORS.\\nThis definition includes what is known of the histogenetic origin of\\ncarcinoma. It refers the tumor to its primary location in mesoblastic\\ntissue, and the origin of its cellular elements to a matrix of embryonic\\nepithelial cells. The heterotopic location of the epithelial cells distin-\\nguishes carcinoma from all the benign epithelial tU7nors. Atypical pro-\\nliferation of epithelial cells means their growth and multiplication in\\na locality where epithelial cells have no legitimate citizenship. The\\nmatrix may occupy such a location from the very beginning when\\nembryonic cells have been displaced into mesoblastic tissue during the\\ndevelopment of the embryo in the case of congenital matrices or\\nwhen in a burn or a wound or an inflammatory process embryonic cells\\nbecome buried in the mesoblast after destruction of the membrana\\npropria in matrices of post-natal origin or, finally, if the matrix is\\nconfined to the epiblastic or hypoblastic tissues, the carcinoma dates\\nback to the time when the embryonic cells passed through and beyond\\nthe membrana propria into the vascular mesoblastic tissues.\\nViews Past and Present regarding the Origin and Nature of\\nCarcinoma. The old authors were familiar with the gross appearances\\nand the clinical aspects of carcinoma. The division into open and sub-\\ncutaneous carcinoma was made at an early day the former was de-\\nscribed as cancer apertus, and the latter as cancer occultus. Celsus\\nunderstood under the term cancer the several forms of gangrene.\\nGalen insisted on an early diagnosis, which he based almost exclusively\\nupon its clinical course. ^Etius gave an accurate description of carci-\\nnoma of the uterus. The classical description of cancer by Soranus\\nwould be no discredit to a modern work on general pathology. All\\nmalignant growths were included under the head of cancer. The first\\nattempt to describe tumors upon an anatomical basis was made by\\nJohannes Miiller in his work on The Structure of Morbid Growths,\\npublished in 1838. Virchow traced the tumor-cells to their histological\\norigin, and thus laid the foundation for a rational classification. He\\nwas also the first to describe the alveolar structure of carcinoma, and\\nhe called attention to the resemblance of carcinoma-cells to epithelial\\ncells. He believed that both stroma and the epithelial cells were pro-\\nduced by the connective tissue.\\nThe microscope was made available as a means of investigating the\\nstructure of tumors by Schleiden and Schwann. Miiller in 1836, in a\\npreliminary communication, divided tumors into benign and malig-\\nnant, by which terms he meant tumors that were curable or incurable\\nby operation. Bichat described carcinoma as a subepithelial tumor, and\\ndistinguished a stroma which he believed consisted of degenerated con-\\nnective tissue and of cells derived from the epithelial layer. Laennec", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0226.jp2"}, "219": {"fulltext": "CARCINOMA. 205\\ndivided tumors into homologous and heterologous, and among\\nthe latter included tubercle, encephaloid, melanosis, and scirrhus. Lob-\\nstein, while admitting the correctness of this division, believed that the\\ndifference between the two kinds of tumors was due to a species of\\nlymph, which, according to the character of the tumor, is either euplastic\\nor cacoplastic. Miiller maintained that the structure of benign and\\nmalignant tumors was identical, and that the classification into homol-\\nogous and heterologous tumors was based on ignorance of their micro-\\nscopical structure. He, however, recognized a neoplastic form of cell-\\nelements, and in the examination of tumor-tissue under the microscope\\nhe speaks of normal tissue, granules, cells, and new connective tissue.\\nFrom that time dates the description of a morphologically specific\\ncaudate cancer-cell which was regarded as the essential element of\\ncancerous infiltration an opinion which prevailed at his time, but\\nwhich was not shared by Miiller. Lebert and Hannover revived again\\nthe theory of the existence of a specific cancer-cell, but, instead of the\\ncaudate cell, described a more primitive structure. Lebert separated\\ncarcinoma of the skin from carcinoma of internal organs, and called it\\ncancroid. About the same time Ecker examined microscopically three\\nspecimens of carcinoma of the lip, and, finding no foreign heteroplastic\\ncells, declared them to be a simple hypertrophy of the papillae. Mayo\\ndiscovered general infiltration in a similar tumor, and therefore classified\\nit with what was then generally recognized as cancerous tumors.\\nRokitansky classified carcinoma of the skin with glandular carci-\\nnoma, and regarded it as a variety of medullary fungus, differing from\\ncarcinoma proper only by the form and aggregation of its cells. Lebert\\nmodified his views regarding the structure and nature of cancroid after\\nhe discovered that in some cases it gave rise to glandular and general\\ninfection, and after having found in it the cell-forms which he regarded\\nas characteristic of carcinoma. In 1845 he- distinguished three kinds\\nof carcinoma of the skin: 1. Papillary excrescences with inflamed,\\nindurated base and superficial ulceration 2. Papillary proliferations of\\nthe cauliflower kind with enlargement of the sebaceous glands 3. Epi-\\nthelial neoplasms consisting of a fibrous framework, its meshes filled\\nwith epithelial cells. Ecker, Mayo, and Lebert referred the origin of\\nthe new epithelial cells to proliferation from pre-existing mature epithe-\\nlial cells, while Virchow, Rokitansky, and Neumann claimed that they\\nwere the product of metaplastic proliferation of the connective tissue.\\nThe glandular origin of carcinoma of the skin was studied by E. H.\\nWeber, and later by Gluge. Ecker, Mayo, Lebert, and Rokitansky\\nbelieved that carcinoma resulted from tissue-proliferation of the papillae\\nof the skin. Virchow applied the term cancroid to surface carcinoma", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0227.jp2"}, "220": {"fulltext": "206 PATHOLOGY AND TREATMENT OF TUMORS.\\nin which, in the tumor-tissue, spaces are formed and are occupied by\\nepithelial cells. Fiihrer called attention to the possible influence of\\nirritation caused by the hair in the production of carcinoma of the lip\\nin men. Robin believed that carcinoma of the skin originated in the\\nsebaceous glands.\\nHannover originated the term epithelioma for carcinoma of the skin\\nand mucous membranes a term which has caused a great deal of\\nconfusion in distinguishing a benign from a malignant epithelial tumor.\\nHe asserted that carcinoma of the skin originated from the rete Mal-\\npighii, and not in the glandular appendages of the skin. Verneuil and\\nForster observed cases of carcinoma of the skin that originated in\\nsweat-glands. A parallel to the history of surface carcinoma is that of\\na form of ulceration of the skin that was called ulcere cancroide by\\nLebert, ulcus rodens by Paget, and ulcus phagedcenicum by Von Bruns.\\nMany English authors adhere to the term rodent ulcer, and describe\\nunder it something which is supposed to be different from true carci-\\nnoma. Modern writers, with few exceptions, look upon rodent ulcer as\\na variety of carcinoma of the skin. Forster observed fatty degeneration\\nof the tissues in carcinoma of the skin, besides a mucous metamorphosis\\nof the cell-masses in the alveoli. Colloid degeneration was found only\\nin exceptional cases. It was ascertained later that the cylindroma of\\nBillroth also represents only a secondary change occurring in surface\\ncarcinoma. In but a few instances was a primary carcinoma found\\naway from the epiblastic or hypoblastic tissues. Virchow reports a\\nprimary cancroid in the tibia O. Weber, in the inferior maxilla Paget,\\nin the inguinal glands. In all these and in similar cases the prolifer-\\nation had its origin from a displaced matrix of embryonic epiblastic or\\nhypoblastic tissue. Cohnheim went a step farther, and claimed that\\ncarcinoma did not originate by proliferation from mature epithelial cells,\\nbut that it was produced, independently of mature pre-existing tissue,\\nfrom a matrix of embryonic epithelial cells, and he advanced the theory\\nwhich assigns to the origin of all tumors a matrix of embryonic tissue.\\nThis theory has been upheld strongly by Waldeyer and a number of\\nmodern writers. It goes farther toward explaining the origin of tumors\\nthan any other theory heretofore advanced. Until quite recently car-\\ncinoma was regarded as a local manifestation of a general dyscrasia.\\nIt was supposed that the essential cause existed in the blood, and that\\nthe tissues the seat of tumor-formation were acted upon by a specific\\nvirus. Virchow assumed the existence in the tissues of a primary\\ncarcinoma of a seminium which, by being brought in contact with\\nlymphatic and other tissues, reproduced the disease in other localities,\\nand which by its action upon the adjacent tissues gave rise to local", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0228.jp2"}, "221": {"fulltext": "CARCINOMA. 207\\ninfection. He asserts that in the primary formation no doubt there is\\nproduced a contagious material which acts upon the tissues with which\\nit comes in contact in the same manner as does the lymph in lymph-\\nglands. The more anastomoses the affected parts have, the more such\\na result may be expected. Cartilage is almost exempt from local infec-\\ntion of a malignant growth, owing to the absence of blood-vessels and\\nlymphatics. In malignant tumors in the epiphyseal region of the long\\nbones the articular cartilage is often found completely separated, and\\nshows the effect of pressure-atrophy rather than of direct implication\\nby the tumor. He believes that local infection from a malignant growth\\ntakes place by the action of an infective fluid brought in contact with\\ncells without the intervention of vessels or nerves. He admits that it\\nis not known whether distant parts are infected in a similar manner or\\nwhether metastasis takes place by transportation of cells. He believes\\nthat the occurrence of metastatic carcinoma of the liver without carci-\\nnoma of the lung speaks against cellular transportation as a cause of\\nmetastatic tumors. W. Miiller and Creighton believe that the virus\\nproduced in a carcinoma affects the tissues with which it is brought in\\ncontact like the spermatozoa affects the ovum, the cell-impregnation\\ngiving rise to tissue-proliferation.\\nMr. Simon in a recent discussion on carcinoma took this standpoint.\\nHe attempted to show that the mere wandering of cancer-cells to parts\\ndistant from the primary tumor, and their overgrowth in their new loca-\\ntion, did not explain the facts as observed in these tumors. He\\nmaintained that the essence of the specific force of malignancy is an\\nimpregnative or spermatic one, whereby the part primarily affected\\nexercises on the tissue receiving its juices an influence which causes\\nthe latter to fructify in conformity with its own deranged pat-\\ntern. But then, again, holding these views, he still is able to\\nsee two functionally distinct classes of disease in cancerous and non-\\ncancerous tumors. It is difficult to conceive how a modern path-\\nologist could hold such views in the face of the numerous and con-\\nclusive proofs of dissemination of carcinoma by migrating and trans-\\nplanted cells.\\nMore recent researches have been made with a view of demonstrat-\\ning the microbic origin of the primary and secondary tumors, but so\\nfar no conclusive proof has been furnished of the microbic origin of\\ncarcinoma. Our present knowledge concerning the origin and growth\\nof carcinoma warrants us in making the statement that carcinoma is the\\nresult of an atypical proliferation from a matrix of embryonic cells, and\\nthe local and general infections are caused by the local and general\\ndissemination of carcinoma-cells.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0229.jp2"}, "222": {"fulltext": "208 PATHOLOGY AND TREATMENT OF TUMORS.\\nHistogenesis. In discussing the histogenesis of carcinoma we shall\\ntake it for granted that all carcinomatous tumors spring from a similar\\nmatrix that is, that they all have a similar histogenetic origin. It has\\nbeen stated elsewhere that the histological structure of the tumor and\\nits behavior to the surrounding tissues are modified by the type of the\\ncells of which it is composed and the nature of its environment but\\nall cancerous tumors bear a resemblance to one another anatomically\\nand manifest the same clinical tendencies. The idea that the old authors\\nentertained in regard to the parasitic nature of tumors of all kinds, but\\nespecially of carcinoma, presents plausible features. Even normal cells,\\nas Virchow says, live a parasitic life. In a stricter sense the term\\nparasitic can be applied to cells which, when detached from their\\nmother-soil, retain under favorable circumstances their vitality when\\ntransplanted into other localities, such as epithelial cells and cartilage-\\ncells. If a piece of connective tissue should become detached and\\nshould engraft itself upon living tissue in some other place, it would\\nhave to be regarded as a parasite, as its existence would depend upon\\nthe abstraction of nutritive material from the new soil. The parasitic\\nnature of malignant tumors is more marked than that of the benign\\ngrowths, because a carcinoma or a sarcoma from its very commence-\\nment destroys pre-existing tissues, besides robbing the part in which\\nit is located of a part of its nutritive supply.\\nParasitism of tumors, in the sense in which the expression is\\nused to-day, is much more limited in its significance than formerly.\\nWhen used in its modern sense, the term signifies the presence\\nin the body of growths which have no existence in the normal\\nbody. We now regard a tumor as an integral part of the organ-\\nism, the product of tissue-proliferation from a matrix of embryonic\\ncells.\\nThe first attempt to trace tumors to their proper histogenetic source\\nwas made by Virchow, who believed that the carcinoma-cells, like the\\ncells of nearly all tumors, were derived from the connective tissue.\\nHe found cells in carcinoma far away from normal epithelial cells, and\\nfrom their resemblance to epithelial cells he called them epithelioid cells.\\nHe believed that these cells were produced in the localities in which\\nhe found them. Forster believed that the cells of the cylinder-celled\\nepithelial cancroid of the gastro-intestinal canal and the squamous\\nepithelioma of the skin were produced by the pre-existing connective\\ntissue of the part in which the tumor originated. Neumann supported\\nVirchow s views in reference to the histogenetic source of the carci-\\nnoma-cells. Koster, a pupil of Recklinghausen, asserted that in carci-\\nnoma of the skin and the stomach the carcinoma-cells were derived", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0230.jp2"}, "223": {"fulltext": "CARCINOMA. 209\\nfrom the endothelial cells of the lymphatic vessels. Virchow describes\\ncell-formation in carcinoma as follows A portion of a large granular\\ncell becomes uniformly transparent, possibly beginning with a degener-\\nating nucleus. This portion shows from the first a definite wall, which\\nbecomes thickened and similar in appearance to cartilage-cells. During\\nthis change the remainder of the old cell becomes more homogeneous\\nand frequently disappears entirely. He considers the cavities, or vacu-\\noles, in carcinoma-cells and in cartilage-cells identical. This condition\\nseems to be the first step to overcome morphologically the apparently\\ngreat differences between epithelial and cartilaginous structures. As\\nillustrations of their close relation, instances of two tumors, one of\\nthe parotid gland and the other of the testicle, are given, in which\\ntumors a portion was of epithelial and the remainder of cartilaginous\\nstructure.\\nVirchow s views prevailed until Remak established the doctrine of\\nthe independence of the different histological elements and founded the\\nlaw of the normal succession of cells. His supported Remak s teach-\\ning in a most positive manner. The same author added to our know-\\nledge of the histogenesis of epithelial tumors by excluding from them\\nendothelial tumors. He regarded the endothelial cells as a variety of\\nconnective-tissue cell derived from a histogenetic source entirely differ-\\nent from the epithelial cells. In the light of recent embryological in-\\nvestigations, the doctrine of metaplasia as expounded by Virchow is no\\nlonger tenable. Connective tissue cannot produce epithelial cells, and\\nepithelial cells cannot produce connective tissue. The law of the legiti-\\nmate succession of cells holds true in the growth of tumors, both benign\\na7id malignant, as well as in the production of normal tissue. The\\norigin of carcinoma-cells from mature pre-existing epithelial cells was\\naccepted by Billroth, Liicke, Rudnow, Thiersch, Klebs, Rindfleisch,\\nand others. Waldeyer went a step farther in explaining the difference\\nbetween the origin of benign and malignant epithelial tumors when he\\ndefined a carcinoma as an atypical epithelial tumor. With this defini-\\ntion he wished to draw a line between a benign and a malignant epithelial\\ntumor. By an atypical proliferation of epithelial cells is meant a condition\\nin which the new cells produced originally within the limits of epithe-\\nlial tissue extend beyond the limits of the physiological type that is,\\nbeyond the basement membrane. An adenoma (Fig. no) as compared\\nwith a carcinoma (Fig. 1 1 1) is a typical tumor because the epithelial\\ncells remain within their normal physiological boundary-line, the mem-\\nbrana propria.\\nBy contrasting Figures 1 10 and 1 1 1 it will be seen at a glance what\\nis meant by a typical and an atypical tumor. Adenoma of the\\n14", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0231.jp2"}, "224": {"fulltext": "210\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nA2i\\ni ii\\nE 5 .S\\n2S _g\\n\u00e2\u0080\u00a2of-\\n3 vT", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0232.jp2"}, "225": {"fulltext": "CARCINOMA. 211\\nbreast is a typical epithelial tumor because the epithelial cells have at\\nno place lost their normal relations with the connective tissue the\\ncells and the connective tissue are separated by the membrana propria.\\nCarcinoma of the tongue is an atypical epithelial tumor because the new\\nepithelial cells have passed beyond the membrana propria and are\\nbeginning to infiltrate the connective tissue. The proliferation here is\\natypical because the epithelial cells are produced in a tissue of a differ-\\nent type and in a place distant from that in which they normally\\noriginate.\\nTo make, the point between typical and atypical proliferation of\\nepithelial cells still stronger the atypical proliferation will be defined\\nas the presence, growth, and multiplication of epithelial cells in the meso-\\nblastic tissues. Klebs defines this process very correctly as a meta-\\nstasis of epithelial cells.\\nCohnheim believed in the epithelial origin of carcinoma, but asserted\\nthat mature epithelial cells are not capable of producing a tumor. He\\nclaimed that all tumors originate from a congenital matrix of embryonic\\ncells. For carcinoma he assumed either a matrix of epithelial cells in\\nlocalities in which epithelial cells normally exist, or a displaced matrix.\\nFrom this standpoint all tumors are atypical. We shall, however, use\\nthe word atypical in the sense in which Waldeyer applied it. We\\nshall hold fast to Cohnheim s theory regarding the histogenesis of car-\\ncinoma. If a carcinoma always originates from epithelial cells, primary\\ncarcinoma in mesoblastic tissue is impossible from a histogenetic stand-\\npoint unless a matrix of embryonic epithelial cells has become displaced\\nduring the development of the embryo, or when epithelial cells have become\\nburied in mesoblastic tissues, after birth, by injury or by disease. Primary\\ncarcinoma of mesoblastic tissues is due to the presence of a displaced\\nmatrix of embryonic epithelial cells. It is from such matrices that\\nprimary carcinoma is occasionally observed in bone, in lymphatic glands,\\nand in other mesoblastic tissues. Deep-seated carcinoma of the neck\\noccurring independently of infection from another source originates\\neither from branchial structures branchiogenous carcinoma (Volk-\\nmann) or from an accessory or supernumerary thyroid gland struma\\ncarcinomatosa accessoria (Guttmann).\\nThe origin of carcinoma in accessory organs must be taken into\\nconsideration in the diagnosis of primary carcinoma in unusual localities.\\nA post-natal matrix of embryonic epithelial cells is more frequently the\\nstarting-point of carcinoma than was formerly supposed. Such a matrix\\nis created in ordinary scar-tissue in scars following deep burns, in\\nulcers, and by the traumatic displacement of fragments of epithelial\\ntissue.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0233.jp2"}, "226": {"fulltext": "212\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nHistology.\\nAll carcinomatous tumors are composed of epithelial cells and an\\nalveolated stroma of connective tissue. One of the strongest argu-\\nments against the microbic origin of carcinoma is the histogenetic\\nsource of the carcinoma-cells. Pathogenic microbes act upon the\\ntissues with which they are brought in contact, and the proliferation\\nresults in cells which correspond in type with the cells acted upon\\nby the microbes. Carcinoma-cells multiply by karyokinesis. Soon\\nafter Flemming published the result of his observations on karyo-\\nFig. ii2.\u00e2\u0080\u0094 A celi-nest from a cancer of the lip X 300 (after D. J. Hamilton) a, the stroma of the alve-\\nolus in which the cell-nest is contained b, small germinal cells of the periphery c, prickle-cells d, com-\\npressed squamous cells; e, degenerated cells in the centre.\\nkinesis, Filbry observed the same structural changes in carcinoma-cells.\\nAll preparations showed, without exception, the indirect mitotic seg-\\nmentation of the nucleus. The best figures were seen in the marginal\\nzone of the epithelial projections, while in sarcoma they were about the\\nsame throughout the tumor. The epithelial cells are derived from the\\nessential tumor-matrix the stroma consists of pre-existing connective\\ntissue. The several varieties of carcinoma formerly separately described\\nepithelioma, scirrhus, encephaloid, colloid, glandular carcinoma differ\\nonly in their structure from their location, the type of cells, or the kind\\nand degree of degeneration of the tumor-tissue the general plan of\\ntheir histological structure is the same. For the purpose of avoiding", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0234.jp2"}, "227": {"fulltext": "CARCINOMA. 213\\nconfusion the different histological forms of carcinoma will be described\\nseparately.\\nSquamous-celled Carcinoma. The characteristic histological feat-\\nure of every carcinoma is the alveolation of the stroma and the group-\\ning of cells in its meshes (Fig. 112).\\nIn carcinoma of the skin the squamous epithelial cells are arranged\\nin concentric layers in the alveoli, forming the so-called cancer-nests\\nor epithelial pearls. The young cells occupy the periphery of the\\nnest, the oldest cells being in the centre. Cell-degeneration always\\nbegins in the oldest cells in the centre of the nest. The alveolated\\nstructure of the stroma was first described by Virchow. The alveoli\\nare formed by the colonies of cells which form in the connective-tissue\\nspaces, each colony the offspring of a single epithelial cell which has\\nfound its way into the connective tissue. As the cell-mass increases im\\nsize the connective-tissue fibres are separated and form the alveolus.,\\nThe epithelial cells act the part of a foreign body and increase the\\nblood-supply to the tissues, thus increasing the vegetative capacity of\\nthe connective-tissue cells, which in turn results in increase of the\\nstroma.\\nKlebs believes that the epithelial cells which have undergone carci-\\nnomatous degeneration are gradually transformed into connective tis-\\nsue and form a part of the stroma. If such a transition occurs, the\\nincrease of stroma-tissue during the growth of the carcinoma could\\neasily be explained. Hatschek and\\nRabl claim that mesoblastic cells are\\nderived from epithelia. Reckling-\\nhausen and Koster have observed\\nmetaplastic tissue-changes in meta- a\\nstatic lymphatic carcinoma, where F-i\\nv.,X\\nendothelial cells were transformed r v\\ninto epithelial cells. These views can v\\nno longer be held, as more recent\\nresearches have established upon a\\nfirm basis the law formulated by Fig. 113.\u00e2\u0080\u0094 Artery from connective-tissue stro-\\nT 1 1 r 11 t t j a ma \u00c2\u00b0f secondary carcinoma of the lower jaw\\nRemak and confirmed by His, that endarteritis deformans et obliterans x 54 Sur\\nCells invariably produce their OWn ical Clinic, Rush Medical College, Chicago):\\nj T7 a, thickened proliferating intima b, internal\\nkind, and no Other. We mUSt there- elastic lamina; c, tunica media.\\nfore assign to the pre-existing con-\\nnective tissue the function of stroma growth.\\nThe stroma is always infiltrated by leucocytes and young carcinoma-\\ncells (Fig. 113, a). In rapidly-growing soft carcinoma the stroma is\\nscanty, the alveoli is large, the cells are numerous, and the local infection", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0235.jp2"}, "228": {"fulltext": "214 PATHOLOGY AND TREATMENT OF TUMORS.\\nis early and extensive. A well-developed, firm stroma renders the\\ntumor hard and retards its growth and local infection. The vessels and\\nlymphatics of a carcinoma are distributed through the stroma. The\\narteries in the carcinomatous tissue frequently undergo degenerative\\nchanges, which have not been studied with sufficient care since Thiersch\\nfirst called attention to them.\\nProliferating endarteritis has been found a rather frequent accompani-\\nment of carcinoma in the laboratory of Rush Medical College, when\\nthere were no indications of the existence of the same condition of the\\n%a :-.v.\\nFig. 114. Carcinoma of the skin; X 4$o (Surgical Clinic, Rush Medical College, Chicago) a, stroma\\ninfiltrated by leucocytes and young carcinoma-cells; b, epithelial nest; c, colloid degeneration in centre of\\npearl; d, new cancer-nest.\\narteries in any other part of the body. The existence of this form of\\narterial degeneration on a large scale cannot but give rise to serious\\nnutritive changes of the tumor-tissue (Fig. 114). It is a subject that\\ncalls for further investigation.\\nCylindrical-celled Carcinoma. In carcinoma of the mucous mem-\\nbrane derived from the hypoblast the parenchyma of the tumor is\\ncomposed of cylindrical cells arranged in the form of tubules in resem-\\nblance of tubular glands. The tubules correspond with the cell-nests of\\n\u00e2\u0080\u00a2squamous-celled carcinoma (see Fig. 25, p. 66). The columnar epithelial", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0236.jp2"}, "229": {"fulltext": "CARCINOMA.\\n215\\ncells are arranged in a somewhat atypical manner in the crypts, forming\\na cellular lining of differing depths (Fig. 115). The tubules vary in size\\nand shape, constituting in this respect a contrast to adenoma of the same\\npart, in which symmetry of the tubules is pre-\\nserved (Fig. 116). The stroma of the tumor\\nis infiltrated with leucocytes and young carci-\\nnoma-cells (Fig. 1 16, c). The cells and stroma\\nof cylindrical-celled carcinoma are prone to\\nundergo mucoid and colloid degeneration.\\nGlandular Carcinoma. Carcinoma of the\\nacinous glands presents the same alveolation of\\nthe stroma as squamous-celled carcinoma. The\\nmorphology of the cells being similar, the gland-\\nular spaces correspond with the connective-tissue\\nspaces, in which, in the latter variety, the epithe-\\nlial cells establish centres of growth and form\\nthe alveoli. In glandular carcinoma the acini a carcinoma of the rectum, show-\\ning multiplication of cells in its\\nconstitute the alveoli, and the interacinous lining; x 170. At a, shrinkage\\nconnective tissue constitutes the stroma (Fig. ^Tm^Ip ,f rgic r a ciini\\nV o Rush Medical College, Chicago).\\n117). In hard, slow-growing glandular carci-\\nnoma the stroma is abundant and the alveoli are small. In soft,\\nrapid-growing carcinoma, formerly called encephaloid, the stroma\\nFig.\\n;5--\\n-A single tubule from\\n0^^^iB\\nFig. 116. From carcinoma of the rectum; X no (Surgical Clinic, Rush Medical College, Chicago):\\na, atypical tubule; b, intratubular growth of cells; c, extratubular infiltration.\\nis scanty and the alveoli are large. A strong reticulum imparts to\\nthe tumor benign qualities.\\nMalignancy.\\nThe clinical interest of carcinoma centres on its malignancy.\\nMalignancy depends not upon the progressive increase in the size\\nof the tumor, as is the popular belief, but upon the extension of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0237.jp2"}, "230": {"fulltext": "2i6 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor to near or distant parts and organs. The intrinsic tendency of\\ncarcinoma is to destroy life. For the lack of a better word, the pro-\\ncess by which the tumor diffuses itself in its immediate vicinity, in the\\nsame region, and throughout the entire body, is termed infection.\\nIf V,\\nI\\nb\\nFig. 117.\u00e2\u0080\u0094 Glandular carcinoma of mamma; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, con-\\nnective-tissue stroma; b, alveoli packed with epithelial cells.\\nBy the term infection as applied to malignant tumors is meant the\\nintrinsic capacity of their cells to leave the primary tumor, and by\\nwandering into the surrounding healthy tissue to establish new centres\\nof growth, or by being transported through pre-existing channels to\\nreproduce the disease in the same region or in distant parts of the\\nbody. It is this cell-migration, and the intrinsic capacity of the cells to\\nreproduce themselves in new and strange localities, that distinguish malig-\\nnant from benign tumors, arid upon which depends their malignancy.\\nLocal Infection. The power of epithelial cells to penetrate into\\nthe apparently healthy tissue, as seen and described by Waldeyer and\\nThiersch, is evidenced in the local diffusion of every carcinoma, but it\\ndoes not explain the malignancy of the tumor, as normal epithelial\\ncells do not possess the same power to proliferate in mesoblastic tissues\\nas do the epithelial cells of a carcinoma. The epithelial cells have", "height": "4276", "width": "2629", "jp2-path": "pathologysurgic00senn_0238.jp2"}, "231": {"fulltext": "CARCINOMA.\\n217\\ntherefore undergone a change, the true nature of which is unknown,\\nwhich endows them with a greatly augmented vegetative capacity. In\\nthe present state of our knowledge we must attribute this increase of\\ntheir formative power, not to a change in the cells themselves, but to*\\nan altered condition of the tissues which they inhabit. This latter\\ncondition we have described as a diminution of physiological resistance.\\nAn anomalous location of epithelial cells under certain conditions\\nmay cause carcinoma this anomaly, however, does not constitute the\\nreal cause, but is only an additional factor, and not an essential ante-\\nFlG.\\n-From an epithelial carcinoma of the clitoris epithelial nests imbedded in a stroma infiltrated\\nby small cells; X 250 (after Perls).\\ncedent condition. Ribbert does not believe that the first changes in\\nthe growth of a carcinoma consist in infiltration of the underlying\\nconnective tissue. He claims that inclusion of epithelial cells takes\\nplace by an outward growth of connective tissue. He has observed as\\nthe first thing an active increase of the cellular elements of the sub-\\nepithelial connective tissue. This causes a lifting up of the epithelial\\nlayer, which becomes irregular and convoluted. The increased con-\\nnective tissue grows up among the epithelial cells, and causes irregular\\nseparation of the cells from their normal relations, so that they become\\ndivided into groups and islands surrounded by the new connective\\ntissue. As the cells are now disconnected from the superficial cells,\\nthey cannot proliferate upward, and so must grow where the connec-\\ntive tissue will allow. They proceed in the direction of the least resist-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0239.jp2"}, "232": {"fulltext": "2l8\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nance namely, into the intercellular spaces and lymph-channels, and in\\nthis manner the carcinoma develops.\\nEvery carcinoma has a benign stage. No matter where the matrix\\nmay be located, the cells composing it are at first isolated from the vas-\\ncular tissues, and the carcinomatous stage begins with cell-migration.\\nLocal infection that is, the growth of the tumor as a whole is the\\nresult of cell-migration. The new epithelial cells, like the ameba and\\nleucocytes, possess the power of independent locomotion. The ameboid\\nFig. 119.\u00e2\u0080\u0094 Colloid carcinoma of the colon: section through the margin of the tumor; X 21 (after Karg\\nand Schmorl). The tumor (c), which started in the mucous membrane (a), has perforated the muscular\\ncoat (6) and presents an adenomatous structure.\\nmovements of carcinoma-cells were studied in 1872 by Carmalt in\\nWaldeyer s laboratory. Cells of carcinoma of the breast obtained im-\\nmediately after amputation constituted the material used. The cells\\nwere detached by scraping the cut surface of the tumor, and were kept\\nimmersed on the thermal object-table of Strieker. The isolated young\\ncells manifested active ameboid movements, while the deeper cells in\\nfragments of tissue remained motionless.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0240.jp2"}, "233": {"fulltext": "CARCINOMA.\\nPlate 4.\\n1. Beginning carcinoma of the lower lip border of the tumor; X 160: it, hypertrophic epidermis mem-\\nbrana propria, continuity disturbed.\\n2. Beginning carcinoma of the lower lip center of the tumor; X 6\u00c2\u00b0 membrana propria still intact:\\n.engorged lymphatic; c, leucocytes d, membrana propria ruptured; wandering ofepithcli.il cells into the\\nconnective tissue.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0241.jp2"}, "234": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0242.jp2"}, "235": {"fulltext": "CARCINOMA.\\n219\\nIn the stroma of every carcinoma small young epithelial cells\\nbesides leucocytes are found (Fig. 118). This infiltration of the tissues\\naround a carcinomatous tumor was called by Waldeyer the inflam-\\nmatory zone. Leucocytes escape through damaged capillary walls and\\nare present in large number in rapidly-growing carcinoma, but among\\nthem young carcinoma-cells can always be seen. All these young\\nepithelial cells, as soon as they have isolated themselves from the\\nprimary tumor, assume an individuality of their own and establish\\nindependent centres of tumor-formation. In cylindrical-celled carci-\\nnoma the membrana propria of the tubules is often absent, bringing\\nthus the carcinoma-cells in direct contact with the vascular connective\\ntissue, which they infiltrate, increasing thereby the size of the tumor and\\nthe area of tissue-proliferation. The glandular tubules are irregularly\\nbranched, are devoid of the membrana propria, and are lined in places\\nby three layers of columnar cells (Fig. 1 19). To the right of the tumor\\nFig. 120.\u00e2\u0080\u0094 Rapid-growing carcinoma of the breast X 5 (Surgical Clinic, Rush Medical College,\\nChicago) a, vascular stroma b, b, alveoli packed with large epithelial cells.\\nis to be seen a second carcinomatous nodule (d) which is undergoing\\ncolloid degeneration. Only at the periphery can carcinoma-cells be\\nseen, while the centre of the space is occupied by colloid material and\\ndegenerated detached cells. The space is enclosed by the muscularis (e).\\nIn glandulai carcinoma ,e infiltration takes place in all directions, and\\nthe tumor is surroundec n all sides by a zone of new alveoli, the con-\\ntents of each alveolus being the product of proliferation of a single cell.\\nNew alveoli are also found in the stroma, especially in rapid-grow-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0243.jp2"}, "236": {"fulltext": "220 PATHOLOGY AND TREATMENT OF TUMORS.\\ning tumors, rendering the tumor softer by diminishing its stroma\\n(Fig. 1 20, b,b).\\nThe local infection of carcinoma takes place in the direction of pre-\\nexisting connective-tissue spaces, and consequently spreads most rap-\\nidly and becomes most extensive in cases in which the primary tumor\\nis surrounded by an abundance of loose connective tissue. It is in\\nsuch cases that the tumor attains the largest size. The local infection,\\nhowever, does not remain limited to the connective tissue. Carcinoma\\ninvolves by local extension all tissues and organs, irrespective of their\\nanatomical structure. This is the most conspicuous pathological and\\nclinical feature of all carcinomatous tumors. Johannes Miiller called\\nspecial attention to this property of carcinoma, and surgeons have always\\nregarded this feature as of the utmost diagnostic value in the differen-\\ntiation between benign tumors and carcinoma. Neumann described\\nand illustrated carcinomatous infiltration of muscular tissue, euided\\nby the belief that the carcinoma-cells were produced by the inter-\\nmuscular connective tissue. The tissues and organs the seat of local,\\nregional, and general dissemination remain passive in the growth of\\ncarcinoma the increase in the size of the tumor is due exclusively to\\ntissue-proliferation of wandering displaced carcinoma-cells. The cells\\nof the regional and metastatic tumors are derivatives from the primary\\nor maternal tumor. Diffuse local infection favors early regional and\\ngeneral infection. It is on this account that glandular carcinoma is\\nfollowed more constantly and at an earlier stage by regional and gen-\\neral infection than is squamous-celled or cylindrical-celled carcinoma. A\\ncarcinoma of the cutaneous or mucous surfaces has only one direction in\\nwhich to infiltrate the tissues, while a glandular carcinoma is surrounded\\nby mesoblastic tissues o?i all sides, with a correspoiidingly increased area\\nof infiltration.\\nThe progressive growth of a carcinoma is due to the establishment\\nof independent centres of growth in the periphery of the tumor. It is\\nfor this reason that spontaneous sloughing of the tumor and its destruc-\\ntion by caustics is not followed by a cure, as is the case in benign growths.\\nRegional Infection. It is a well-known clinical fact that a carcinoma,\\nwherever it may be located, gives rise to infection of the lymphatic\\nglands of the same region. Simon and Paget were of the belief that\\ncarcinoma extends from the primary tumor, not through any active\\npart of the interposed lymphatic channels, but through the lymph.\\nThey explained regional infection as follows: 1. The disease in the\\nlymphatic glands resembles the primary tumor, the deviation being\\ndependent on the structures surrounding the carcinoma in the lym-\\nphatic gland 2. It appears about midway in the course of the disease", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0244.jp2"}, "237": {"fulltext": "CARCINOMA.\\n221\\ntoward death 3. Usually the primary tumor makes more rapid prog-\\nress, but occasionally the reverse is the case 4. The disease extends\\nalong the lymphatics in the direction of the thoracic duct distant lym-\\nphatics are rarely affected. Paget believes that minute fragments of\\nthe protoplasm of the cancer-cells, mingled with the blood, may be as\\neffectual as whole cells in reproducing the disease.\\nThe migrating young epithelial cells find their way into the lym-\\nphatic vessels within or near the primary tumor, are carried by the\\nlymph-stream to the nearest lymphatic gland, which serves as a filter,\\narresting their further progress, and as soon as they become localized\\nthey establish new centres of growth in the lymphatic gland. There\\nmust exist in the primary tumor or in its vicinity favorable conditions\\nfor the entrance of the cells into the lymphatic channels.\\nLanghans made a careful study of injected preparations of the\\nmammary gland, with the special object of ascertaining the relations of\\nlymphatics to the acini and ducts of the gland. He found the acini\\nFig. 121. The internal lymphatics of the mammary gland injected, and terminating in two trunks in the\\naxilla (after Astley Cooper).\\nand ducts surrounded by a delicate network of lymphatic vessels, but\\nin none of the specimens did the lymphatic vessels reach the interior\\nof the acini or ducts, or even the membrana propria. Such a direct\\ncommunication between these structures is claimed by Ludwig Tomsa.\\nThe abundance of lymphatic vessels in the mammary gland is well", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0245.jp2"}, "238": {"fulltext": "222\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nshown in Figure 121. The lactiferous tubes are also partially injected,\\nand may be seen under the network of lymphatics. It is more than\\nprobable that normal lymphatic vessels are impermeable to emigrating\\nepithelial cells, and that their entrance is effected by destruction of the\\nwall of pre-existing lymphatics or through the defective walls of new\\nlymphatic channels in the tumor-tissue. This subject is well worthy\\nof a most careful investigation. Gussenbauer maintained that second-\\nary carcinoma of the lymphatic glands results from the transportation\\nof minute infective corpuscular elements which are carried from the\\nprimary tumor through the lymphatic channels into the lymphatic\\nglands, where they infect pre-existing glandular tissue, bringing about\\na heterologous change in the tissue-elements resembling the structure\\nof the primary tumor. He found in sections of glands recently infected,\\non staining with picro-carmine, minute granules of an intense red color\\nin the cells of the infected gland-territory. The cells thus infected then\\npresented various changes in their structure. This theory was in accord\\nwith views expressed by Virchow and Creighton, that cancer-cells are\\nproduced by the action of a virus or seminium upon mature cells. We\\nhave shown conclusively that the cells of which the primary tumor is\\ncomposed are derived not from mature tissue, but from a matrix of\\nembryonic epithelial cells, and we shall now proceed to prove that all\\nmetastatic tumors, local, regional,\\nand distant, owe their origin and\\ngrowth to cells derived from the\\nprimary tumor.\\nAfanassiew made some very\\ninteresting investigations in Rud-\\nnew s laboratory at St. Petersburg\\nconcerning the growth of second-\\nary carcinoma in the lymphatic\\nglands. Inflammatory enlarge-\\nment of the glands is observed\\nonly when the carcinoma has ul-\\ncerated, and is then caused by the\\nentrance into the lymphatic sys-\\ntem of pathogenic microbes or of\\nchemical irritants. Enlargement\\nof the lymphatic glands under\\nother circumstances denotes the\\nregional dissemination of the dis-\\nFig. 122. Secondary carcinoma of lymphatic\\ngland; X 480, reduced one-third (Surgical Clinic,\\nRush Medical College, Chicago) a, groups of carci-\\nnoma-cells b, lymphoid corpuscles and reticulum.\\nEach one of the epithelial nests is the product of\\ntissue-proliferation of a single carcinoma-cell.\\nease. The first changes observed\\nin such glands are the presence of carcinoma-cells from the primary", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0246.jp2"}, "239": {"fulltext": "CARCINOMA.\\n223\\ntumor in the lymphatic channels, and irritation of the connective-tissue\\nreticulum caused by the invaders. The lymphoid corpuscles take no\\nactive part in the process. As the carcinoma increases in size by pro-\\nliferation of the transplanted carcinoma-cells new connective tissue is\\nformed from the granulation-elements. The parenchyma of the gland\\nis subjected to pressure and is gradually destroyed, its place being\\noccupied by carcinoma-tissue. The carcinoma-cells that reach the\\ninterior of the lymphatic channels are conveyed with the lymph-\\ncurrent to the nearest lymphatic gland, in the meshes of which their\\nonward course becomes arrested. As soon as a wandering carcinoma-\\ncell has reached its destination it undergoes karyokinetic changes, and\\nthe product of tissue-proliferation constitutes the secondary gland-\\nular tumor, the connective tissue of the gland becoming its stroma\\n(Fig. 122).\\nThe stroma of the carcinoma is derived from the pre-existing retic-\\nulum of the gland, which reticulum is increased in consequence of the\\nstimulation caused by the carcinoma-cells, which act the part of a for-\\neign body. Simultaneously or in succession additional centres of growth\\nmay become established in different parts of the gland by new cells\\nemerged from the primary tu-\\nmor to the lymphatic gland.\\nNew centres of growth are,\\nhowever, exhibited also by the\\nmigration of young epithelial\\ncells from the first glandular\\nfocus along the lymph-spaces\\ninto other parts of the gland\\n(Fig. 123,4\\nThe local infection of sec-\\nondary tumors is as marked\\nas that of the primary tumor,\\nand takes place in the same\\nmanner. The cells corre-\\nspond in shape, size, and\\nmanner of grouping to those\\nof the primary tumor. The\\nstroma is modified by the\\ncharacter and amount of\\nconnective tissue in the new\\nlocality. It has been known\\nfrequently grows much more\\nR\u00e2\u0080\u0094 b\\nFig. 123. Secondary carcinoma in the lymph-spaces of\\na lymphatic gland, from a carcinoma of the abdominal wall\\nX 480, reduced one-third (Surgical Clinic, Rush Medical Col-\\nlege, Chicago) a, lymph-spaces b, groups of carcinoma-\\ncells c, carcinoma-cells in the parenchyma of the gland d,\\nleucocytes.\\nfor a long time that a secondary tumor\\nrapidly than the primary tumor. This\\nfact can readily be explained by assuming that the pre-existing connec-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0247.jp2"}, "240": {"fulltext": "224 PATHOLOGY AND TREATMENT OF TUMORS.\\ntive tissue surrounding the secondary tumor is more scanty and of a\\nlooser structure than the stroma of the primary tumor. As the local\\ninfection in the lymphatic gland increases, the parenchyma of the gland\\ndisappears until its capsule becomes distended by carcinomatous tissue.\\nDuring this time the capsule of the gland has become thickened in a\\nvain attempt to limit further extension of the disease. As soon as the\\ncapsule is reached by the carcinoma-cells infiltration takes place, the\\ncapsule itself becomes carcinomatous, and the zone of infiltration\\nextends now to the loose paraglandular connective tissue. Until now\\nthe gland has remained movable, but as soon as the disease reaches the\\nsurrounding tissues the gland becomes immovably fixed.\\nFrom what has just been said in reference to the local infection of\\nlymphatic secondary carcinoma it will be seen that enucleation of car-\\ncinomatous glands is bad practice. Such practice prevails still to a\\nlarge extent, and is responsible for the local recurrence that invariably\\nfollows such a procedure. Not only the paraglandular zone of infiltra-\\ntion remains, but also the connecting lymphatic channels.\\nCarcinoma of the lymphatic channels has not received the attention\\nit deserves. The writer is firmly convinced that many of the second-\\nary glandular tumors that have invariably been regarded as infected\\nlymphatic glands were carcinomatous nodules which developed in the\\nlymphatic vessels. There is no reason to doubt that carcinoma-cells\\nmay by mural implantation become arrested in lymphatic vessels and\\nproduce the same results as in a lymphatic gland. The number of\\nnodules removed from the axillary space in operations for carcinoma of\\nthe breast frequently exceeds by far the number of normal lymphatic\\nglands in that locality. For the purpose of removing the zone of infil-\\ntration around carcinomatous glands, as well as with a view of removing\\nall the connecting lymphatic channels, the radical operation for regional\\ncarcinoma should consist in the removal by clean excision of the entire\\nlymphatic apparatus in that locality, with the surrounding connective and\\nadipose tissue.\\nRegional infection is always progressive. Epithelial cells from the\\nfirst secondary tumor reach the efferent part of the lymphatic vessel\\nand are conveyed to the second lymphatic gland, where the same pro-\\ncess repeats itself, until finally, if the disease is allowed to pursue its\\ncourse and the patient lives long enough, the last of the chain of\\nglands is reached, when the cells from this tumor reach the thoracic\\nduct and from there the general circulation, producing metastatic tumors\\nin distant organs. Regional infection through the deep lymphatic\\nglands begins near the primary tumor, and extends from there, from\\ngland to gland, until the last filter is passed, when general infection", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0248.jp2"}, "241": {"fulltext": "CARCINOMA. 225\\ntakes place. Regional infection retards, and frequently prevents, general\\ninfection. Surgeons are aware of the fact that in the most rapidly fatal\\ncases the lymphatic infection is either entirely absent or, at any rate,\\nnot well marked. Usually the lymphatic affection occurs in the same\\nregion as that occupied by the tumor. For instance, in carcinoma of\\nthe breast the axillary glands on the same side, in carcinoma of the\\nrectum the retro-peritoneal glands behind the rectum, and in carcinoma\\nof the lip the submental and submaxillary glands, are affected. The\\nwriter not long ago observed a case of carcinoma of the breast with\\nextensive regional infection of the axillary glands. Local recurrence\\nsoon after the operation was followed by enlargement of the inguinal\\nglands first on one side and then on the other. Microscopic exam-\\nination of sections taken from these regions showed typical gland-\\nular carcinoma.\\nLocal infection through the superficial lymphatics of the skin travels\\nas often against as with the lymph-current. The extension of carcinoma\\nthrough the superficial lymphatics of the skin, as observed in cases of\\nlenticular carcinoma, always reminds one of thd manner of spreading\\nof erysipelas. In such cases the lymphatic vessels take an important\\npart in the diffusion of the disease. Lymphatic channels become\\nblocked, the lymph-current is arrested, and consequently the direction\\nof the dissemination of the disease is no longer governed by the lymph-\\nstream. The original infection takes place in all directions. The swell-\\ning of the arm in extensive regional infection of the axillary glands\\nis the combined result of lymphatic obstruction and pressure of the\\nglandular tumors upon the large axillary vessels.\\nGeneral Infection. General infection in carcinoma consists in the\\nappearance of carcinomatous tumors in organs or tissues of the body\\nthat have anatomically 710 connection with the region occupied by the\\nprimary tumor. Such tumors are called metastatic tumors, and the\\nprocess by which they are produced is termed metastasis. Klebs\\nspeaks of a cell-metastasis in local and regional infection of a carci-\\nnoma, but we shall restrict the term metastasis to tumor-formation\\nanatomically disconnected with the primary tumor. Carcinoma-cells\\nretain their vitality and intrinsic power of tissue-proliferation during their\\njourney through the lymphatic vessels and blood-vessels, and as soon\\nas they become arrested by mural implantation or embolism they begin\\nto proliferate and to produce tumors identical with the primary tumor.\\nMetastatic carcinomatous tumors always occur in connection with a\\nblood-vessel on the arterial side of the circulation. The process of\\ndistribution of tumor-tissue resembles embolism. Generalization of car-\\ncinoma takes place in consequence of the entrance into the general circu-\\n15", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0249.jp2"}, "242": {"fulltext": "226 PATHOLOGY AND TREATMENT OF TUMORS.\\nlation of carcinoma-cells or fragments of tumor-tissue, which, when\\narrested anywhere in the arterial system, constitute carcinomatous emboli\\nfrom which the metastatic tumors grow. The entrance of carcinoma-\\ncells into the general circulation is effected in two ways: I. Direct\\nentrance by perforation of a vein-wall by the tumor; 2. Migration of\\ncells through the lymphatic system. In the first instance isolated\\ntumor-cells may be washed away from the projecting tumor-mass, or\\nfragments may be broken off and conveyed into the general circulation.\\nIn the second manner of general dissemination isolated cells reach the\\nvenous circulation through the thoracic duct by migration of cells\\nthrough the lymphatic channels and glands from the primary tumor\\nwithout causing lymphatic carcinoma or, what is usually the case, carci-\\nnoma-cells enter from the last gland of the chain of lymphatic glands in\\nthe region occupied by the primary tumor, reach the thoracic duct, and\\nfrom there the venous circulation. The location of the metastatic tumors\\nis determined largely by the size of the carcinomatous emboli. Isolated\\nsmall epithelial cells can pass through the pulmonary capillaries, reach\\nthe arterial circulation, and become arrested in the minute capillaries\\nof some distant organ as minute emboli or they adhere to the intima\\nof the arterioles or capillaries, mural implantation takes place, and the\\ncell becomes the starting-point of a metastatic tumor. Large tumor-\\nfragments become arrested as emboli in the branches of the pulmonary\\nartery (see Fig. 28, p. 77).\\nGeneral dissemination by isolated cells frequently gives rise to miliary\\ncarcinosis the fragments of tumor-tissue, to embolism of the pulmonary\\nartery. A metastatic tumor of the lung becomes a distributing-point of\\ncarcinoma-cells, which from here reach the general circulation, becom-\\ning the direct cause of more remote metastatic tumors or, perchance,\\nof miliary carcinomata. All histological varieties of carcinoma may give\\nrise to metastatic carcinoma, and all vascular organs of the body may be-\\ncome the seat of a metastatic carcinoma. The type of cells of the primary\\ntumor is reproduced in the metastatic tumors that is, a squamous-\\ncelled carcinoma produces a squamous-celled metastatic tumor; a colum-\\nnar-celled carcinoma, a columnar-celled metastatic tumor, etc. It seems\\nthat this reproduction of tissue of a similar structure is a strong proof\\nagainst the microbic origin of carcinoma, and a convincing argument in\\nfavor of the doctrine that carcinoma is the result of erratic growth of epi-\\nthelial cells, and that local, regional, and general dissemination is caused by\\nthe migration and transportation of cells derived from the primary tumor.\\nThe lungs and the liver are the organs most frequently the seat of\\nmetastatic carcinoma.\\nWagner of Chicago has collected fifteen cases of metastatic car-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0250.jp2"}, "243": {"fulltext": "CARCINOMA. 227\\ncinoma of the choroid, and has made some interesting observations\\nin reference to the manner of local\\ndiffusion of the metastatic tumors in\\nthis locality. Rapid local dissemina-\\ntion of the tumor in this locality ap-\\npears to be one of its main clinical\\nfeatures. In the case that came under\\nWagner s observation, and illustrated\\nby Figure 124, the primary tumor was\\na carcinoma of the stomach. If a large\\nbranch of the pulmonary artery is ob-\\nstructed by a carcinomatous embolus,\\nhemorrhage around the infarct is of\\nr ci 1 J Fig. 124. Metastatic carcinoma of choroid\\nfrequent occurrence. Skrzeczka de- (after Carl Wagrer)\\ncribes such a case. The entire lung\\nwas the seat of hemorrhagic infiltration. Lebert examined twelve cases\\nof colloid carcinoma of the gastro-intestinal canal, and found meta-\\nstasis in eleven of them. Hauser made a special study of metastatic\\ncarcinoma of the liver to determine whether the pre-existing liver-\\nsubstance takes an active part in the growth of the tumor. He found\\nthat the parenchyma-cells in the vicinity of the carcinomatous nodules\\nwere destroyed and took no part whatever in the growth of the tumor,\\nthus confirming the observations made by Thiersch and Waldeyer.\\nIt will be seen from Figures 125 and 126 that the glandular structure\\nof the metastatic tumors corresponds with the type of the epithelial\\ncells and the structure of the primary tumors.\\nIf a carcinomatous embolus becomes impacted in an artery or in a\\nbranch of the portal vein, the metastatic tumor first fills the lumen\\nof the vessel that is, a carcinomatous thrombus forms around the\\nembolus (Fig. 127). As soon as the pre-existing space in the lumen\\nof the vessel becomes completely blocked by the endovascular meta-\\nstatic carcinoma, the wall of the vessel becomes infiltrated and is soon\\nincorporated in the tumor. After this time the paravascular tissues\\nbecome successively involved, and on examining such tumors all traces\\nof the original vessel-wall have disappeared and nothing remains to\\nindicate the endovascular origin of the tumor.\\nCarcinoma of bone, with very rare exceptions in which the tumor\\ndevelops from a displaced epiblastic matrix, is the result of metastasis.\\nMetastatic carcinoma of bone (Fig. 128) is a frequent cause of so-called\\nspontaneous fracture. Fractures occurring under such circumstances\\nshould be called pathological fractures, to distinguish them from\\nfractures resulting from trauma. The writer has observed metastatic", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0251.jp2"}, "244": {"fulltext": "228 PATHOLOGY AND TREATMENT OF TUMORS.\\ncarcinoma of bone most frequently in aged women suffering from latent\\ncarcinoma of the breast with moderate or no regional infection.\\nIn metastatic carcinoma of bone spontaneous fracture usually occurs\\nbefore any external swelling has developed. If life is sufficiently pro-\\nlonged, a tumor appears later at the site of fracture. As Rokitansky\\n0\\n\u00e2\u0096\u00a0y\\nII\\nr^ a\\nFig. 125. Metastasis of a rectal carcinoma in the lungs X 36 (after Karg and Schmorl). The nodule\\nin the lung resembles in structure the primary tumor. It is composed of tubules lined by a single layer of\\ncolumnar epithelium imbedded in a delicate stroma of fibrillated connective tissue. The emphysematous pul-\\nmonary tissue in the upper part of the picture is sharply defined against the border of the nodule.\\nsays Cancer of the bone appears sometimes in the form of a nodule,\\nof about the size of a walnut or a hen s egg, which is developed mostly\\nin the medullary canal of the long bones it displaces the bony tissue,\\nand, producing atrophy of it by pressure, is frequently the cause of one\\nor more spontaneous fractures of the bone which occur as the result\\nof the most trifling causes. Union of the fracture by bony callus,\\ndespite the growth of the carcinoma, occasionally takes place.\\nIn patients suffering from advanced carcinoma the bones often\\nbecome so brittle that fracture occurs upon the application of slight\\nforce without metastatic carcinoma. Paget remarks But some of", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0252.jp2"}, "245": {"fulltext": "CARCINOMA.\\n229\\nthe spontaneous fractures in cancerous patients are due to the wasting\\nand degenerate atrophy which the bones undergo during the process\\nof cancer, and which seems to proceed to an extreme more often than\\nin any other equally emaciating and cachectic disease. There is, how-\\never, reason to believe that in most cases of spontaneous fracture with-\\nv..\\nup\\nFig. 126. Metastasis of a carcinoma of the breast in the liver; X 4\u00c2\u00b0 (after Karg andSchmorl). The\\ncarcinomatous nodule (a), which is quite sharply separated from the parenchyma of the liver (3), consists\\nof narrow cellular cords imbedded in a coarse reticulum of connective tissue.\\nout tumor-formation, in which it was believed the fracture occurred\\nwithout implication of the bone, the fracture was the result of the\\nsecondary bone-carcinoma, which was overlooked, life not being suf-\\nficiently prolonged for the appearance of a swelling. In favor of this\\nview is the fact that pathological fractures under such circumstances\\nare seldom multiple, which would be the case if the marasmus of car-\\ncinoma produced general atrophy of the bones. The carcinomatous\\nmaterial is previously deposited in the Haversian canals, along which it\\ninfiltrates the bone, producing enlargement of the canals.\\nMiliary carcinosis very closely resembles miliary tuberculosis.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0253.jp2"}, "246": {"fulltext": "230\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nfife- t 5\\nA\\nFig. 127. Carcinomatous embolus in a branch of the portal vein after primary carcinoma of the breast;\\nX 250 (after Karg and Schmorl). The branch of the portal vein (a) is dilated and filled by a plug of carci-\\nnoma-celis b, bile-duct. The surrounding liver-tissue is normal.\\nDemme reported seven cases of miliary carcinosis, and, basing his\\nFig. 128. Metastatic carcinoma of bone (after Hickmann) enlarged Haversian canals filled with carcino-\\nmatous tissue.\\nopinion regarding its etiology upon a study of the clinical history of\\nthese cases, came to the conclusion that it is most frequently produced", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0254.jp2"}, "247": {"fulltext": "CARCINOMA.\\n231\\nby trauma. The diffuse general dissemination of carcinoma is usually\\ninitiated by a rise in temperature and by other febrile disturbances that\\nFig. 129.\u00e2\u0080\u0094 Carcinomatous capillary embolism of the choroid; X 320 (after Perls): b, capillary net dilated\\nand filled partly with red blood-corpuscles and partly with carcinoma-cells c, large nuclei.\\nclosely simulate the general symptoms which inaugurate and attend\\nmiliary tuberculosis. In almost all organs of the body, and more par-\\nticularly upon the serous surfaces, innumerable nodules, from the size\\nof a mustard-seed to that of a hempseed, appear. The nodules are\\nproduced by capillary emboli composed of carcinoma-cells (Fig. 129).\\nMiliary carcinosis is a rapidly fatal affection. It is probably produced\\nmost frequently by perforation of a vein-wall by the primary or a\\nsecondary carcinoma, the epithelial cells of the projecting and rapidly-\\nproliferating endovascular part furnishing the material for the diffuse\\nembolic process.\\nEtiology.\\nRemaining true to the theory that all tumors originate from a matrix\\nof embryonic cells of congenital or post-natal origin, we necessarily\\nmust regard the presence of a matrix of embryonic epithelial cells as\\nthe essential cause of carcinoma. In the absence of such an essential\\nhistological basis, no exciting cause or combination of exciting causes\\nwill result in the production of a carcinoma. The matrix of embryonic\\ncells furnishes the essential material for the construction of a carcino-\\nmatous tumor the exciting causes simply set in motion the machinery\\nwhich increases the building material. We took it for granted that\\nnon-malignant epithelial tumors spring from a similar matrix. The\\nquestion naturally arises, What influences or agencies determine the\\ndifference in the character of the tumors springing from a similar\\nmatrix Two leading thoughts present themselves in answering this\\nquestion I The epithelial cells in the matrix of carcinoma are arrested", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0255.jp2"}, "248": {"fulltext": "232 PATHOLOGY AND TREATMENT OF TUMORS.\\nin their development and are set aside at an earlier stage, and the prod-\\nuct of their tissue-proliferation will therefore be less specialized than\\nthat of epithelial cells which have reached a higher degree of differen-\\ntiation. 2. The environment of a carcinoma-matrix offers less resistance\\nto ingrowing of epithelial cells than does that of a papilloma or an\\nadenoma. It is more than probable that the matrix of carcinoma is\\ncomposed of cells of a lower degree of differentiation than that of a\\npapilloma or an adenoma, and it is almost certain that the conditions\\nunder which a carcinoma-matrix assumes active tissue-proliferation\\nresult in a diminution of physiological resistance of the tissues in the\\nimmediate vicinity of the tumor-matrix. It remains for us to discuss\\nmore in detail the exciting causes concerned in awakening a dormant\\ntissue-matrix to active tissue-proliferation.\\nHeredity. In the majority of cases the tumor-matrix is congenital.\\nIn the remaining cases it is of post-natal origin, formed in pathological\\nproducts in which some of the young epithelial cells fail to reach\\nmaturity and are buried in the scar-tissue following the healing of a\\nwound or the repair of an inflammatory lesion. Friedreich records a\\ncase in which a carcinomatous mother gave birth to a child affected by\\ncarcinoma. A few cases of congenital carcinoma have been reported.\\nAn hereditary disposition, predisposition, or aptitude, local or gen-\\neral, for carcinoma-growth is generally recognized. It is a difficult\\ntask to obtain accurate information concerning the frequency with\\nwhich carcinoma occurs in the offspring of carcinomatous parents.\\nIn this respect statistics as well as many family histories are exceed-\\ningly unreliable. Mr. Cripps wishes to exclude from such statistics all\\ncases bearing upon distant relatives, excluding even grandparents. In\\nthis way he reaches opposite conclusions from those of Sir James Paget,\\nwho recognizes heredity as a fruitful cause of carcinoma. Figuring on\\nthe cases from Paget s practice, Mr. Baker makes the statement that\\n22.4 per cent, of the cancerous patients were of one or more relatives\\nwith the same disease. He then gives a table of 103 cases in which\\none or more relatives were affected. These 103 cases representing only\\n22.4 per cent, of the total number examined, the whole number must\\nhave been 460. In these 103 cases, among the relatives are included\\naunts, uncles, first, second, and third cousins, great-aunts, and a great-\\nuncle. Among the parents of cancerous patients the death-rate from\\ncancer is (1) According to Paget, 1 in 24.8; (2) according to Baker,\\n1 in 22.4 (3) according to St. Bartholomew s Hospital, 1 in 28. Accord-\\ning to Mr. Cripps, among the whole community over twenty years of\\nage the death-rate is 1 in 29.\\nIn studying the influence of heredity it is not fair to exclude from", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0256.jp2"}, "249": {"fulltext": "CARCINOMA. 233\\nthe statistics distant cancerous relatives, as has been done by Cripps,\\nbecause it is well known that congenital deformities, physiognomy,\\nand mental peculiarities frequently reappear several generations apart\\nand in distant relatives. There is no reason to doubt that an aptitude\\nfor cancer is transmitted in a similar manner. In certain families the\\nheredity of carcinoma has been shown in a marked manner. Paget\\nrelates a case in which a lady, two of her daughters, and eight of her\\ngrandchildren died of carcinoma. A still more marked and far-reaching\\nhereditary influence has been referred to in the section on the Etiology\\nof Tumors. Lebert relates two cases of colloid carcinoma of the rec-\\ntum in which one of the parents in each case was similarly affected.\\nTo ignore the existence of an hereditary predisposition to carcinoma\\nwould be to ignore such a predisposition to the acquirement of all\\nother pathological processes.\\nWhat such an hereditary predisposition consists of is not known.\\nWe regard it as a diminution of the physiological resistance of the\\ntissues adjacent to the matrix. Such a resistance diminished or abol-\\nished, the tumor-matrix is no longer held in check, but assumes active\\ntissue-proliferation, and the new cells infiltrate the tissues weakened by\\nlocal or general causes.\\nTraumatism. Injuries of various kinds have been regarded from\\ntime immemorial as a fruitful cause of carcinoma. Without the presence\\nof the essential tumor-matrix no amount or kind of injury will produce\\na carcinoma. Injury of a part inhabited by the tumor-matrix will act\\nas an exciting cause by diminishing the physiological resistance of the\\ntissues adjacent to the matrix. Paget asserts that about one-fifth of\\nthose who have cancer ascribe it to injury. In some the cancer follows\\nalmost immediately after the injury; in others it follows as a more\\nremote effect. In another and more frequent class of cases repeated\\ninjuries are necessary to produce this result.\\nBillroth maintains that in about 20 per cent, of all cases of carci-\\nnoma that came under his notice the growth of the tumor could be\\ntraced to an injury of some kind. Boll s statistics show a traumatic\\norigin in 14 per cent, and Cohnheim in 350 cases estimated trauma\\nas the principal exciting cause in about 20 per cent. Injuries to plants\\nare quite frequently followed by tumor-formation. The immediate cause\\nof tumor-growth under such circumstances is attributed by some\\nauthors (Williams) less to the injury itself than to a change in the\\nnutrition of the tissues in the locality. Galls are produced by the\\ninstillation of the virus of gall-wasps into the tissues of oak-leaves.\\nThe virus comes in contact with only a few cells, and the new forma-\\ntion is due to proliferation of the infected cells. The structure of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0257.jp2"}, "250": {"fulltext": "234 PATHOLOGY AND TREATMENT OF TUMORS.\\ngall depends more on the kind of vulnerating insect than on the par-\\nticular variety of oak. In the plant buds may form in any place where\\nundifferentiated cells are present. The stimulants which determine the\\nnutritive flux may be either intrinsic or extrinsic. It is well known\\nthat in plants injuries frequently result in the formation of a large\\nnumber of adventitious buds. The initial cause of such variations is\\nprobably to be found in perversions of the secretions of the affected\\npart. Injury to a part inhabited by a tumor-matrix alters normal nutri-\\ntion, which must result in a diminished physiological resistance of the\\ntissues to infective diseases as well as to tumor-growth.\\nPhysiological resistance is illustrated by allowing one plant out of\\na number to go without water. Insect-stings in the w r eakly plant\\nproduce definite changes not produced in well-nourished plants. Local\\ninfluences and among them we must include trauma which pervert\\nnutrition diminish the physiological resistance of the tissues, and by\\ndoing so they become an exciting cause of carcinoma.\\nAge. Carcinoma is most prevalent in persons of middle and past\\nmiddle life. The tumor-matrix present at the time of birth or acquired\\nlater remains in a latent condition until the tissues undergo certain\\nchanges incident to advanced age, when there are created the local\\nconditions necessary to enable the matrix-cells to resume their latent\\nvegetative function and to assume active tissue-formation. That these\\nsenile tissue-changes are something different from ordinary marasmus\\ncaused by disease or by insufficient nourishment becomes evident from\\nthe fact that persons debilitated by disease or by starvation are not\\nmore liable to carcinoma than persons of the same age otherwise in\\nperfect health. If carcinoma develops in a young person, it is a proof\\nthat the cells of the tumor-matrix possess more than the ordinary degree\\nof vegetative power, or that the person is unduly adapted to cancer-\\nformation, or, finally, that the part which contained the tumor-matrix\\nhas been subjected to influences which produced changes in the tissues\\nanalogous to those found in the tissues of the aged in other words, a\\nlocal senility of the tissues. Thiersch has shown that in the lips of\\nold people the fibrous tissue wastes away while the glandular tissue\\nbecomes overgrown, this condition favoring the development of cancer.\\nThe capacity of a part of the organism to resist a certain amount\\nof pressure and still to preserve its histogenetic function will determine\\nits vitality. If this power of resistance is lost, then the. part becomes\\nsubject only to passive changes. This is the case for physiological as\\nwell as for pathological conditions, and as a rule the quantity of paren-\\nchymatous fluid is in direct proportion to the capacity of cell-produc-\\ntion. This is the case in the skin of elderly persons as far as pertains", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0258.jp2"}, "251": {"fulltext": "CARCINOMA. 235\\nto the stroma. When in this weakened stroma there are present\\norganic parts the histogenetic properties of which are still operative,\\nthose parts will proliferate and lead to a hyperplasia of the epithelial\\ntissue which eventually predisposes to the development of carcinoma.\\nIt may be objected that the abundance of capillaries and their dilatation\\nare in opposition to the theory of atrophic condition of the stroma as a\\ncause of carcinoma, as claimed by Thiersch. This vascular change is,\\nhowever, only a result of the rarefaction of the connective tissue with\\nconsequent diminished support against intravascular pressure.\\nAs the blood furnishes a plasma to the tumor, and likely favors\\ndevelopment much as a starting plant favors the growth of aphis, it is\\npossible that in the aged there may occur blood-changes which favor\\nthe development of carcinoma.\\nWalshe has clearly shown that the mortality from cancer that is,\\nthe number of deaths in proportion to the number of persons living\\ngoes on steadily increasing with each succeeding decade until the\\neightieth year. His result is obtained from records of deaths, but it is\\nalmost exactly confirmed by the tables collected by Paget showing the\\nages at which the cancers were first observed by the patients or ascer-\\ntained by their attendants.\\nPaget s Table showing the Influence of Age in the\\nDevelopment of Carcinoma.\\nUnder 10 years 5 per cent.\\nBetween 10 and 20 years 6.9\\n20 30 21\\n30 40 48.5\\n40 50 100\\n50 60 113\\n60 70 107\\n70 80 126\\nThe influence of age in the production of carcinoma is pronounced\\nthe tissue-changes enumerated by Thiersch offer the most plausible\\nexplanation of this influence, and can be applied with equal propriety\\nto carcinoma of all parts of the body as to carcinoma of the lips and\\nthe skin.\\nDiet. Diet appears to exercise some influence in the causation of\\ncarcinoma. Legrain states that epithelioma is unknown in Algeria,\\nexcept as it appears in a European. This may possibly be due to the\\nvegetarian diet without meat, and absolutely without pork. Verneuil\\nand Reclus asserted long ago that the herbivora were much less\\nliable to carcinoma than the carnivora and they ascribe the sixfold\\nincrease in the number of patients suffering from carcinoma at their", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0259.jp2"}, "252": {"fulltext": "236 PATHOLOGY AND TREATMENT OF TUMORS.\\nhospital during the last forty years to the increased consumption of\\nmeat by the laboring classes.\\nClimate. Climate and the attending habits of life and state of\\ncivilization appear to exert an influence in the causation of carcinoma.\\nWalshe collected evidence that the maximum number of carcinoma\\npatients are found in Europe, and that carcinoma is very rare among\\nthe people at Hobart Town and Calcutta and among the natives of\\nEgypt, Algiers, Senegal, Arabia, and the tropical parts of America.\\nInquiries that have been made relative to the prevalence of carcinoma\\namong the Indians of North America seem to show that they are\\nsingularly immune to this affection. Few authenticated cases of carci-\\nnoma have been reported among the Indians unaffected by advancing\\ncivilization.\\nMental Depression. A few pathologists have attributed to the ner-\\nvous system an important part in the etiology of carcinoma. Mental\\ndepression has often been quoted as one of the causes in the production\\nof carcinoma. While mental anxiety and worry of all kinds may favor\\nthe origin and growth of carcinoma by impairing nutrition, and thus\\ndiminishing the physiological resistance of the tissues in the vicinity of\\na tumor-matrix, we have no evidence that nervous influences exert a\\nmore direct effect in the causation of carcinoma. It is different with\\ndread or fear of carcinoma. The writer recollects two patients who for\\nno tangible reason whatever were in constant dread of the disease for\\nmany years, when finally their fears were realized. Apprehensions\\nof this nature certainly exert a positive influence in the etiology of\\ncarcinoma.\\nTuberculosis. Rokitansky maintained that tuberculosis and car-\\ncinoma never existed at the same time in the same person. Other\\ninvestigators have convinced themselves of the incorrectness of this\\nassertion. Dittrich states that of one hundred and fifty cases, in only\\none did tuberculosis and carcinoma exist at the same time. Friedreich\\nwas the first to discover tuberculosis and carcinoma in the same\\norgan. Recently there have been reported a number of well-authen-\\nticated cases in which carcinoma developed in tubercular affections\\nof the skin. Tubercular lesions prepare the soil for carcinoma, and\\nthey may even furnish the essential post-natal matrix of embryonic\\ncells.\\nProlonged Irritation and Inflammation. Long-continued local\\nirritation is frequently the exciting cause of carcinoma. If the irrita-\\ntion is sufficient in intensity to stimulate the mature tissue-cells to pro-\\nliferation, it may also furnish a post-natal matrix of embryonic cells,\\nand consequently constitute both the essential and exciting causes.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0260.jp2"}, "253": {"fulltext": "CARCINOMA.\\n237\\nThe frequency with which carcinoma is met with in localities exposed\\nto repeated and prolonged irritation points to the fact that the latter is\\noften a cause of carcinoma. Carcinoma is frequently found about the\\norifices of the body the lips, the cervix of the uterus, the rectum, and\\nthe nose localities often exposed to irritation. The tobacco-pipe has\\noften been quoted as a cause of carcinoma of the lip, but since the\\npublication of Melzer s statistics the views on this subject have under-\\ngone a change. Carcinoma of the scrotum has been attributed to\\nirritation caused by coal-dust the effect of this source of irritation has,\\nhowever, been over-estimated greatly. Abrasions, punctures of the\\nskin, and small wounds have occasionally served as exciting causes.\\nUnskilful shaving must also be enumerated as a possible cause. In\\none instance the writer saw a carcinoma develop from a small razor-cut.\\nSimilarly, insignificant lesions are often referred to as a possible cause\\nof carcinoma. Chronic inflammatory lesions of all kinds and the rem-\\nnants of acute inflammation have more often been starting-points of\\ncarcinoma than was formerly supposed or than many are willing to\\nadmit at the present time. Inflammation not only diminishes the physi-\\nological resistance of the tissues, but its product may also furnish a\\npost-natal matrix of embryonic epithelial cells. In a chronic ulcer, for\\ninstance, young epithelial cells often become buried in the granulation-\\ntissue, which may serve as a tumor-matrix, and assume active tissue-\\nproliferation at any time when the local conditions are such as to per-\\nmit such tumor-formation. The writer has repeatedly seen carcinoma\\ndevelop in scar-tissue or upon the surface of a chronic ulcer (Fig. 130).\\nFig. 130. Extensive carcinoma which developed in the scar-tissue eighteen years after a severe burn involv-\\ning the gluteal region and posterior surface of the thigh. Inguinal glands extensively involved.\\nLangenbeck observed three cases of lupus in which, after healing of\\nthe ulcerated surface, carcinoma developed in the scar-tissue. Similar\\ncases have been referred to elsewhere.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0261.jp2"}, "254": {"fulltext": "238 PATHOLOGY AND TREATMENT OF TUMORS.\\nDesbonnet has collected from different sources 86 cases in which\\nepithelioma developed either in the scar-tissue following the healing of\\nlupus or in active lupoid ulcerations. The largest number of cases\\noccurred in persons between forty and fifty years of age. The carci-\\nFig. 131. Epithelioma developing in lupus (after Desbonnet).\\nnomatous complications usually set in many years after the beginning\\nof the tubercular process. Fig. 131 furnishes a good illustration of\\nthe appearance of an epithelioma upon a tubercular base.\\nGoodhart has called special attention to irritation as a cause of\\nichthyosis of the tongue and of carcinoma. It has been known for a\\nlong time that this superficial chronic inflammation of the tongue fre-\\nquently precedes carcinoma of this organ. In more than one instance\\ncarcinoma of the tongue and of the mucous membrane of the cheek\\nhas been traced to displaced carious teeth and to the sharp margins\\nof normal teeth.\\nOne of the most instructive evidences of the influence of prolonged\\nirritation and inflammation in the causation of carcinoma is chronic\\neczema of the nipple, known as Paget s disease of the nipple. The\\netiological relation of this affection of the nipple to carcinoma of the\\nbreast was first pointed out by Sir James Paget. Mr. Butlin has cor-\\nroborated Paget s views, and has shown that there can be traced struct-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0262.jp2"}, "255": {"fulltext": "CARCINOMA. 239\\nural changes extending from the diseased part of the skin along the\\nepithelial linings of the gland-ducts in the nipple, and thence along\\ntheir branches into the acini of the carcinomatous part of the gland.\\nThese acini become dilated and filled with proliferating epithelium,\\nwhich is at length, so to speak, discharged into the surrounding tissues.\\nPaget says: The cases of cancer thus following eczema are illustra-\\ntions of a general rule that a part which has long been the seat of con-\\nstant or often-recurrent inflammation, or, if I may write intentional\\nobscurity, of frequent or consta?tt irritation, is apt to become cancerous\\n(the italics are the writer s). Similar instances of the rule are observed\\nin tongues long affected with psoriasis or ichthyosis, in uteri long or\\noften ulcerated, in scars that often break out, in lower lips long\\ncracked or excoriated, in warts often irritated, sore, and scabbed, some-\\ntimes in old scrofulous or other ulcers or in sinuses. Paget admits\\nthat irritation alone and of itself is not enough to produce carcinoma.\\nHe continues It may therefore be deemed very probable that the\\nchief or sole effect of irritation is, by inducing a degeneration, to render\\nthe parts more fit for the invasion of a disease which is essentially of\\nan internal origin.\\nPaget still adheres to the humoral etiology of carcinoma, but we\\nassign, as he does, to chronic irritation and inflammatory products an\\nimportant role in the causation of carcinoma by diminishing the physi-\\nological resistance and by occasionally at least furnishing at the same\\ntime the essential tumor-matrix of embryonic epithelial cells.\\nAnother inflammatory product very often the starting-point of car-\\ncinoma is the wart. The warts upon the forehead and cheeks of aged\\npersons (verruca senilis) most frequently undergo such a transformation.\\nThe only cases in which the writer has seen primary multiple carcinoma\\nwere those in which carcinoma had such an origin. The claim might\\nbe made that these papillomatous swellings were carcinomatous from\\nthe beginning. Examinations of numerous specimens of this kind have\\nfurnished pictures showing all stages of transition of an inflammatory\\nswelling into a carcinoma, and there can therefore be no doubt of their\\nprimary inflammatory origin.\\nMicrobes. The local, regional, and general dissemination of carci-\\nnoma is strongly suggestive of the existence of some virus or microbe\\nas the prime etiological factor of the origin and dissemination of carci-\\nnoma. In some respects carcinoma resembles several of the infective\\nprocesses the microbic origin of which has been well established. The\\ninfectiveness of tuberculosis was recognized a long time before its\\nmicrobic origin was demonstrated. Pathologists have made numerous\\nexperiments to prove the inoculability of carcinoma. Langenbeck", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0263.jp2"}, "256": {"fulltext": "240 PATHOLOGY AND TREATMENT OF TUMORS.\\ninjected cancer-juice into the jugular vein of dogs, and it is asserted\\nthat in one instance the experiment resulted in carcinoma of the lungs.\\nNovinsky in 1876, and later Wehr and Hanau, succeeded in inocu-\\nlating animals, and Hahn and Bergmann have inoculated the human\\nbeing.\\nCarcinoma has frequently been engrafted from one animal into\\nanother of the same species, and in some instances the experiment\\nyielded positive results. The writer has made numerous experiments\\non dogs by implanting carcinoma and sarcoma from man, and the results\\nwere always negative. A slight induration around the implanted graft\\nwas all that was ever observed. Induration and graft all disappeared\\nby absorption in the course of two or three weeks. The same results\\nfollowed the implantation of malignant grafts from one animal into\\nanother of the same species. In a recent work Adamkiewicz declares\\nthat after implantation of a piece of a carcinoma in the brain of a rabbit\\ndeath always took place in about two hours. In the brains thus inocu-\\nlated were always found disseminated round-celled metastatic deposits of\\ncarcinoma which showed a tendency to break down in the centre. The\\ncarcinoma-cells nearly all disappeared from the engrafted piece, leaving\\nonly the stroma. Adamkiewicz believes that cancer-cells are living, inde-\\npendent organisms belonging to the class of protozoa. Geissler, who\\nrepeated the experiments of Adamkiewicz, found that fragments of\\ncarcinoma-tissue imbedded in the brains of rabbits produced no reaction\\nand were absorbed like other aseptic absorbable substances. The views\\nof Adamkiewicz regarding the origin of carcinoma are as fallacious as\\nthe hope he entertained of cancroin as a specific therapeutic agent has\\nbeen shown to be unfounded. The search for a specific microbe dates\\nback to the early days of bacteriology as a science. One of the first\\nefforts in this direction was made in 1881 by Wedopil.\\nThe excitement which Scheuerlen s alleged discovery of a specific\\nbacillus of carcinoma produced spread over the world and stimulated\\nothers to renewed activity in the bacteriological investigation of carci-\\nnoma. For a short time Scheuerlen s claims were seriously entertained\\nand considered, and Schill and Frere went to the trouble to dispute his\\nclaim to priority of the discovery of the carcinoma bacillus. Later,\\nDarier, Wickham, Malassez, Albarran, and Soudakewitsch described\\ncoccidia-like bodies in tumors. These bodies were studied carefully in\\ntumor-tissue by Pfeiffer, Sjobring, Thoma, Podysoski, Delepine, and\\nespecially by Ruffer. The last author regarded them as psorosperms,\\nand he studied their behavior to different kinds of staining material.\\nHe found them in the protoplasm of cells in all carcinomatous tumors.\\nStroebe, Steinhaus, O. Israel, Karg, Eberth, Ribbert, Hauser, and other", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0264.jp2"}, "257": {"fulltext": "CARCINOMA. 241\\npathologists entertained more conservative views in regard to the\\netiological importance of these bodies in the causation of tumors.\\nMany of these pathologists are of the opinion that the bodies which\\nhave been described as psorosperms are only the product of cell-\\ndegeneration.\\nThe experiments of Ballance and Shattock in the cultivation of\\ncancer on nutrient media, and the direct inoculation of cancer per-\\nformed by Hanau, Klebs, and others, argue against a microbic origin\\nof carcinoma. The sporozoa which have been found in cancer-tissue\\nby different observers no doubt play their part in irritation, but there is\\nso far no evidence that they are the cause of carcinoma.\\nThe bacteriological examination of carcinoma tissue continues, one\\nof the most recent efforts in that direction being that of Roncali. This\\nauthor found in a carcinoma of the ovary numerous intracellular and\\nintercellular blastomycetes in various stages of development, which he\\nregards as the cause of the disease.\\nKurloff considers it very desirable that those engaged in investigating\\nthe supposed organism of carcinoma should furnish with each published\\ncase the history of the patient and a clinical and pathologico-anatomical\\naccount of the tumor. Only by some such plan can we hope to\\nsystematize the results arrived at by different investigators. Korotneff\\ndiscovered in carcinoma an organism which he called rlwpalocephalus\\ncanceromatosus. Kurloff found the same parasite in a vacuole within\\nthe epithelial cells of a carcinoma of the breast. Ohlmacher of Chicago\\nmade very extensive investigations concerning the etiological relation\\nof sporozoa to carcinoma, and in a recent paper on this subject he\\npointed out that many objects have been described as the parasites\\nof carcinoma because the subject has been treated unscientifically. A\\ngreat number of reagents have been used, hence the diversity of results.\\nArtificial products are sometimes found by the reagents. It has been\\nfound that sporozoa treated by different fixing solutions act differently.\\nSome agents distort the spores and interfere with the subsequent\\nstaining. All the present methods of investigation are faulty, and no\\nresults are to be looked for until new methods are devised.\\nTo prove the microbic origin of carcinoma it is necessary for bac-\\nteriologists to demonstrate the presence of the same organism in every\\ncarcinomatous tumor. They must isolate the organism and cultivate it\\noutside the body upon artificial nutrient media, and with pure cultures\\nthey must reproduce the disease in some of the lower animals. This has\\nso far not been done, and until it is done we have no right to claim for\\ncarcinoma a microbic origin. It has been shown elsewhere that the local\\nand general dissemination of carcinoma is effected exclusively by cell-\\n16", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0265.jp2"}, "258": {"fulltext": "242 PATHOLOGY AND TREATMENT OF TUMORS.\\nmetastasis and cell-transportation, and that the secondary and meta-\\nstatic tumors are the exclusive products of tissue-proliferation of cells\\nderived from the primary tumor. In all infective swellings the cellular\\nelements are derived exclusively from the corpuscular elements of the\\nblood and proliferation from pre-existing tissue. Carcinoma-tissue is\\nderived exclusively from a matrix of embryonic epithelial cells. The\\npre-existing tissues remain passive in carcinoma as well as in all other\\ntumor-formations.\\nDe Morgan in 1874 said: I can see no analogy between new\\ngrowth, whether as innocent as lipoma or as malignant as cancer, and\\nthe products of true general or blood disease. From the first a tumor\\nis a living, self-dependent formation, capable of continued growth by\\nvirtue of its own power of using the nutritive materials supplied to it.\\nNothing like this is seen in any of the blood diseases. Until additional\\nand more positive light is shed upon the microbic origin of carcinoma\\nwe must adhere to the theory that carcinoma is an atypical proliferation\\nof cells from a matrix of embryonic epithelial cells of congenital or post-\\nnatal origin.\\nPathology.\\nThe most important aberration of the normal growth in carcinoma\\nconsists in the presence of epithelial cells in vascular connective tissue.\\nThe epithelial cells retain their vegetative power in the new locality.\\nThe stroma is derived from the pre-existing connective tissue, and its\\nabundance depends largely on the amount of connective tissue in the\\npart affected and the intrinsic vegetative capacity of the epithelial cells.\\nIf the organ affected is dense and fibrous, the pre-existing material for\\nthe stroma is abundant, and the tumor, at least during its earlier stages,\\nwill be firm. If the epithelial cells proliferate slowly, the pre-existing\\nconnective tissue constituting the stroma is increased by the production\\nof new connective tissue in response to the stimulation created by the\\ncarcinoma-cells, which act as an aseptic foreign substance. If the epi-\\nthelial cells possess a maximum power of tissue-proliferation, the stroma\\nis rapidly broken down, and little or no new connective tissue is formed,\\nthe resulting tumor grows very rapidly, is soft, and local infection takes\\nplace early and in a short time becomes diffuse. In hard carcinoma of\\nthe breast, the so-called scirrhus, the stroma is abundant and the\\nparenchyma is scanty. The same conditions are found in atrophic\\ncarcinoma and in cancer en cuirasse. In the so-called encephaloid\\ncarcinoma the conditions are reversed a scanty stroma and an abun-\\ndance of rapidly-proliferating cells.\\nCarcinoma is distinguished from all other tumors by the irregularity", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0266.jp2"}, "259": {"fulltext": "CARCINOMA. 243\\nof its surface and the existence of a wide zone of infiltration. Virchow\\nyears ago observed a zone of infiltration extending from three to four\\nlines from the macroscopical boundary-line of the tumor. Waldeyer\\ndescribed this zone as the inflammatory zone, because he found in\\nthe connective tissue numerous small cells. This zone often presents\\nalmost a typical appearance of tissue the seat of a chronic inflamma-\\ntion. The infiltration consists of leucocytes and small young epithelial\\ncells which, like the leucocytes, wander by virtue of their ameboid\\nmovements into and along the connective-tissue spaces (Fig. 132). The\\nFig. 132. Zone of infiltration around carcinoma; X 330 (Surgical Clinic, Rush Medical College, Chi-\\ncago) section from near the macroscopical boundary-line of a carcinoma of the abdominal wall a, young\\nepithelial cells infiltrating the stroma, beginning formation of new alveoli b, stroma c, wandering leuco-\\ncytes.\\ninfiltration in rapid-growing carcinoma is so extensive that the con-\\nnective-tissue spaces are packed with small round cells to such an\\nextent as to obscure the stroma completely (Fig. 133, c).\\nThe leucocytes escape from new imperfect capillary vessels or from\\nvessels damaged by the tumor-tissue, and consequently are present in\\ngreat abundance in rapid-growing tumors a condition which exem-\\nplifies the well-known clinical fact that the more closely a carcinomatous\\ntumor resembles an inflammatory product, the greater is its malignancy.\\nThe young epithelial cells possess the maximum capacity to change\\ntheir location by ameboid movements hence we find in the zone of\\ninfiltration exclusively young epithelial cells which have left the primary\\ntumor and are actively engaged in increasing its area. From the sur-\\nface of the carcinoma there project into the surrounding tissue tumor-\\nmasses which render its surface uneven and nodular. These projections\\nof the tumor can be seen to greatest advantage in squamous-celled\\ncarcinoma. They appear first as conical or column-shaped infiltrations\\nconnected on one side with the primary tumor and projecting into the\\nconnective tissue on the other (Fig. 134). These projecting parts of", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0267.jp2"}, "260": {"fulltext": "244\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nFig. 133. Extensive ground-cell infiltration at the margin of a carcinoma of the lower jaw; extension\\nof disease from the lip X 130: a, carcinoma-cells wandering into site of former pearl; b, colloid material;\\nc, round-cell infiltration d, young carcinoma-cells.\\nFig. i 34 .-Carcinoma of the tongue; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, columnar\\nprojections of carcinoma-cells b, epithelial nests c, blood-vessels d, submucous connective tissue.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0268.jp2"}, "261": {"fulltext": "CARCINOMA. 245\\nthe tumor impart to it from the very beginning a certain degree of\\nimmobility and cause the nodulated condition of its surface.\\nThe stimulation of the tissues caused by the invasion of so many\\nforeign bodies results also in the formation of new blood-vessels,\\nbrought about by a process of budding from the pre-existing blood-\\nvessels adjacent to the tumor-matrix. The vascularization, not being\\n9.\\ne\\nf e\\nW\\nd\\nFig. 135. Deep-reaching epithelioma upon the leg, with papillary excrescences. Specimen injected.\\nSection from the part of the tumor which occupied the cavity in the tibia; X 6 (after Thiersch) a, new\\nvessels composed of numerous loops; b, elongated pedunculated proliferation of vessels; c, large vessel-\\ntrunks which suddenly terminate in capillaries d, compact masses of epithelial cells arranged in concentric\\nlayers, cut transversely or obliquely, and surrounded by vascular stroma e, part of a cleft-like cavity con-\\ntaining epithelial debris;,/ flat polygonal cells in irregular layers, answering to the horny epithelial cells of\\nthe skin g, layer of cells representing the rete Malpighii.\\nunder the normal control of the nervous tissue, and being in a district\\nof planless tissue-proliferation, always assumes an atypical type. The\\nepithelial cells in carcinoma are brought in direct contact with the new\\nblood-vessels (Fig. 135, d).\\nRibbert has recently advanced the theory that the histogenesis\\nof carcinoma is caused by a proliferation of the connective tissue,\\nwhich isolates the epithelial cells and brings them in contact with\\nvascular tissue. This view has been vigorously opposed by Hauser\\nand Notthafft, who have made observations on the penetration of\\nepithelial cells during the early stage of the development of car-\\ncinoma.\\nThe atypical vascularization of a carcinoma exerts a potent influence\\nin determining its clinical course. Great vascularity is a prominent", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0269.jp2"}, "262": {"fulltext": "246 PATHOLOGY AND TREATMENT OF TUMORS.\\nfeature of rapid-growing tumors. In slow-growing hard tumors the\\nblood-supply is scanty. In atrophic carcinoma the vessels are com-\\npressed and often obliterated by the cicatricial contraction of the massive\\nstroma. Perforation of a vessel-wall by tumor-tissue is apt to be followed\\nby metastatic carcinoma or miliary carcinosis. Thrombosis of a prin-\\ncipal vessel of the tumor results in speedy and extensive degeneration\\nor necrosis of the tumor-tissue.\\nCarcinoma-cells retain their embryonic character and never reach\\nmaturity. The imperfect development of epithelial cells in carcinoma\\nis one of the distinctive features between them and the mature epithelial\\ncells of benign epithelial tumors. The juvenile condition of the paren-\\nchyma-cells of a carcinoma explains the rapid growth of the tumor\\nand the early degenerative changes which take place in its tissues.\\nThiersch has well said that the tissue of carcinoma is characterized\\nfrom the start by degeneration. While the degeneration is progressing\\nthe parts first affected suffer a retrogressive change, without, however,\\nit being followed by complete absorption. The pre-existing connective\\ntissue is utilized as a temporary scaffolding for the tumor-tissue. The\\nparenchyma-cells of all organs affected by carcinoma are subjected to\\npressure, undergo fatty degeneration, and are gradually removed by\\nabsorption as the tumor advances. The complete removal of glandular\\ntissue in secondary carcinoma of the lymphatic glands furnishes a\\nstriking illustration of the gradual substitution of tumor-tissue for\\nthe pre-existing glandular structure. The connective tissue of the\\npart affected furnishes the stroma of the tumor this stroma is increased\\nunder favorable circumstances, but is likewise subject to degenerative\\nchanges and to gradual removal by the increasing number of cells.\\nThe degenerative changes which occur most frequently in carcinoma-\\ncells are I. Fatty degeneration 2. Colloid degeneration; 3. Mucoid\\ndegeneration. Fatty degeneration begins always\\nin the centre of the alveoli, in the oldest cells,\\nand in the parts most distant from the vascular\\nsupply. The cells in the centre of an epithelial\\nnest (Fig. 136) show first in their protoplasm\\ngranules of fat which increase in size and number\\nuntil the cell breaks up in fragments, leaving\\nminute particles of fat and a granular detritus.\\nriG. 136. .Lpitheual pearl r\\nfrom carcinoma of skin of leg; Fatty degeneration begins at different points in\\nX no, reduced one-fourth (Surg- i\\nicai clinic, Rush Medical college, the same alveolus (Fig. 137).\\nChicago) a, a. centre of cancer- T1 j i_ r r ^.j. j _\u00e2\u0080\u00a2\\nnests, showing fatty degeneration The product of fatty degeneration in squa-\\nts cells mous-celled and glandular-celled carcinoma in\\nits naked-eye appearances resembles very much the contents of an ath-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0270.jp2"}, "263": {"fulltext": "CARCINOMA.\\n247\\nroma. It is composed, like the latter, of detached dead and degenerated\\nepithelial cells, granules of fat, and a granular detritus. While the centre\\nof an alveolus is undergoing this\\nchange the disease extends in its\\nperiphery, where cell-proliferation is\\nprogressing in the outer layer of the\\nyounger epithelial cells. In ulcer-\\nating carcinoma of the lip and the\\nskin the products of fatty degen-\\neration, in the form of small plugs\\npresenting the appearance of athe-\\nromatous material, can be squeezed\\nout upon the surface by pressure.\\nThe same condition is not met with\\nin any other ulcer, and is ^therefore\\nof the greatest diagnostic importance.\\nIn glandular carcinoma the same\\nkind of material can be squeezed\\nfrom the surface on making a sec-\\ntion through the tumor. Fatty de-\\ngeneration of the parenchyma of a\\ncarcinoma is most marked in slow-\\ngrowing hard tumors, and must\\nbe regarded as a favorable retrogressive change tending to retard the\\ngrowth of the tumor.\\nFig. 137. Multiple points of fatty degeneration\\nin the same alveolus X 480 (Surgical Clinic, Rush.\\nMedical College, Chicago) a, highly refractile non-\\nstaining area.\\nFig. 138. Carcinoma of the rectum with extensive colloid degeneration of the cells lining the tubules\\n(after Perls). In the small alveoli, beginning colloid degeneration of the cells the larger alveoli are distended\\nby colloid material and are without attached cells.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0271.jp2"}, "264": {"fulltext": "248\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nColloid degeneration occurs in the parenchyma and stroma of car-\\ncinoma, and is not limited to tumors of any particular type of cells\\n(Fig. 139). Colloid degeneration of the stroma is found in rapid-\\ngrowing glandular carcinoma. The colloid material is often so abun-\\ndant as to obscure the cellular elements and the stroma so much so\\nFig. 139. Colloid degeneration of stroma in carcinoma of the mamma X 350 (Surgical Clinic, Rush Medical\\nCollege, Chicago) a, stroma b, alveoli packed with epithelial cells c, colloid masses in stroma.\\nas to induce many authors to regard it as a special form of tumor.\\nLebert showed that what was known as colloid carcinoma is a car-\\ncinoma modified by the character of the regressive tissue-metamor-\\nphosis of its cells or its stroma, or both. Colloid degeneration is of\\nvery frequent occurrence in carcinoma of the alimentary canal, the\\nfavorite locality of what was formerly described as colloid cancer\\n(Fig- 138).\\nMucoid or myxomatous degeneration may occur in either the cells\\nor the stroma of a carcinoma. Columnar-celled carcinoma is very apt\\nto undergo this form of regressive metamorphosis. It is again the\\noldest cells that first undergo this change. In cylindrical-celled car-\\ncinoma, in which the cells are arranged in several layers, the layer next", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0272.jp2"}, "265": {"fulltext": "CARCINOMA.\\n249\\nto the lumen of the tubule is destroyed by the myxomatous process,\\nand the mucoid material accumulates in the glandular spaces, forming\\ncysts of various sizes (Fig. 140). If the areas of degeneration are\\nFig. 140.\u00e2\u0080\u0094 Cylindrical-celled carcinoma of stomach X 250 (after Perls). The cells in the central part of\\nthe alveoli are destroyed by myxomatous degeneration.\\nextensive, the consistence of the tumor varies in different places a\\nmatter of importance in diagnosis. Secondary tumors are subject to\\nthe same degenerative changes as the primary. Ulceration in car-\\ncinoma of the skin and the mucous membranes is present almost from\\nthe beginning. Carcinomatous ulcers of the cutaneous surface are\\nusually covered by a crust formed by inspissation of the secretion,\\nwhich crust, if detached, uncovers an ulcer which bleeds upon the\\nslightest touch. An nicer once formed remains permanently, increases\\nin size, and manifests no tendency to heal. The differentiation of such\\nan ulcer from lupus and from ulcerating syphilitic affections is always\\ndifficult and sometimes impossible. When the tumor involves the skin\\nor when a deep-seated carcinoma has reached the skin, ulceration takes\\nplace, the central part, being more abundantly supplied with epithelial\\ncells and being less vascular, becoming the seat of necrotic changes.\\nAs soon as the continuity of the surface is destroyed, micro-organisms\\ntake a part in the subsequent work of destruction, as the tumor-tissue\\nbecomes the seat of suppurative inflammation. A carcinomatous ulcer\\nis characterized by its deep, crater-like cavity, which again may present\\nnodules, as well as by its thickened and indurated margins. The ulcer\\nmay also be flat where the thin infiltrations appear to be destroyed by\\nulceration. These ulcers are always surrounded by steqp, abrupt", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0273.jp2"}, "266": {"fulltext": "250 PATHOLOGY AND TREATMENT OF TUMORS.\\nmargins, and present a flat floor with few or no granulations, being\\nthus distinguished from many other kinds of ulcers resulting from\\ninfective causes. Large ulcers are usually the seat of putrefactive pro-\\ncesses and emit an exceedingly offensive odor. The putrefaction is\\ncaused by the presence of putrefactive bacilli which develop in the\\ndead tissue attached to the ulcerated surface. A carcinoma covered\\nby normal intact skin may become infected with pyogenic microbes by\\nlocalization in the tumor-tissue of floating microbes. Suppurative\\ninflammation of the tumor-tissue under such circumstances is attended\\nby the usual symptoms which accompany acute inflammation. Tem-\\nperature, rapid pulse, and other symptoms of sepsis, with increase of\\nswelling, pain, tenderness, and oedema, are the symptoms to be relied\\nupon in ascertaining the existence of this complication. If the tumor\\nis large and the infection is extensive, a large part of the tumor may\\nslough, leaving a crater-like excavation after the elimination of the\\ndead material.\\nIt will be necessary to add to the general remarks on the pathology\\nof carcinoma a brief description of the\\nHistological Varieties of Carcinoma.\\nSquamous-celled Carcinoma. This variety of carcinoma develops\\nupon the surface of the skin, and is usually described under the term\\nepithelioma. The term epithelioma has given rise to a great deal\\nof confusion, as some authors describe under it a benign, and others a\\nmalignant, tumor of the skin or the mucous membranes. The word\\nshould be abolished in the nomenclature of tumors.\\nA squamous-celled carcinoma contains as the essential tumor-\\nelement squamous or pavement epithelium in imitation of the epithelial\\nlayers of the skin. The growth usually begins as a small surface\\ndefect a crack or fissure of the skin covered by a crust. With the\\ncancer-formation the epithelial cells dip down beyond the membrana\\npropria into the subcutaneous vascular connective tissue. The tumor\\nthen is slightly elevated above the level of the surrounding skin, with\\na hard base, and with indurated margins from which infiltrations extend\\ninto the surrounding tissues. The tumor beneath the skin or under\\nthe ulcer appears to the palpating finger as a hard mass, almost of the\\ndensity of a piece of cartilage. The tumor ulcerates early, as the oldest\\nportion does not receive a blood-supply adequate to nourish its tissues.\\nWhen the epithelial layer is destroyed the connective tissue furnishes\\nthe surface with a layer of vascular granulations but an attempt in\\nthis direction is only partially successful, as some of the epidermal\\nplugs penetrate deeply into the subcutaneous tissue. If these epidermal", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0274.jp2"}, "267": {"fulltext": "CARCINOMA. 251\\nplugs are carefully examined, their connection with the surface epithelia\\nis readily traced by making the section in a right direction if it is made\\noblique, the deeper parts of the tumor appear disconnected with the\\nsurface.\\nIn the proper interpretation of the diagnostic significance of these\\nepithelial plugs not only is their net-like branching characteristic, but\\nof greater import are their shape and combination. Benign epithelial\\nproliferations show the same regular form and arrangement of the cells as\\nthe normal inversions of the epidermis, and they gradually become nar-\\nrower toward the depth, while in the carcinomatous epithelial prolifera-\\ntion the nature of the growth is revealed by the irregular arrangement\\nof the epithelial cells and their relations to the connective tissue. New\\nepithelial cells which form on the surface of granulations in the healing\\nof a wound or an ulcer do not possess the power to penetrate into the\\ndeeper tissues, while penetration of the connective tissue is the most\\nconspicuous pathological feature of carcinoma. The carcinoma-cells\\nfirst penetrate the entire thickness of the skin, and later the subcutane-\\nous connective tissue and any other tissue within their reach. Another\\nimportant differential point is that in non-malignant affections of the\\nskin the normal shape of the different forms of epithelial cells is main-\\ntained, while in carcinoma there is a great similarity in the shape of the\\ncells. Epithelial pearls in non-malignant affections appear in the form\\nof concentric layers of cells, with the oldest cells in the centre in car-\\ncinoma the cells of such a pearl are the product of tissue-proliferation\\nof a single cell. In carcinoma the cells are often multinuclear, and\\nonly gradually, by flattening and arrangement in concentric layers, form\\nthe epithelial nests.\\nIn ordinary granulation-tissue but few leucocytes are found in\\ncarcinoma they are abundant, especially near capillary vessels. In\\nchronic ulcer of the leg, if malignancy sets in, young epithelial cells\\nbecome buried underneath the benign granulations, and a carcinoma of\\nconsiderable size may be produced by them before its presence would\\nbe recognized by surface indications. If a carcinoma of the skin is\\nallowed to run its course undisturbed, regional infection is sure to take\\nplace, and other complications, in common with glandular carcinoma,\\nset in sooner or later, furnishing an abundance of clinical evidence to\\nprove the carcinomatous nature of the tumor.\\nThe favorite localities of squamous-celled carcinoma are the lips,\\nthe skin of the face, the mouth, the nose, the ear, the penis, the vulva,\\nand the anus. In the oesophagus it most frequently attacks that part\\nof the tube which lies behind the cricoid cartilage and the bifurcation of\\nthe trachea. Carcinoma of the tongue commences most frequently at", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0275.jp2"}, "268": {"fulltext": "252 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe margin and base of the organ, at points irritated by sharp or defect-\\nive teeth. Carcinoma is also quite frequent in the larynx, the vocal cords,\\nand, as Stork has observed, from polypoid or papillomatous growths,\\nwarts, and scars in this organ. The deep, squamous-celled carcinomata\\noriginate from an incompletely obliterated branchial cleft (Volkmann),\\nfrom remnants of the urachus and of dermoid tumors, or from a dis-\\nplaced matrix of embryonic cells in any part of the body. Friedlander\\nfound in the apex of the lung of a phthisical patient a squamous-celled\\ncarcinoma which projected into a principal bronchus. He believed that\\nthe columnar cells in this locality had become transformed into squa-\\nmous epithelium, and he refers to the observations made by Griffini and\\nZiegler, who found pavement epithelium upon ulcerous, tubercular, and\\nsyphilitic defects of the trachea. It is, however, more probable that the\\ncarcinoma had developed from a displaced matrix of epiblastic tissue.\\nErbse saw a case of squamous-celled carcinoma of the lung after\\nperforation into the trachea of an oesophagus-carcinoma composed of\\nepithelial cells resembling the primary tumor. Klebs thinks that cells\\nentered the lung by aspiration before perforation occurred.\\nAs compared with glandular carcinoma, squamous-celled carcinoma\\npursues a chronic course. This, as we have explained elsewhere, is to\\nbe attributed not so much to its lesser intrinsic malignancy as to the\\ndifference in the anatomical location of the two growths. If left to\\nitself, squamous-celled carcinoma ultimately presents all the clinical\\nfeatures of glandular carcinoma.\\nMelanotic carcinoma is a pigmented squamous-celled carcinoma. It\\ndevelops in structures which are pigmented most frequently in pig-\\nmented moles. The pigment appears as granules in the protoplasm of\\nthe cells. This form of carcinoma is regarded as exceedingly malig-\\nnant, giving rise to early and extensive regional infection and to general\\ndissemination. The secondary tumors show the same structure, and\\nare pigmented like the primary tumor.\\nCylindrical-celled Carcinoma. The cylindrical-celled carcinoma\\nresembles the squamous-celled in so far that it develops upon a free\\nsurface, but it differs from it in the shape and arrangement of its cells.\\nThe cells are derived from the hypoblast, are columnar in shape, and\\nare attached in single or multiple layers to the inner surface of imper-\\nfect tubules. The histological structure of a cylindrical-celled carci-\\nnoma is an imitation of gland-ducts and of mucous glands of the\\ngastro-intestinal canal. The carcinomatous process begins with an\\nanomalous vegetation of columnar epithelial cells. The membrana\\npropria is defective at points, and permits the cells to escape from the\\ntubules into the surrounding connective tissue, where they continue to", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0276.jp2"}, "269": {"fulltext": "CARCINOMA. 253\\nreproduce themselves by indirect cell-division. The connective tissue\\nalso proliferates and enters into the formation of the tumor. The dis-\\nconnected development of epithelial cells is an important factor in the\\nlocal extension of the tumor. It marks the first deviation from normal\\ngrowth, and it is always followed by local and regional infection, and,\\nas Lebert has shown, very frequently by general dissemination.\\nMetastatic tumors, especially of the bones, are often associated with\\na small primary tumor showing greater aptitude for local and general\\ndissemination than does squamous-celled carcinoma. The primary\\ntumor in such cases has often been overlooked entirely. Klebs\\nbelieves that the extension to bone usually takes place through lymph-\\nglands, especially those in the lumbar region.\\nCompared with squamous-celled carcinoma, cylindrical-celled carci-\\nnoma is a much more malignant affection. A partial explanation of\\nthis difference in their clinical behavior is the presence in the former\\nof an abundance of firm connective tissue to serve the purpose of\\nstroma, and in the latter of a scanty, loose bed of connective tissue.\\nGlandular Carcinoma. The morphological prototypes of this\\nvariety of carcinoma in normal tissue are the acinous glands, some\\nof which are derived from the epiblast and some from the hypoblast.\\nThe hard variety of glandular carcinoma has been called scirrhus\\nfor centuries, and this name still figures prominently in our modern\\ntext-books. The texture of the tumor varies according to the amount\\nof stroma present. If the stroma is abundant and firm, the tumor is\\nfirm the so-called scirrhus if the stroma is scanty and the amount\\nof tumor-cells is consequently increased, the tumor is soft, constituting\\nwhat was formerly, from its resemblance in consistence and appearance\\nto brain-tissue, termed an encephaloid or medullary cancer. If such\\na tumor ulcerated and fungous masses appeared on the surface of the\\nulcer, which bled easily on being touched, it was called fungus hema-\\ntodes. Such a distinction between glandular tumors is no longer justi-\\nfiable upon histological or clinical grounds, as the same tissue-elements\\nare present in all varieties, only in different proportions, and all of these\\nvarieties result in regional, and frequently in general, infection. The\\nclassification of carcinoma should be made upon a histological basis,\\nand if this is done, all malignant epithelial tumors of acinous glands\\nmust be brought under one head as glandular carcinoma.\\nGlandular carcinoma varies greatly according to the character of the\\nmother-soil and the arrangements of its histological elements, but\\nmany of the features of the varieties formerly regarded as distinct\\ntypes of tumors have so much in common as to constitute a well-\\ndefined form of carcinoma. The most distinguishing feature between", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0277.jp2"}, "270": {"fulltext": "254 PATHOLOGY AND TREATMENT OF TUMORS.\\nglandular carcinoma and carcinoma of the cutaneous and mucous sur-\\nfaces is that the former gives rise to the formation of a large tumor.\\nThe reason that a surface carcinoma does not form a large tumor is that\\nit can grow in one direction only, and that, being exposed to frequent\\nirritation of all kinds, and receiving its blood-supply only from one direc-\\ntion, it falls an early prey to ulceration. As soon as a surface carcinoma\\nhas ulcerated, the tumor-tissue is exposed to infection with pathogenic\\nmicrobes, which infection, by producing a suppurative inflammation, aids\\nin the destruction of tumor-tissue. A glandular carcinoma is better pro-\\ntected against irritation, injury, and infection with pathogenic microbes,\\nis surrounded everywhere by tissue, and receives its blood-supply from\\nall sides, and it is for these reasons that the tumor attains larger size\\nand that ulceration sets in later than in a surface carcinoma.\\nCarcinoma of the breast is the most familiar representative of the\\nglandular group. In the hard glandular tumor the epithelial cells lose\\ntheir typical shape sooner than in the soft variety, owing to the pres-\\nsure to which they are subjected on the part of the massive stroma\\nand to the scanty blood-supply. The defective acinous grouping of\\nthe epithelial cells (Fig. 141) points to a deeper nutritive disturbance\\nthan is the case in adenoma (Fig. 142), and should always be looked\\nfor in making a differential diagnosis by the aid of the microscope.\\nThe carcinomatous character of the tumor becomes evident when the\\ntissues adjacent to the tumor are examined. If the tumor, for instance,\\nis surrounded by fat, this tissue will be found infiltrated with new\\nepithelial cells, and hence what might have been considered macro-\\nscopically as the most important features, adhesion and infiltration,\\nbecome corroborated by examination of these tissues under the micro-\\nscope. When the tumor starts in the acini of the gland or, rather, when\\nthe tumor presents an acinous structure the picture is entirely changed,\\nas the histological arrangement in a hard glandular tumor presents no\\nresemblance whatever to normal gland-tissue the glandular tissue has\\ngiven way to a firm, quite homogeneous, fibrous mass only numerous,\\nnarrow, somewhat deeply-stained stripes indicate the location of the\\ncompressed, proliferating epithelial cells. The carcinomatous, tissue pre-\\nsents a peculiarly distinctive histological type. This tissue consists of a\\nmixture of epithelial cells and connective tissue, the mutual topographical\\nand numerical relations of which deviate completely from the normal\\nstructure of the mammary gland.\\nThe highest degree of atypical tissue-proliferation is met with in\\ncarcinoma of the mammary gland. The local infection extends along\\npre-existing connective-tissue spaces, and ultimately extends beyond\\nthe limits of the gland to the overlying skin and the wall of the thorax,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0278.jp2"}, "271": {"fulltext": "CARCINOMA.\\n255\\nO u u\\nrt a\\n3", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0279.jp2"}, "272": {"fulltext": "256 PATHOLOGY AND TREATMENT OF TUMORS.\\nwhich is frequently perforated by the growth, either by continuity of\\ngrowth and successive involvement of the different tissues, or in the\\ncourse of the lymphatics until the pleura is reached, when the disease\\nspreads rapidly over the serous surfaces, usually resulting in hydro-\\nthorax. The serum in such cases is frequently stained by the admix-\\nture of blood. Glandular carcinoma is followed at an early stage\\nby regional infection. The lymphatic glands nearest the organ affected,\\nin the direction of the lymph-current, are usually involved first, when,\\nstep by step, successive glands are implicated until the entire chain of\\nglands has become infected. General infection at this stage may occur\\nat any time and may hasten the death of the patient. The glands\\nmost frequently the seat of carcinoma are the mammary, thyroid,\\nparotid, submaxillary, ovary, testicle, kidneys, pancreas, and prostate.\\nDiagnosis.\\nThe difficulty in the diagnosis of carcinoma depends on the size and\\nlocation of the tumor. In advanced carcinoma of the external parts\\nof the body a correct diagnosis can often be made on first sight. The\\ndiagnosis of carcinoma of internal organs is frequently made only in\\nthe post-mortem room. The successful treatment of carcinoma\\ndepends upon an early and a correct diagnosis and prompt and\\nthorough operative interference. The early diagnosis requires a care-\\nful study of the clinical history of the case, supplemented by a\\nthorough examination of the tumor, and followed by a critical analysis\\nof the signs and symptoms presented. In doubtful cases a correct\\ndiagnosis is possible only by differentiating from a supposed carcinoma\\nswellings and tumors which simulate it that is, by exclusion. Inoc-\\nulation experiments and the use of the microscope may become neces-\\nsary to make a differential diagnosis between carcinoma and some of\\nthe infective swellings. In obtaining the clinical history it is important\\nto inquire into the family history in reference to the possible existence\\nof an hereditary predisposition to carcinoma. To elicit information of\\nvalue concerning this point it is necessary to trace back the family\\nhistory for two or three generations, because such an hereditary predis-\\nposition does not necessarily occur in the immediate offspring of car-\\ncinomatous parents, but may appear in the second, third, or fourth\\ngeneration. The writer knows of one family in which both parents\\ndied of carcinoma the husband of carcinoma of the stomach, the\\nwife of carcinoma of the uterus and yet the children, one of whom\\nhas now reached his sixtieth year, have shown no symptoms of this\\ndisease. In tracing the family history in the cases of carcinoma that\\nhave come under his observation the writer has had patients tell him", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0280.jp2"}, "273": {"fulltext": "CARCINOMA. 257\\nrepeatedly that one of the grandparents or great-grandparents died of\\ncarcinoma. It is also important to elicit the existence of malignant\\ndisease among more distant relatives, as the hereditary predisposition\\nmay follow with varying degrees of intensity different branches of the\\nsame family.\\nThe age of the patient is an important element in the diagnosis of\\ndoubtful tumors. Carcinoma is a disease that in preference attacks\\npersons of middle or past middle life. The aptitude for this disease\\nincreases after middle life. In very rare instances it has been of con-\\ngenital origin or has developed during childhood. It is quite rare in\\npersons less than twenty years of age, and is more common during the\\nthird decade of life. The writer has seen carcinoma of the rectum in\\na boy eighteen years of age, carcinoma of the breast in a girl twenty-\\nfive years old, carcinoma of the lower lip in a man twenty-seven\\nyears old, and carcinoma of the stomach in a man of thirty. Cases\\nof carcinoma in persons less than thirty years of age are, however,\\nextremely rare. A tumor of the lip occurring in a man less than thirty\\nyears of age is in all probability anything else than a carcinoma, while\\nin persons past middle life the probability of its being carcinomatous is\\ngreatly increased. If a woman less than thirty years of age is suffering\\nfrom pelvic distress, menorrhagia, and profuse leucorrhoeal discharge,\\nthe probability of these symptoms being caused by carcinoma of the\\nuterus is exceedingly small, while the same complexus of symptoms\\noccurring in a woman at the time of the menopause or later points\\nstrongly in that direction. A solid tumor in females less than twenty-\\nfive years of age is usually of a benign nature, while its appearance in\\nwomen past thirty years of age should arouse a strong suspicion of\\nits malignant character.\\nSex exerts a strong influence in determining the location of carci-\\nnoma. Pyloric obstruction of the stomach is caused by carcinoma\\nmuch more frequently in men than in women. Carcinoma of the lip is\\nextremely rare in women. Carcinoma of the breast in the male is an\\nexceptional occurrence. Carcinoma of the genital organs is much more\\nfrequent in women than in men.\\nRapidity of growth is a marked feature of carcinoma as compared\\nwith benign tumors. A rapid-growing tumor is therefore more apt\\nto be mistaken for an inflammatory swelling than for a carcinoma.\\nRapidity of growth as a diagnostic evidence, however, must be weighed\\ncarefully before conclusions are drawn from it, otherwise the surgeon\\nis very likely to be misled. A carcinoma may remain latent for main-\\nyears before manifesting malignant qualities. An inflammatory swell-\\ning, as a rule, increases in size more rapidly than a carcinoma. Patients\\n17", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0281.jp2"}, "274": {"fulltext": "258 PATHOLOGY AND TREATMENT OF TUMORS.\\nhave been sent to the writer repeatedly with the diagnosis of carcinoma\\nof the breast, when the clinical history showed that the swelling had\\nreached its maximum size in from four to six weeks the result of\\nan almost painless subacute suppurative inflammation of the breast.\\nIn rapidly-growing tumors particular pains should be taken to ascertain\\na possible source of infection. If, for instance, a tumor of the testicle\\nattains the size of a hen s egg in a few weeks in a man more than thirty\\nyears of age, a suspicion of syphilitic infection should be excited. A\\ngumma of the testicle will increase in size much more rapidly than a\\ncarcinoma of the same organ. A rapid-growing carcinoma must be\\ndifferentiated carefully from infective swellings of all kinds gumma,\\nttcberculosis, actinomycosis, and chronic suppuration.\\nTenderness and pain, although present to a more or less marked\\ndegree in advanced carcinoma, are symptoms of greater prominence in\\ninflammatory affections. Non-professional men and women have an\\nexaggerated idea of pain as a symptom of carcinoma. They are im-\\npressed with the belief, handed down for ages, that carcinoma is an\\nexceedingly painful affection, and it is difficult to make them under-\\nstand that carcinoma may occur as a painless affection. Carcinomata\\nof the skin and mucous membranes are not attended by much pain.\\nPatients who have suffered perhaps for a year or more from carcinoma\\nof the rectum generally complain of but little pain, and seek medical\\nadvice for what they have regarded all along as piles. Carcinoma of\\nthe stomach is a comparatively painless affection, and the suffering\\ncaused by it is more from the mechanical obstruction than from the\\ncarcinoma per se. The temporary sharp, shooting, lightning pains so\\nfrequently described as a characteristic symptom of carcinoma are often\\nentirely absent and are always of an intermittent character. The writer\\nhas frequently opened the abdomen for acute intestinal obstruction, and\\nhas found carcinoma of the intestine without the patient s having known\\nthat there was anything seriously wrong before the symptoms of acute\\nobstruction set in.\\nTenderness, a symptom of the greatest diagnostic importance in\\ninflammatory affections, is usually entirely wanting in uncomplicated\\ncarcinoma. Dilatation of the superficial veins is the result of great\\nvascularity or of deep-seated venous obstruction, and is present as fre-\\nquently in infective swellings as in carcinoma. Redness is present in\\ncarcinoma when the tumor has reached and implicated the skin and\\nis on the verge of ulceration. It is only under similar circumstances\\nthat it is present in infective swellings. CEdema, so significant of the\\npresence of a deep-seated abscess, is present in carcinoma when the\\nregional infection interferes with the lymphatic or venous circulation", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0282.jp2"}, "275": {"fulltext": "CARCINOMA. 259\\nor when the tumor has become the seat of infection with pus-mi-\\ncrobes.\\nPrimary multiplicity of the tumor seldom occurs in carcinoma, but\\nis of frequent occurrence in the case of benign epiblastic, hypoblastic,\\nand mesoblastic tumors. Carcinoma as a multiple affection is occa-\\nsionally met with in the aged, when the disease originates by the trans-\\nformation of senile warts into carcinoma. Cases of primary multiple\\ncarcinoma have been reported by Liicke, Winiwarter, Klebs, Kaufmann,\\nBucher, Walter, and Schimmelbusch. Schimmelbusch explains primary\\nmultiplicity of carcinoma by a process of implantation of carcinoma\\ncells at a point opposite or some distance from the primary tumor, the\\nlatter furnishing the cells for the secondary tumor growth. Bucher\\nattributes the occurrence of multiple carcinoma in the same organ to a\\nmultiplicity of points of irritation. Another potent cause for the occur-\\nrence of multiple carcinoma in the same organ or in different parts of\\nthe body is the presence of the essential tumor matrix in tissues dis-\\nposed to tumor-formation, and subjected to the same influences which\\nact as exciting causes. Recently there came under the observation of\\nthe writer a case in which four carcinomata of the face developed\\nalmost simultaneously. One tumor occupied the malar region on the\\nleft side another, the lobe of the left ear a third was situated over\\nthe angle of the lower jaw and the fourth was a typical ulcerating\\ncarcinoma of the lower lip that had given rise to infection of the sub-\\nmental and submaxillary glands.\\nBenign tumors are always encapsulated, hence, unless bound down\\nby surrounding tissues, are movable and have well-defined margins.\\nCarcinoma is an infiltrating tumor, and has abrupt, well-defined mar-\\ngins. The infiltration gives rise to nodulation of its surface and to\\nimmobility of the tumor. A nodulated fixed tumor is in all probability\\na carcinoma. To test the mobility of the tumor it should be palpated\\ncarefully between the two index fingers to ascertain the points of fixa-\\ntion caused by the infiltration. An adenoma of the breast will slip\\nbetween the fingers, while a carcinoma of the same size will be more\\nor less fixed in its location by the peripheral parts of the tumor which\\nproject into the surrounding tissues.\\nHardness of the tumor is usually recognized as a sign of malig-\\nnancy. A fibro-adenoma could not be differentiated from a carcinoma\\nby this sign. A carcinoma with a scanty reticulum and extensive de-\\ngenerative changes is a soft tumor, resembling in this respect an\\nadenoma with cystic degeneration. The diagnostic importance of this\\nproperty of carcinoma has been overestimated greatly.\\nFluctuation, when too much relied upon, leads to frequent mistakes", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0283.jp2"}, "276": {"fulltext": "260 PATHOLOGY AND TREATMENT OF TUMORS.\\nin diagnosis and treatment. It is present in cystoma, cystic adenoma,\\nand inflammatory swellings with central softening, as well as in soft\\ncarcinoma with extensive regressive degeneration of the centre of the\\ntumor. Pseudo-fluctuation is often present in soft carcinoma without\\ncystic degeneration. This sign has often induced surgeons to puncture\\na malignant carcinoma under the belief that they were opening an\\nabscess. Such mistakes, in addition to being a source of mortifica-\\ntion to the surgeon, have always resulted disastrously to the patient\\nby transforming a subcutaneous into an open carcinoma, with all the\\nannoyances and dangers incident to such a change. A suspicious fluctu-\\nating swelling shotdd never be punctured or incised without having ex-\\ncluded the existence of a soft carcinoma, sarcoma, or gramdoma by the\\nuse of the exploratory syringe.\\nOne of the important steps in the diagnosis of a carcinoma is the\\nexamination of the lymphatic glands. In suspected carcinoma of the\\nlip, the submental and submaxillary glands in tumors of the mam-\\nmary gland, the glands of the axilla in ulcerative affections of the\\ncervix of the uterus, the sacral glands, should be examined carefully.\\nMany conclusions have frequently been drawn from the results of such\\nan examination. In tumors of the breast a diagnosis of their benign\\nnature has often been based upon the absence of palpable lymphatic\\nglands in the axilla. Some excellent modern authorities continue to\\nadvise, when no enlarged glands can be felt in the axilla, that this\\nregion should not be invaded in operations for carcinoma of the mam-\\nmary gland. This is teaching of a dangerous kind. The writer has\\nfrequently failed to find any evidences of regional infection by examina-\\ntion through the intact skin in cases of carcinoma of the breast, when\\nduring the operation, upon exposing the deep lymphatics of the axilla\\nby free incision, numerous glands the size of a marble were found. In\\nobese women it is impossible by external palpation to detect glands the size\\nof a pea or even that of a marble, and consequently such an examination\\ncannot be relied upon in determining the extent of the operation before-\\nhand. Carcinoma of the skin does not give rise to early regional infec-\\ntion, and yet when the disease has become quite extensive exposure\\nof the submental and submaxillary glands by a free incision frequently\\nreveals the presence of glands, as large as a pea, which could not be\\nfelt through the intact skin. Examination of the retroperitoneal lym-\\nphatic glands in suspected cases of carcinoma of the uterus should\\nnever be neglected. In carcinoma of the skin of the extremities the\\nglands in the different regions should be subjected to a scrutinizing\\nexamination. Enlarged glands under such circumstances have often\\nbeen overlooked, and such oversights have been responsible for many", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0284.jp2"}, "277": {"fulltext": "CARCINOMA. 261\\ndisappointing results. Enlargement of lymphatic glands in the region\\noccupied by the tumor, without ulceration of the surface and without\\ninvolvement of the glands in other regions, is almost positive proof of\\nthe carcinomatous nature of the tumor. Enlargemeiit of the lymphatic\\nglands in the region occupied by an ulcerating tumor may be the result\\nof infection of the lymphatic glands, in which case pathogenic microbes\\nhave entered the lymphatic channels through the surface defect. In lymph-\\nadenitis the glands are not so hard as in secondary carcinoma of the\\nlymphatic glands, and are more tender 011 pressure. In ulcerating car-\\ncinoma the lymphatic glands in the region occupied by the tumor may\\nbe the seat of both microbic infection and cell-metastasis, when the local\\nsigns and symptoms correspond with this double infection. If from\\nother evidences a diagnosis of ulcerating carcinoma can be made, the\\nlymphatic glands should be subjected to treatment as though their enlarge-\\nment lucre exclusively due to cellular infection. Universal lymphatic\\nhyperplasia is one of the most important indications of syphilitic infection,\\nand a tumor occurring in a person showing such a condition should be\\nexamined with the utmost care, to exclude the possibility of its being a\\ngumma.\\nThe greatest difficulties are encountered in the diagnosis of ulcer-\\nating tumors. It is in such cases that it is so important to ascertain\\nfrom the patient s statements the probable starting-point of the tumor.\\nEpithelial tumors, with few exceptions, start in the tissues derived from\\nthe epiblast or the hypoblast that is, in the skin, the mucous mem-\\nbrane, or the glandular tissue. If the tumor developed in the skin or\\nthe mucous membrane, it appeared first as a surface tumor, and could\\nbe moved only by moving the skin or the mucous membrane in which\\nit originated that is, it was in the beginning superficial and not covered\\nby skin or by mucous membrane. If it developed in an acinous gland,\\nit could be moved with the gland and was covered by skin or by\\nmucous membrane. All mesoblastic tumors start as subcutaneous or sub-\\nmucous tumors. Infective swellings seldom appear primarily as surface\\nlesions. If they occur as lesions of the skin or the mucous mem-\\nbrane, the incipient swellings appeared as nodules covered by skin or\\nby mucous membrane. If they originated in the connective tissue\\nmore distant from the skin, as is more frequently the case, the skin\\nor the mucous membrane became involved later as the infection\\nextended toward the surface.\\nThe lesions most frequently mistaken for ulcerating carcinoma\\nof the skin are tuberculosis, syphilis, actinomycosis, and chronic\\nulcers of the leg. The greatest diagnostic doubts arise in connection\\nwith ulcerating affections of the nose, face, lips, tongue, and cervix", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0285.jp2"}, "278": {"fulltext": "262\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nuteri. It will interest the student to know that primary syphilis of the\\nlip, tonsil, and vulva has repeatedly been mistaken for carcinoma. Such\\ninflammatory swellings have been excised, and a correct diagnosis was\\nonly made, if the physician was honest enough to admit his mistake,\\nafter the appearance of secondary symptoms. In chancre the swelling\\nappears rapidly upon the expiration of the usual period of incubation,\\nand gives rise to regional infection of the lymphatic glands soon\\nafter the appearance of the first symptoms of local infection. Gland-\\nular infection is unusually severe and extensive in chancre of the lip.\\nTuberculosis of the nose attacks in preference the alae, while syphilis\\nattacks most frequently the septum. Carcinoma starts most frequently\\nat the junction of the skin with the mucous membrane.\\nTubercular and syphilitic ulcers often heal wholly or in part spon-\\ntanously or under proper local and general treatment. Carcinomatous\\nulceration may remain stationaiy for a long time, but never heals, and\\nassumes sooner or later a progressive character. Syphilitic ulceration\\nis preceded by gummatous infiltration, and examination of the whole\\nbody will usually reveal the marks of antecedent syphilitic lesions or the\\nexistence of such in other parts of the body, and among them hyper-\\nplasia of the lymphatic glands in the different regions, notably the post-\\ncervical and cubital glands. With few exceptions carcinoma appears as\\nan isolated affection, while syphilitic and tubercular ulcers often occur\\nas a multiple lesion. Regional infection through the lymphatics is sel-\\ndom present in tuberculosis and syphilis, but is a frequent complication\\nin advanced cases of carcinoma of the\\nskin. Actinomycosis seldom presents\\nitself to the surgeon except as a swell-\\ning connected with the maxillary bones,\\nwhere it simulates sarcoma more closely\\nthan carcinoma. The discovery of\\nactinomyces by the aid of the micro-\\nscope, or the discovery of the fungus\\nby the naked eye in the secretions as\\nminute yellowish-gray particles, will\\nsettle the diagnosis. Sections taken\\nfrom the margins of the ulcer in carci-\\nnoma will reveal the characteristic typi-\\ncal structure of the tumor, while the\\ntissues from all infective swellings will\\nFig. 143.\u00e2\u0080\u0094 Carcinoma of the lower lip and\\nmultiple carcinoma of the face.\\nexhibit the typical structure of granu-\\nlomata. If the microscope is inadequate\\nto make a positive diagnosis, inoculation experiments will shed addi-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0286.jp2"}, "279": {"fulltext": "CARCINOMA.\\n263\\ntional light and dispel doubt. Implantation of carcinoma-tissue and\\nof tissue from a gumma in guinea-pigs and rabbits will yield a nega-\\ntive result, while inoculation with tubercular tissue will reproduce the\\ndisease in the animal.\\nThe diagnosis of carcinoma of internal organs must often be based\\nalmost exclusively upon the functional disturbances produced by the\\ntumor. A circular constricting carcinoma of the pyloric end of the\\nstomach often eludes detection by external examination during the\\nlifetime of the patient, but the symptoms produced by pyloric stenosis\\nin men more than thirty years old strongly suggest as the mechanical\\nobstruction a malignant tumor. Progressive intestinal stenosis in per-\\nsons advanced in years points in the same direction. In aged men\\nhematuria not caused by stone in the bladder indicates the probable\\nexistence of carcinoma of this organ. (Esophageal obstruction in per-\\nsons past middle life is in the great majority of cases caused by carci-\\nnoma. In the absence of urgent indications for prompt operative inter-\\nference the clinical history of the tumor should be followed carefully.\\n1\\n=r~\\n\u00c2\u00abwawBg rou i i ^j,i 111 i iwi i y 1\\nSSjdHB\\nmm\\nj\\nFig. 144. Fibro-adenoma of the breast, showing the epithelial cells lining the duct greatly increased\\nin number, but in their normal anatomical locations (Surgical Clinic, Rush Medical College, Chicago)\\na, massive stroma of fibrous tissue free from epithelial infiltration b, tubule cut longitudinally, lined by\\nseveral layers of epithelial cells.\\nThe rapidity of its growth and its extension to tissues irrespective of\\ntheir anatomical structure should be noted carefully, and the micro-\\nscope should be made use of as a diagnostic aid.\\nThe first indication of the malignant nature of an epithelial tumor\\nis cell-metastasis, upon which depends the local infection. In non-\\nmalignant epithelial tumors the normal relations between the epithelial", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0287.jp2"}, "280": {"fulltext": "264 PATHOLOGY AND TREATMENT OF TUMORS.\\ncells and the membrana propria are preserved. The epithelial cells\\nmay be increased greatly in number, the layers increased in number,\\nand the cells closely packed and irregularly arranged, but the mem-\\nbrana propria remains as an impermeable wall (Fig. 144).\\nThe most reliable evidence of the malignant nature of the tissues\\nshown on Plate 5 is the infiltration by epithelial cells of the adipose\\ntissue adjacent to the tumor. Normal adipose tissue does not con-\\ntain epithelial cells their presence in it could have occurred only by\\nmigration from a carcinomatous tumor in its vicinity. The presence of\\nyoung proliferating epitlielial cells in any of the mesoblastic tissues is an\\nunmistakable evidence of carcinoma. In making a diagnosis of carci-\\nnoma under the microscope we search for the presence of epithelial\\ncells in mesoblastic tissues, and when we find epithelial cells anywhere\\nin vascular connective tissue in a state of proliferation, the diagnosis of\\ncarcinoma can be made with certainty. The student must make him-\\nself perfectly familiar with the morphological appearance of the different\\nkinds of epithelial cells under different circumstances, so that he will be\\nable to distinguish them at a glance from other histological elements.\\nThe absence of epithelial cells in abnormal localities in a section from a\\nsuspicious tumor is no proof of the non-malignant nature of the tumor.\\nThe section may have been taken from a part of the tumor devoid of\\ncarcinomatous tissue. If the microscope is to be relied upon as a\\ndiagnostic resource in the examination of a tumor, the sections must\\nbe taken from parts of the tumor where the growth is most manifest.\\nCarcinoma grows by infiltration the specimen to be examined should\\ntherefore be taken from the base or the periphery of the tumor, near\\nits macroscopical boundary-line. If the first section under the micro-\\nscope presents negative evidence, sections from different parts of the\\ntumor must be examined in order to prove either its malignant or its\\nbenign character. In ulcerating surface carcinoma a fragment of tissue,\\nshould be clipped with scissors from the indurated margin. In papillary\\nexcrescences a papilla is removed and examined. In deep-seated\\ntumors Warren s harpoon is employed in obtaining the material for\\nmicroscopic examination. From fragments of tissue thus obtained\\nseveral sections are made and examined. The products of scraping or\\nteasing preparations should not be used for the purpose of making a\\ndiagnosis by the aid of tjie microscope.\\nPrognosis.\\nThe prognosis of carcinoma is greatly influenced by the histological\\nstructure and the location of the tumor. Squamous-celled carcinoma\\nis a much more chronic affection than cylindrical- and glandular-celled", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0288.jp2"}, "281": {"fulltext": "CARCINOMA.\\nPlate 5.\\nZW/J\\nTubular carcinoma of mamma (after Klebs) a, milk-duct with hyaline contents; r, proliferating gland-\\ntissue; c, group of acini, showing tissue-changes; d, adipose tissue with groups of epithelial cells near the\\ntumor-tissue the cells are not arranged in the form of acini. (Obj. 4l oc. 2.)", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0289.jp2"}, "282": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0290.jp2"}, "283": {"fulltext": "CARCINOMA. 265\\ncarcinoma. The location of a carcinoma influences the prognosis in\\ntwo ways: (1) If the carcinoma is located on an exposed part of the\\nsurface of the body, the patient is soon made aware of its existence\\nhis friends discover the tumor and remind him constantly of its presence,\\ninducing the patient to seek timely medical advice. A tumor thus\\nlocated is accessible to a radical operation. (2) In carcinoma of the\\ninternal organs the tumor, as a rule, is not discovered by the patient or\\nhis physician until extensive regional infection has made its complete\\nremoval impossible. A carcinoma of the breast is often only discovered\\naccidentally after the axillary glands have become extensively involved.\\nA patient suffering from carcinoma of the stomach is usually treated for\\nindigestion, dyspepsia, or catarrh of the stomach for weeks and months\\nuntil the clinical course has demonstrated the malignant nature of the\\naffection long after the disease has passed beyond the reach of a radical\\noperation. Examination of the stomach and the adjacent organs,\\nincluding the retroperitoneal lymphatic glands, in the writer s fifteen\\ncases of gastro-enterostomy revealed regional infection beyond the\\nlimits of a radical operation in all but one case, and in this case the\\npatient had been reduced to a skeleton by the pyloric obstruction\\ncaused by a constricting circular carcinoma.\\nWomen suffering from carcinoma of the uterus console themselves\\nfor months with the thought that they are undergoing the ailments\\nincident to the menopause before they seek medical advice and when\\nthis is finally done, in more than two-thirds of all the cases the disease\\nhas passed far beyond the limits of a successful radical operation. In\\nthe writer s practice less than 25 per cent, of the cases of carcinoma of\\nthe uterus were found within the justifiable limits of a radical operation.\\nThe prognosis in operable cases of carcinoma must therefore largely rest\\nupon the location of the tumor and the exteiit and accessibility of the\\nregional infection.\\nIf the carcinoma involves a part or an organ inaccessible to operative\\ninterference as the pancreas, for instance the disease will pursue its\\ntypical course uninfluenced by treatment, and in the course of a year\\nor two will result in the death of the patient. In carcinoma of the\\nkidney this disease has usually progressed beyond the reach of a suc-\\ncessful operation before its true nature is recognized. Such early\\noperations as Israel s, in which the tumor was not larger than a cherry,\\nwould of course promise a permanent result, but diagnosis at such an\\nearly stage is possible only in the hands of expert diagnosticians, and\\nwill always be considered as an evidence of special skill and training.\\nThe greatest progress in the treatment of carcinoma will hare been\\nmade when we are placed in possession of an infallible means of early", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0291.jp2"}, "284": {"fulltext": "266 PATHOLOGY AND TREATMENT OF TUMORS.\\ndiagnosis. The extent of the regional infection and the accessibility of\\nthe secondary tumors to operative treatment will also greatly modify\\nthe results to be expected from operative treatment. Even extensive\\nregional infection of the axilla in cases of carcinoma does not preclude\\nthe possibility of a radical cure. On the contrary, limited axillary\\ninfection with enlargement of the lymphatic glands in the supraclavic-\\nular region is an evidence that the disease has passed beyond the reach\\nof a successful operation. The appearance of a metastatic tumor or\\na miliary carcinosis seals the fate of the patient and furnishes a positive\\ncontraindication to local treatment with a view of removing the primary\\ntumor. The average duration of life in carcinoma permitted to follow\\nits own course is from two to three years. Death finally results from\\nmetastasis, septic infection, or exhaustion when the primary or any of\\nthe secondary tumors interfere with an important physiological func-\\ntion. Favorable indications, so far as the primary tumor is concerned,\\nare hardness, slow growth, and its location in an organ not essential to\\nthe maintenance of life. Unfavorable conditions are rapid growth and\\nsoftness of the tumor. The more a carcinoma resembles in its local\\nbehavior an inflammatory process, the greater is its malignancy and\\nthe greater the immediate danger to life. The writer has come to\\nregard rapid-growing secondary tumors of the lymphatic glands, re-\\nsembling in their physical properties and clinical aspects suppurative\\nlymphangitis, as a noli-me-tangere. From a prognostic standpoint,\\nimperfect removal of the primary tumor by caustics or by the use of\\nthe knife must be regarded as a measure calculated to aggravate the\\nlocal conditions and to shorten life. Carcinoma grows much more\\nrapidly, and terminates fatally sooner, in young than in old persons.\\nAs a rule, the malignancy of carcinoma is in an inverse ratio to the\\nage of the patient.\\nTreatment.\\nEvery modern writer on carcinoma insists upon the importance of\\nearly operative treatment. Carcinoma is no longer regarded as a con-\\nstitutional or blood disease. It has a benign stage, during which it\\nresembles benign epithelial tumors, and it is amenable to successful\\ntreatment by thorough removal. Every surgeon knows that complete\\nremoval by excision of a carcinoma of the lip during its early stages\\nis seldom followed by local or regional recurrence, and that the opera-\\ntion furnishes almost certain protection against general dissemination.\\nWhat is possible in these cases is wifhin the reach of successful surgery\\nin the case of cylindrical-celled and glandular carcinoma, provided the\\noperation is performed with the same thoroughness and under similar", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0292.jp2"}, "285": {"fulltext": "CARCINOMA. 267\\nfavorable conditions. In fact, the writer is of the opinion that the\\nremoval of the entire breast at a time when the disease is still local,\\nand the extirpation of the uterus at a time when the disease remains\\nlimited to the cervical canal, would yield as satisfactory results as\\ndoes early excision of carcinoma of the lip. The removal of an\\nentire organ for carcinoma at an early stage of the disease can hardly\\nfail in removing the zone of local infection. What surgery has to con-\\ntend with is late operation. The writer is an ardent advocate of all\\nlegitimate attempts to eradicate carcinoma by operation, but is satisfied\\nthat the furor operativus has been carried too far at the present time in\\nthis department of surgery as well as in nearly all others.\\nThe successful treatment of carcinoma requires a bold surgeon. A\\ngood and safe surgeon is guided by prudence and good judgment in\\nthe selection of his cases. Like a good general, he looks over the\\nwhole ground and estimates carefully the strength of his enemy before\\nmaking an attack. The surgeon is too apt to look only upon the\\ntumor, and to ignore the patient, when he decides upon the propriety\\nof an operation. A remunerative fee or the fear that the patient might\\nget into the hands of his competitors often deadens his sense of\\nmoral obligation toward his patient when he renders his final judgment\\nconcerning the propriety of an operation. For the welfare of the pa-\\ntient, the reputation of the surgeon, and the honor and good standing\\nof the profession it is just as important to look for contraindications to,\\nas for indications for, a radical operation. That the treatment of carci-\\nnoma has been marred by many sins of omission and of commission in\\nthe hands of competent surgeons goes without saying. The tempta-\\ntions to carry operative procedures to their maximum limits, and beyond,\\nare greater in the treatment of carcinoma than in any other department\\nof surgery. We find patients suffering from incipient carcinoma often\\naverse to the use of the knife, but willing to lose their lives on the\\noperating-table in attempts to secure relief when the disease has passed\\nfar beyond the limits of successful surgery. It requires moral courage\\nto refuse an operation when such a patient begs his surgeon to perform\\nit and is willing to shoulder all risks and responsibilities. The surgeon\\nhas no moral right to become a legitimate executioner under any circum-\\nstances.\\nA radical operation is contraindicated by 1. Extreme senile maras-\\nmus 2. Extensive local infection 3. Regional infection beyond the\\nreach of complete removal of all the infected tissues 4. General infec-\\ntion 5. The coexistence of another disease which in itself will prove\\nfatal in a short time.\\nIt is difficult to set a limit by age to the operative treatment of car-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0293.jp2"}, "286": {"fulltext": "268 PATHOLOGY AND TREATMENT OF TUMORS.\\ncinoma. The writer has removed successfully from the temporal region,\\nin a lady eighty-five years of age, under partial anesthesia, a fungous\\ncarcinoma the size of a large orange. The large wound granulated in\\nthe course of two weeks, and healed by the aid of Thiersch s skin-grafts\\nfour weeks after the operation. The writer has seen patients not more\\nthan fifty years of age so marantic from senile degenerations that the\\nsmallest wound would probably have failed to heal. In persons past\\nseventy years of age suffering from a slowly-growing carcinoma in a\\nlocality requiring a formidable operation it requires good judgment to\\ndecide whether an operation will benefit the patient or whether it will\\nshorten life. It is in such cases that the extent of the operation must\\nbe planned carefully and the patient s strength be estimated before an\\noperation is advised. If the local infection has extended so far that\\nthere is no prospect of healing the wound by plastic operations or by\\nskin-grafting after the removal of the primary tumor, the patient s\\ninterests demand conservative treatment. Usually in such cases the\\ntumor has so far infiltrated the deep tissues that a complete removal\\nof all the infected tissues is impossible, and the wound-surface soon\\nbecomes the seat of a diffuse local return attended by conditions much\\nmore annoying and disagreeable to the patient than the primary\\ntumor. It is the regional infection that renders the results of opera-\\ntions so problematical in the treatment of carcinoma. Every honest\\nsurgeon must confess that the permanent results of operations per-\\nformed after regional infection had occurred are few and far apart. The\\ndisease may not return for one, two, or three years, but return it will, in\\nthe great majority of cases, sooner or later. The writer has seen local\\nrecurrence five and seven years after operation. The time set usually\\nthree years is therefore not reliable in drawing conclusions as to the\\npermanency of the result after operations for carcinoma. Permanent\\nresults will follow the operative treatment of carcinoma if the operation is\\nperformed before regional infection lias occurred on the contrary, non-\\nrecurrence zvill be the exception, and recurrence the ride, if the primary\\ntumor is not reinoved until regional infection lias set in. If the regional\\ninfection is extensive, or if it occupies a locality not accessible to thor-\\nough removal of all infected tissues, the patient will be more comfort-\\nable, and will live longer, if no radical operation is performed. The\\nwriter regards the presence of carcinomatous glands in the supraclavic-\\nular space in carcinoma of the breast, and extensive infiltration of the\\nsacral glands in carcinoma of the uterus, as contraindications to a\\nradical operation. The existence of a metastatic tumor or of diffuse\\nmiliary carcinosis is, of course, an absolute contraindication to an\\nattempt to remove the primary tumor. The existence of a carcinoma", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0294.jp2"}, "287": {"fulltext": "CARCINOMA. 269\\nin an unusual locality should induce the surgeon to make a critical ex-\\namination for the purpose of detecting the primary tumor, as when the\\nmother-tumor can be located operative procedure is out of the question,\\nas the metastatic origin of the tumor first discovered has then been\\ndemonstrated. If a carcinomatous patient is suffering at the same time\\nfrom an otherwise fatal disease, such as pulmonary tuberculosis, Bright s\\ndisease, diabetes, cerebral softening, locomotor ataxia, etc., it is wisdom\\non the part of the surgeon to withhold the use of the knife and to limit\\nhis efforts to palliation. Unfortunately, it is seldom that the surgeon\\nhas the opportunity to give the patient his advice in time. In the great\\nmajority of cases he has to deal with carcinoma after regional infection\\nhas set in, and in cases in which the disease has advanced too far for a\\nsuccessful radical operation he must content himself with resort to\\npalliative measures.\\nPalliative Operations. In inoperable subcutaneous carcinoma it\\nshould be the aim of the surgeon to preserve the cutaneous surface\\nover the tumor intact so long as possible, as the misery which attends\\nthis condition is much less than in open carcinoma, and life is prolonged\\nby the avoidance of septic infection. The surface of the tumor should\\nbe kept covered by aseptic absorbent cotton held in place by a circular\\nbandage or by strips of adhesive plaster. If the skin becomes red and\\nits perforation by the tumor-mass is threatened, the complication should\\nbe anticipated by a timely resort to antiseptic precautions, so that when\\nan ulcer forms infection with pathogenic microbes will be prevented.\\nThe surface of the tumor should be disinfected in the same manner as\\nin making preparations for an operation, after which it is covered by\\na few layers of iodoform gauze, over which is applied a thick compress\\nof sterilized gauze, and the whole is covered by a filter of absorbent\\ncotton. After the skin has given way the dressing is changed as often\\nas necessary, and at each change the surface of the ulcer is washed\\nwith an antiseptic solution. Should the dry dressing prove a source\\nof discomfort to the patient, it is replaced by a thick gauze compress\\nwrung out of a saturated solution of acetate of aluminum and kept\\ncovered by an impermeable fabric like oiled silk, thin rubber sheeting,\\nor mackintosh cloth. Attempts have been made, by covering large\\ncarcinomatous ulcers by skin-grafting, to render the condition of the\\npatient more endurable by transforming the open ulcerating tumor into\\na subcutaneous lesion. These attempts have proved successful in some\\ninstances, but it is doubtful if the gain of such short duration will over-\\nbalance the pain and inconvenience caused by the scraping and the\\ntransplantation of Thiersch s skin-grafts. If the carcinomatous ulcer\\nhas become infected with pyogenic and putrefactive microbes, the sur-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0295.jp2"}, "288": {"fulltext": "270 PATHOLOGY AND TREATMENT OF TUMORS.\\ngeon has to contend with an additional evil. It is an exceedingly diffi-\\ncult task to render such a surface aseptic by chemical disinfectants.\\nThe surface is so irregular, and there are so many inaccessible nooks\\nand corners which the solutions and powders cannot reach, that com-\\nplete disinfection with chemical agents is usually not attained. The\\nremedies which have proved most efficient in correcting the odor in\\nsuch cases are Labarraque s solution of chlorinated soda, chlorine-\\nwater, aqueous solution of iodine and bromine, and iodoform in powder\\nor mixed with boric acid (1 5). The strength of the solutions should\\nnot be such as to produce pain. If these milder measures do not\\nsucceed, a strong solution of chloride of zinc (25 per cent.) should be\\ntried.\\nOf the modern deodorants in the treatment of open inoperable\\ncases of carcinoma aristol deserves special mention. If an ointment\\ndressing is indicated, aristol, with vaselin of suitable strength, is among\\nthe best (gr. xx to 3ij to \u00c2\u00a7j). This or any other ointment will be more\\ngrateful to the patient if spread upon a thick layer of absorbent cotton,\\ninstead of lint or gauze. In carcinoma of the uterus, a deodorizing\\nlotion is of the first importance, and one containing eucalyptus is pre-\\nferable to a plain antiseptic solution. The vagina may also be loosely\\npacked with cotton tampons, saturated with a mixture of aristol in\\nalbolin, 5 per cent. A pad of finely picked oakum should be placed\\nover the vulva, as this material is hygroscopic and a good deodorant.\\nTemporary benefit is always derived from a vigorous use of Volk-\\nmann s sharp spoon. The necrosed tissue attached to the ulcerated\\nsurface is the soil in which the putrefactive bacilli live and multiply\\ntheir removal with the sharp spoon, including in the curettage also the\\nfungous, bleeding; masses, removes the culture-medium of the microbes\\nwhich have caused the putrefaction, and will accomplish more than the\\nuse of chemical agents in rendering the ulcer aseptic. The scraping\\noperation should be followed by the use of the actual cautery. The\\nvigorous use of the flat point of the Pacquelin cautery will accomplish\\na great deal in this direction without the use of the sharp spoon.\\nScraping and cauterization have proved of great value in mitigating\\nthe distress in inoperable cases of carcinoma of the uterus, the breast,\\nand the mouth.\\nThe removal of a carcinomatous breast as a palliative measure is\\noccasionally indicated when enough skin can be preserved to cover\\nthe wound, and in this manner transform an open into a subcutaneous\\ncarcinoma. The ligation of* the principal artery to a part the seat of\\ncarcinoma is indicated only when hemorrhage is threatened or has\\nactually occurred and cannot be controlled by more conservative", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0296.jp2"}, "289": {"fulltext": "CARCINOMA. 271\\nmeasures. In inoperable carcinoma of the uterus antiseptic vaginal\\ninjections should be employed at least once or twice a day. In carci-\\nnoma of the mouth an antiseptic gargle or spray is indicated. Trache-\\notomy in inoperable cases of carcinoma of the larynx, and colostomy\\nin the same condition of the rectum, are exceedingly useful and grate-\\nful palliative operations. Gastrostomy in impermeable carcinomatous\\nstricture of the oesophagus, gastro-enterostomy in pyloric carcinoma,\\nand suprapubic cystotomy in advanced cases of carcinoma of the\\nprostate gland, afford great relief and should always be suggested in\\nappropriate cases.\\nRadical Operations. Operations which are intended to remove\\nall. the infected tissues, local and regional, are called radical opera-\\ntions. A radical operation is indicated in all cases in which general\\ninfection has not occurred, and the primary and original tumors are of\\nsuch size and extent and are so located as to enable their complete removal\\nby an operation not immediately endangering the life of the patient, and\\nleaving a wound which can be closed by suturing or which can be healed\\nby a plastic operation or by skin-grafting, and the patienfs strength is\\nsuch as to warrant the operation.\\nIf a radical operation is undertaken, it should be radical. The\\nsurgeon must not forget that carcinoma extends in the vicinity of the\\ntumor along pre-existing connective-tissue spaces, and that conse-\\nquently the zone of infiltration can be removed only by including with\\nthe primary tumor a wide strip of apparently healthy tissue on all sides.\\nThe incisions should be carried from four lines to an inch away from\\nthe macroscopical boundary-line of the tumor, according to the charac-\\nter of the tumor, its size, and its environment not only on one or two\\nbut on all sides. If the tumor is near the surface, the overlying skin\\nshould be removed. A zone of apparently healthy tissue at the base of\\nthe tumor as well as on the sides should be included in the excision.\\nNo blunt force should be used in the removal of the primary tumor\\nits removal must be effected by a clean dissection. Pressure and tear-\\ning are liable to give rise to traumatic dissemination. Grasping the\\ntumor with vulsellum forceps is attended by the same danger. If vul-\\nsellum forceps are necessary to bring the tumor near the surface, the\\ninstrument should be so applied as not to penetrate the tumor. If the\\ntumor is located in a part of the body from which the circulation can\\ntemporarily be excluded by elastic constriction, this should be made\\nuse of, as the bloodless procedure enables the surgeon to identify the\\ntissues more accurately, and aspiration of tumor-cells or of fragments\\nof tumor-tissue into the open lumen of cut veins is less likely to occur.\\nIf temporary hemostasis is inapplicable owing to the location of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0297.jp2"}, "290": {"fulltext": "272 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor, the hemorrhage should be arrested as the operation pro-\\nceeds, for if this precaution is not practised projecting parts of the\\ntumor may be overlooked and not again be found after the tumor has\\nbeen removed. The external incision must be made at a point which\\naffords easy access to the tumor, and in a direction parallel with important\\nmuscles, nerves, and vessels. The external incision must be large enough\\nto expose freely the entire periphery of the tumor to sight as well as to\\ntouch, and if this cannot be done safely by one straight or curved incision,\\nit is joined at suitable points by cross cuts. The margins of the wound\\nduring the operation must be kept out of the way by retractors. The\\ntumor and the surrounding zone of infiltrated suspicious tissue should be\\nremoved in one mass. The removal of projecting portions after the\\nremoval of the tumor is bad practice and should be avoided.\\nThe dissection must be made through healthy tissue outside the\\nzone of infiltration from the beginning to the end of the operation.\\nThe employment of the dilute nitric-acid test, as suggested by Stiles,\\nto ascertain during an operation whether or not all the diseased tissues\\nhave been removed, is not reliable and is of no use to the careful\\ndissector. If the tumor after its removal is immersed in the 5 per\\ncent, nitric-acid solution, the boiled-egg appearance upon some parts\\nof the tumor will show that fragments of considerable size have been\\nleft behind, but it will fail in demonstrating that cellular remnants of\\nthe tumor have not been removed. In small carcinomata of the lip or\\nof the skin presenting no evidences of glandular infection it is sufficient\\nto excise with the tumor a zone of apparently healthy tissue in order\\nto remove the peripheral invisible part of the tumor. In operating\\nupon the lip it is not advisable to plan the details of a subsequent\\nplastic operation, as there is great danger that the surgeon will be\\nguided in the excision of the carcinoma by the plans of the restorative\\npart of the operation. The prime indication of the operation slwidd be\\nto remove all the diseased tissues, regardless of the cosmetic residt. After\\nthe carcinoma has been removed the surgeon sutures the wound in\\nsuch a manner as to secure the best possible cosmetic results, or he\\nresorts at once to a plastic operation.\\nIn the removal of all carcinomatous tumors the incision or in-\\ncisions should be made in the direction of the lymphatics, because it is\\nin this direction that the local infection becomes regional. In gland-\\nular carcinoma the entire gland should be removed if the gland so\\naffected does not perform a function essential to the maintenance of\\nhealth and life. Partial removal of the breast or the parotid or sub-\\nmaxillary gland for carcinoma cannot be condemned too strongly.\\nIf any doubt exists in regard to the presence of regional infection,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0298.jp2"}, "291": {"fulltext": "CARCINOMA. 273\\nthe lymphatic glands through which regional infection would occur\\nshould be exposed by an incision, and if any of the glands are found\\nenlarged, the entire chain of glands should be removed in one uninter-\\nrupted piece with the primary tumor. In carcinoma of the breast the\\naxillary region from the margin of the gland to the apex should be\\ncleared of lymphatic glands and connective and adipose tissue, regardless\\nof the condition of the glands. Typical cleaning out of the axillary\\nspace is urgently indicated in all cases of carcinoma of the breast\\nThe whole chain of glands, with the surrounding connective and adi-\\npose tissue, must be removed by a clean dissection. The same plan\\nshould be pursued in the removal of the external genitals with infection\\nof the inguinal gland.\\nEnucleation of carcinomatous glands is invariably followed by recur-\\nrence. Rupture of glands by pressure or traction is apt to be followed\\nby traumatic dissemination. The primary tumor and regional tumors\\nand healthy glands, with the tissues surrounding them, should be\\nremoved in one uninterrupted piece this will ensure the removal of\\nthe connecting lymphatic channels which are so often the seat of\\nregional infection. The wound after the removal of a carcinoma should\\nbe covered at once by integument if this cannot be done by the use\\nof sutures, the surface should be covered by a plastic operation or by\\nskin-grafting. Healing of the entire wound by primary intention should\\ninvariably be aimed at in the removal of a carcinoma by excision.\\nThe use of caustics in the radical treatment of carcinoma has a limited\\nfield of usefulness. Caustics should be used only when patients object\\nto the use of the knife, and their use should be restricted to small car-\\ncinomata of the skin. Chloride of zinc should be given the preference\\nover arsenic or the mineral acids. The treatment by caustics is more\\npainful than excision under local or general anesthesia, requires more\\ntime, and the cosmetic result is less satisfactory.\\nTopography.\\nThe study of the topographical distribution of carcinoma is an in-\\nteresting one, as it tends to show that carcinoma is most frequently\\nfound in localities in which the most active and complicated tissue-\\nchanges take place in the embryo, and in situations most exposed to\\ninjuries, irritations, and other post-natal influences which result in\\ndiminution of the physiological resistance of the tissues. We also find\\nit frequently in localities the favorite seat of benign epithelial tumors.\\nThe influence of age, sex, and occupation in determining the origin of\\ncarcinoma in certain parts and organs of the body has repeatedly been\\nreferred to.\\n18", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0299.jp2"}, "292": {"fulltext": "274\\nPATHOLOGY AND TREATMENT OF TUMORS.\\n*vr\\nvSR?\\nFig. 145. Carcinoma of the sweat-glands, showing the tubular arrangement of the tumor parenchyma (after\\nFordyce).\\nfsJLi b\\nFig. 146.\u00e2\u0080\u0094 Carcinoma of skin of nates; X no, reduced one-third (Surgical Clinic, Rush Medical Col-\\nlege, Chicago) a, hypertrophied stratum corneum b, growth of epithelial cells into subcutaneous tissue;\\nc, epithelial nest in vascular connective tissue.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0300.jp2"}, "293": {"fulltext": "CARCINOMA. 275\\nSkin. Squamous-celled carcinoma occurs most frequently upon\\nthe lower lip, the eyelids, the labia, and the glans penis it is also fre-\\nquent in the mouth, the oesophagus, the vagina, and about the cervix\\nuteri. When the growth takes its starting-point in the sudoriparous\\nor sebaceous glands, the cells of the carcinoma are cuboidal in shape\\nand the growth presents a tubular structure (Fig. 145). The latter\\nvariety is most frequent on the nose and the eyelids, and is least\\nmalignant.\\nHistological Structure. The manner of growth and the forms of epi-\\nthelial tissue are varied, and the changes to which a carcinoma is subject\\nare manifold. The stroma supplies the vascular part of the papillary\\nexcrescences, yields to the penetrating epithelial cells, surrounds the\\nepithelial nests with a network of vessels, and finally becomes the seat\\nFig. 147.\u00e2\u0080\u0094 Vertical section througn carcinoma of the skin X 50 (Surgical Clinic, Rush Medical College,\\nChicago) a, subcutaneous connective tissue and stroma of tumor; b, proliferation of epithelial cells into the\\nconnective tissue c, sebaceous gland in a state of active tissue-proliferation d, normal tissue not yet affected\\nby the carcinoma.\\nof ulcerative destruction. The equilibrium between the hyperplastic\\nmasses of epithelial cells and the underlying vascular connective tissue\\nis destroyed with the beginning carcinomatous process. Conditions", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0301.jp2"}, "294": {"fulltext": "276\\nPATHOLOGY AND TREATMENT OF TUMORS.\\napparently leading to embryonal development of papillary and follicular\\nstructures appear to be arrested, and a functionally useless, planless\\ngrowth supervenes. Generally the preponderant growth of epithelium\\ninitiates the change this, however, is to be found not so much on the\\npart of the proliferating epithelial cells as in a lessened resistance of the\\nadjacent tissues. The first evidence of the appearance of epithelial\\ncells in the vascular connective tissue underlying the epithelial layer\\nof the skin announces the transition of the benign into the malignant\\nstage of carcinoma (Fig. 146). Vertical section through a carcinoma\\nof the skin in its earliest stages shows thickening of the layer of\\nepithelial cells between the epidermis and the membrana propria\\n(Fig. 146, b). As soon as the epithelial cells have reached the con-\\nnective tissue they form nests. The glands of the skin in the area\\nof carcinomatous infiltration assume more active tissue-proliferation,\\nwhich results in increased secretion (Fig. 147). The stroma in the non-\\nFig. 148. Carcinoma of the skin, showing alveolated structure of the stroma and numerous epithelial\\nnests; X 150 (Surgical Clinic, Rush Medical College, Chicago) a, stroma; b, epithelial infiltration of con-\\nnective tissue c, c, epithelial nests.\\nulcerating part of the tumor increases in quantity by proliferation of\\nthe pre-existing cells caused by the presence of the numerous epithelial\\ncells, which to them are foreign bodies. The alveoli of the stroma are", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0302.jp2"}, "295": {"fulltext": "CARCINOMA.\\n277\\nFig. 149. Vertical section through carcinoma of the skin, showing hair-follicle and epithelial nests;\\nX 300 (Surgical Clinic, Rush Medical College, Chicago) a, hair-follicle containing a hair b, epithelial infil-\\ntration c, stroma; d, large epithelial nest; e, e, beginning formation of epithelial nests.\\njlands X iS (after Thiersch)\\nd, convoluted sweat-gland with\\nFig. 150.\u00e2\u0080\u0094 Carcinoma of the skin starting from epithelial cells of sweat\\na, epidermis b, cutis; c, normal lanugo-hairs with their sebaceous glands;\\ndistinct lumen e, branched and anastomosing proliferation of gland lumen can be seen only in part\\nbranched proliferation with terminal and lateral knob-shaped cellular projections g, round masses of cells,\\nseparate or in several groups, which lie loose in spaces of the connective tissue, and which appear either as\\nterminal knobs or as transverse sections of cellular strings.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0303.jp2"}, "296": {"fulltext": "278 PATHOLOGY AND TREATMENT OF TUMORS.\\npacked with epithelial cells (Fig. 148). The progressive infiltration of\\nthe skin from the surface is well shown in Figure 149.\\nThiersch has repeatedly traced the origin of carcinoma of the skin\\nto sudoriparous glands. Carcinomata of such an origin present under\\nthe microscope a tubular structure resembling cylindrical-celled carci-\\nnoma of the mucous membrane (Fig. 150).\\nIn superficial ulceration of a carcinoma of the skin the papillary\\nstructure of the skin remains, and the surface presents the appearance\\nof an ordinary ulcer (Fig. 151). As soon as a surface carcinoma be-\\ncomes the seat of microbic infection the connective-tissue stroma takes\\nan active part in the suppurative process, as elsewhere. Destruction\\nof the stroma by suppuration liberates the contents of the more super-\\nficial cell-nests, the contents being discharged with the inflammatory\\nproduct. The progressive destruction of the stroma results in the\\nd\\n\u00e2\u0080\u0094g _\\nFig. 151. Deep carcinoma of the skin of the heel vertical section; X 16 (after Thiersch) a, papillse-\\nof surface of ulcer; b, their epidermal covering c, vascular stroma; d, inner surface of a parenchymatous\\ncavity studded with papillae; e, epidermal covering of papillae; _/, masses of cells in concentric layers in the\\ninterpapillary spaces g, the same, belonging to the free epithelial masses.\\nincrease in size and depth of the carcinomatous ulcer. In ulcus rodens,.\\nonly one of the many varieties of carcinoma of the skin, the stroma is", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0304.jp2"}, "297": {"fulltext": "CARCINOMA. 279\\nvery scanty; hence progressive increase in the size of the ulcer and\\nslight induration of its base and margins are conspicuous pathological\\nfeatures.\\nRegional Infection. Regional infection, usually a late occurrence in\\ncarcinoma of the skin, does not depend upon the size of the tumor or\\nulcer. The writer has seen glandular infection in connection with a\\ncarcinoma of the lip not larger than a pea, and has seen it absent in\\n7\\nFig. 152.\u00e2\u0080\u0094 Carcinoma of the sole of the foot. The regional infection involved both the deep and superficial\\nlymphatic glands of the leg and the anterior aspect of the thigh.\\ncases in which almost the entire lower lip was destroyed by the carci-\\nnoma. The occurrence of glandular infection appears to be influenced\\nmore by the diminished loss of resistance of the connective tissue than\\nby the proliferation of epithelial cells. Of all the surface carcinomata\\naffecting the skin, carcinoma of the lip is followed more constantly\\nby regional infection than carcinoma of any other part of the body.\\nThe submental glands are usually first involved, later the submaxillary,\\nand finally the cervical glands. The writer has seen the most malig-\\nnant form of regional infection develop several years after the removal\\nof a small carcinoma of the lip by using caustics or by employing the\\nknife.\\nFor some reasons which remain unexplained, the upper lip is very\\nseldom the seat of carcinoma, and in the few cases which have come\\nunder the observation of the writer there was no glandular infection.\\nIt has already been explained that the late glandular infection in carci-\\nnoma of the skin is attributable to the location of the tumor, and not\\nto its lesser degree of malignancy than glandular carcinoma. A carci-\\nnoma surrounded on all sides by tissues has an extensive area of infil-\\ntration, while in surface carcinoma infiltration is limited to one direction.\\nIn the former instance the tumor is subjected to pressure which must", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0305.jp2"}, "298": {"fulltext": "28o PATHOLOGY AND TREATMENT OF TUMORS.\\nfavor lymphatic infection, while in surface carcinoma this cause of dis-\\nsemination of the tumor-elements is entirely wanting. The probable\\nexistence of regional infection must not be lost sight of in the operative\\ntreatment of surface carcinoma.\\nDegeneration of Tumor-tissue. Fatty degeneration of the contents\\nof the alveoli is the most frequent form of degeneration of carcinoma\\nof the skin. In the older parts of the tumor the alveoli contain only\\nthe product of this form of degeneration, all the epithelial cells having\\nundergone this change. In chronic cases calcification often follows\\nfatty degeneration. Colloid and myxomatous degeneration, such con-\\nstant regressive metamorphoses in glandular and cylindrical-celled car-\\ncinoma, occur less frequently, and never reach the same degree. Early\\nulceration is the most characteristic feature of carcinoma of the skin.\\nThe ulcer forms over the centre of the tumor, and spreads more or\\nless rapidly in the direction of the base of the tumor and toward its\\nperiphery. As soon as the tumor-tissue is exposed the connective\\ntissue takes an active part in the ulcerative process. If the resistance\\nof the connective tissue is not much reduced, granulations spring up\\nfrom the stroma, the base of the tumor as well as the margins of the\\nulcer become infiltrated with inflammatory product, and for a time it\\nmay seem that the inflammatory process has exerted an inhibitory\\ninfluence on the local extension of the tumor. The inflammatory\\nmaterial, however, serves only a temporary purpose in retarding the\\nextension of the tumor the connective tissue and the exudation suc-\\ncumb to the combined effects of tumor-growth and microbic infection,\\nand the disease resumes its progressive tendencies.\\nLip. Clinical Course. Carcinoma of the lip usually commences at\\nthe junction of the mucous membrane with the skin. It seldom starts\\nfrom the angles of the mouth and the upper lip. In a case of carcinoma\\nof the upper lip that recently came under the observation of the writer\\nthe tumor appeared some distance from the margin of the upper lip\\n(PL 6, Fig. 2). The patient was a man forty-five years of age. The\\ntumor was noticed five years ago, when it was not larger than a millet-\\nseed and appeared to be imbedded in the skin a year later the tumor\\ncommenced to increase in size, an ulcer formed on its surface, and the\\nbase became very much indurated. The base of the tumor was of the\\ndensity of cartilage its surface was covered by fungous granulations.\\nThe margins of the ulcer were covered by the overlying undermined\\nskin.\\nCarcinoma of the lower lip is common in men, but very rare in\\nwomen. Konig estimates that the proportion of males to females is\\n20:1. Lortet s statistics show the proportion to be 7.6 I. Warren", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0306.jp2"}, "299": {"fulltext": "CARCINOMA. 28l\\nobserved 4 cases in women out of 73 cases, and states that 3 of the\\nwomen were smokers. In 145 patients suffering from carcinoma Koch\\n(Erlangen) attributed the affection in 15 to an injury. The tumor-\\nformation is frequently preceded by a crack or a fissure or an eczema-\\ntous condition of the margin of the lip. At a very early stage the\\ncentre of the indurated area ulcerates, and from the ulcerated surface\\nthe atheromatous contents of the exposed epithelial nests can be\\nsqueezed out. By extension of the ulcer the lower lip is destroyed\\n(PI. 6, Fig. 1), when the cheek, the chin, the lower maxilla, and the\\nfloor of the mouth are successively involved. The submental and sub-\\nmaxillary glands, which now have become enlarged, are often firmly\\nattached to the lower jaw, simulating primary malignant disease of the\\nperiosteum or the bone. With few exceptions the disease, if allowed\\nFig. i 53.\u00e2\u0080\u0094 Secondary carcinoma of the submental and submaxillary lymphatic glands, following carcinoma\\nof the lip.\\nto pursue its course, terminates fatally within from three to five years.\\nDeath results from marasmus, from sepsis, or from general dissemina-\\ntion of the disease.\\nDiagnosis. The superficial diffuse form of carcinoma of the lip is\\nfrequently mistaken for eczema. The deeper layers of the skin are\\nexposed, presenting a papillomatous appearance. The raw surface is\\nconstantly moistened by a serous transudation. Careful palpation will,\\nhowever, detect in the skin and the mucous membrane an induration\\nwhich is absent in eczema of the lip. Chancre of the lip develops\\nrapidly and is attended at an early stage by diffuse glandular infection.\\nSecondary syphilitic lesions of the lip start usually in the mucous", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0307.jp2"}, "300": {"fulltext": "282 PATHOLOGY AND TREATMENT OF TUMORS.\\nmembrane of the mouth, and reach the lip by extension. Papilloma\\nof the lip appears as a permanent tumor, and its base lacks induration.\\nPrimary tuberculosis of the lip is an exceedingly rare affection it\\noccurs almost from the beginning as a more diffuse affection than\\ncarcinoma, and it lacks the induration so characteristic of carcinoma.\\nCarcinoma of the lip appears as an ulcerating tumor with indurated base\\nand margins, which tumor ultimately gives rise to regional and general\\ninfection. If any doubt remains as to the nature of the tumor, a frag-\\nment of tissue should be taken from the base or margin of the ulcer,\\nfrom which sections should be made for microscopic examination.\\nPace. Carcinoma of the skin in other localities usually pursues\\na course similar to that of carcinoma of the lip. The face is the\\nmost frequent seat of carcinoma of the skin. O. Weber found in\\n740 cases of tumors of all kinds subjected to operative treatment\\n133 cases of carcinoma of the face. The ages of the patients vary\\nfrom forty to eighty. According to Thiersch, carcinoma of the skin\\nappears either as a superficial ulceration {ulcus rodens) or it penetrates\\nthe tissues deeply and involves the different structures successively.\\nIf the carcinoma starts from the appendages of the skin, the colum-\\nnar epithelial cells are arranged in groups resembling tubules if it is\\ncomposed of squamous cells, it appears from the beginning as an in-\\nfiltration with small epithelial cells, which before ulceration occurs\\nfill the alveoli of the stroma. Like carcinoma of the lip, carcinoma\\nof the skin begins as a minute surface defect with a limited area\\nof induration at its base. From this point the ulceration spreads un-\\nequally in different directions, so that the ulcerated surface presents\\nirregular outlines. In the superficial form of carcinoma peripheral\\nextension takes place rapidly, but the destructive process is limited to the\\nskin. In the penetrating or deep variety the ulceration extends at the\\nsame time in the direction of the base of the ulcer, involving succes-\\nsively different tissues irrespective of their anatomical character. In this\\nvariety the ulceration is generally preceded by a deep infiltration of the\\nskin and the subcutaneous connective tissue. So long as the papillae\\nof the skin remain, the surface of the ulcer presents a papillary appear-\\nance. When the papillse are destroyed, the epithelial nests are exposed,\\ntheir contents escape with the inflammatory product, and the surface\\nof the ulcer assumes a honeycomb appearance. The prognosis of this\\nvariety of carcinoma of the skin is more unfavorable than that of the\\nsuperficial variety. The ulceration spreads very rapidly, and results in\\nvery extensive destruction of tissue in a remarkably short time. Lym-\\nphatic infection occurs frequently at quite an early stage, and occa-\\nsionally death results from metastatic tumors. Carcinoma of the face", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0308.jp2"}, "301": {"fulltext": "CARCINOMA. 283\\nattacks most frequently the eyelids, the nose, and the malar and frontal\\nregions. Carcinoma of the eyelids, if not removed in time, extends to\\nthe eyeball and the other contents of the orbit, causing not only loss\\nof the eye, but also producing a frightful disfigurement.\\nDiagnosis. Carcinoma of the face must be distinguished from tu-\\nberculosis, syphilis, suppurating benign growths, and retention-cysts.\\nTuberculosis of the face, the so-called lupus, often appears as a\\nmultiple affection. The same can be said of tertiary syphilitic lesions.\\nMultiple carcinomatous tumors are exceptional, and they almost always\\noriginate from the transformation of senile warts into carcinomata.\\nTubercular ulcers often heal, in part or completely, spontaneously or\\nunder appropriate local treatment something never observed in carci-\\nnoma. The base of the tubercular ulcer presents to the palpating\\nfinger a doughy, cedematous sensation the base and margins of the\\ncarcinomatous ulcer are firm and indurated. Careful examination of\\npatients suffering from tertiary syphilitic affections of the skin usually\\nreveals additional syphilitic lesions in other parts of the body, or traces\\nof former affections that have healed. If any doubt remains, the\\npatient should be given the benefit of the doubt by subjecting him to\\nantisyphilitic treatment for a number of weeks. The differential diag-\\nnosis between carcinoma and tubercular affections of the skin may\\nrequire the use of the microscope and a resort to inoculation experi-\\nments. The former will reveal the typical structure of the existing\\naffection, and the latter will yield positive results if the lesion is tuber-\\ncular, and negative if it is a carcinoma.\\nOperative Treatment of Carcinoma of the Lip. The best curative\\nand cosmetic results are obtained by early and thorough excision.\\nIf the tumor is small, the operation can be done without anesthesia\\nif large and if a plastic operation must follow to correct the defect,\\npartial anesthesia will answer the purpose. The coronary artery should\\nbe compressed at both angles of the mouth\\nby compression-forceps or between the\\nthumbs and index fingers of the hands of\\nan assistant. In diffuse superficial carci-\\nnoma of the lip involving only the mucous\\nand submucous tissues the entire margin\\nof the lip, from one angle of the mouth\\nto the other, is excised. The incision is\\nmade at a safe distance (about half an inch) fig. 154. -Suturing after excision of\\nfrom the palpable margin of the tumor the enti J e rgin \u00c2\u00b0,V he lip for carcU\\n1 r noma (after Esmarch).\\nthe mucous membrane is then carefully\\nstitched to the margin of the skin with fine catgut sutures (Fig. 1 54).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0309.jp2"}, "302": {"fulltext": "284 PATHOLOGY AND TREATMENT OF TUMORS.\\nThe cosmetic and functional results following this operation are entirely\\nsatisfactory. The lip is long enough to retain the secretions of the\\nmouth, and there is formed from the mucous membrane a new pro-\\nlabium which in the course of a few months resembles the normal\\nprolabium in appearance.\\nIf the tumor involves not quite one-half of the lip and has pene-\\ntrated the tissues deeply, it is included in a V-shaped incision the apex\\nof which must extend to the lower border of the jaw (Fig. 155). The\\nFig. 155.\u00e2\u0080\u0094 Wedge-shaped excision of the lip for car- Fig. 156.\u00e2\u0080\u0094 Operation completed (after Esmarch).\\ncinoma (after Esmarch).\\ncoronary artery is either twisted or included in one of the deep sutures.\\nThe deep sutures of silk or of silkworm gut should embrace all the\\ntissues except the mucous membrane, which should be sutured with\\nfine catgut from the mouth before the deep sutures are tied, in order to\\nprevent the interposition of mucous membrane between the. margins of\\nthe wound. The lower lip gradually elongates after the operation\\n(Fig. 156).\\nIf the tumor involves more than one-half of the lip, it should be\\nexcised by a curved incision, with the convexity directed downward, at\\nleast half an inch distant from the palpable margin of the tumor. The\\nmucous membrane is then sutured over the surface of the wound to\\nthe skin. The semilunar defect, which is quite apparent after the\\noperation, gradually diminishes in the course of time. If the whole\\nor nearly the whole lip is involved, complete excision becomes neces-\\nsary, and a new lip must be made by a plastic operation. Wolfler\\nrecently described an operation which yielded excellent results After\\nexcision of the entire lip a curved incision about two inches below\\nthe margins of the wound, and extending a little beyond the angles\\nof the mouth, is made through the skin and the subcutaneous con-\\nnective tissue. The quadrangular flap is then so raised that its upper\\nmargin will occupy the normal level of the lip, when the flap is sutured\\nto the anterior surface of the jaw with catgut sutures, so as to ex-\\nclude from the wound the cavity of the mouth and to fix the new lip\\nsecurely in its new place. The flap is retained by a proper dressing", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0310.jp2"}, "303": {"fulltext": "CARCINOMA.\\n285\\nin this position. After clearing out the submental and submaxillary\\nspaces of lymphatics, the lower margin of the wound is sutured sepa-\\nrately to the jaw and the new lip, and drainage is established through\\na small buttonhole in the centre, at the most dependent part of the\\nwound. If the whole wound cannot be covered with skin in this man-\\nner, the remaining surface should be paved with Thiersch s skin-grafts.\\nAs soon as the flap is detached the submental and some of the sub-\\nmaxillary glands come in view, and should be dissected out carefully\\nwith the adjacent connective and adipose tissue. Langenbeck restored\\nthe lower lip by taking a flap from the region of the neck (Figs. 157,\\n1 5 8). In this operation it is necessary, after the formation of the flap, to\\ncarry the incision downward in the median line to expose and remove\\ninfected lymphatic glands.\\nThe great difficulty in Langenbeck s operation is that the free mar-\\ngin of the new lip cannot be covered with mucous membrane, and a\\ncertain amount of cicatricial contraction ensues during the healing of\\nthe wound. In Wolfler s operation there can often be preserved a\\nFig.\\nOperation completed (after Langen-\\nbeck).\\nFig. 157. Langenbeck s method of restoring the\\nlower lip after excision for carcinoma (after Lan-\\ngenbeck).\\nnarrow strip of mucous membrane with which to line the free margin\\nof the lip and thus to secure in the course of time a normal prolabium.\\nPartial excision of the upper lip is made in the same way as for car-\\ncinoma of the lower lip. If the entire upper lip has to be excised, the\\ndefect is restored after the method devised by Bruns (Figs. 159, 160).\\nThe two lateral flaps are brought down to the proper level, are united\\nin the median line by a number of sutures, and are stitched to the\\nmargin of the wound below the nose finally, the wound on each side\\nis diminished in size as far as possible by suturing. In plastic opera-\\ntions a number of superficial sutures of horsehair are always of great\\nservice to bring the skin in accurate coaptation. The sutures should", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0311.jp2"}, "304": {"fulltext": "286\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nbe removed as soon as the union is firm enough to render them super-\\nfluous, which will be the case in from three to five days.\\nSutures should be tied carefully, and only with firmness sufficient\\nto bring the margins of the wound in contact. Tension from tying the\\nFig. 159. Cheiloplasty (after Bruns). Fig. 160. Operation completed (after Bruns).\\nsutures too tightly not only gives rise to pain, but also interferes with\\nan ideal healing of the wound. A suture that causes undue linear\\ncompression should be removed at once. If the flap in plastic opera-\\ntion does not require an external mechanical support, the writer is not\\nin the habit of applying a dressing in operations upon the lip. The\\noperation should be performed under strict antiseptic precautions, and\\nafter its completion the line of suturing should be covered by a thin\\nlayer of carbolated vaselin.\\nOperative Treatment of Carcinoma of the Face. The eyelids are\\nquite frequently the seat of carcinoma. An early operation in this\\nlocality is of the utmost importance, as the disease always manifests\\nFig. 161. Blepharoplasty after removal of carci-\\nnoma of lower eyelid (after Dieffenbach).\\nFig. 162.\u00e2\u0080\u0094 Operation completed (after Dieffen-\\nbach).\\na tendency to extend to the eye and the other contents of the orbit.\\nIf the operation is performed before the conjunctiva has become\\ninvolved, the functional and cosmetic results are satisfactory. The\\nincisions circumscribing the tumor should be made at a safe distance,\\nand the conjunctiva should be preserved carefully. The defect is\\nremedied in a satisfactory manner by Dieffenbach s method (Figs. 161,\\n162). The tumor is included in a V-shaped incision, and the part to", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0312.jp2"}, "305": {"fulltext": "CARCINOMA.\\n287\\nbe removed is carefully dissected away from the conjunctiva. If the\\ntumor has reached the tarsal cartilage, this must be removed with the\\neyelashes. A square flap is now made by carrying a straight incision\\nfrom the outer angle of the eye outward and backward, corresponding\\nin length to the length of the eyelid, joined at the outer terminus by\\nan incision extending downward and inward to a level with the apex\\nof the V-shaped incision. The flap is now detached and by sliding is\\nbrought into its new location, when the operation is completed by\\nsuturing with fine silk, catgut, or horsehair, as shown in Figure 162.\\nThe wound-surface which cannot be covered by suturing should be\\npaved by Thiersch s grafts at once.\\nIf the disease has extended to the conjunctiva, the entire eyelid must\\nbe removed. In such cases it is much more difficult to replace the parts\\nlost by disease than those lost by the operation. Dieffenbach s method\\nmust be modified so far that the inner surface of the new eyelid should\\nbe covered with a Thiersch graft, which should be retained in its proper\\nposition by a few fine catgut sutures. Hotz has shown that conjunc-\\ntival defects can be repaired successfully by skin-grafts. The writer has\\nresorted to this expedient a few times in making new eyelids, and the\\nresults have been exceedingly satisfactory. The skin grafted soon\\nadapts itself to its new location and serves a useful purpose as a sub-\\nFig. 163.\u00e2\u0080\u0094 Partial rhinoplasty by taking a\\nflap from the opposite side of the nose (after\\nLangenbeck).\\nFig. 164. Partial rhi- Fig. 165. Partial rhinoplasty\\nnoplasty completed (after by taking a pedunculated flap\\nLangenbeck). from the face along the base of\\nthe nose (after Esmarch).\\nstitute for the conjunctiva. A new eyelid lined on both sides by skin\\nis less liable to shrink and to become distorted than when skin-graft-\\ning is omitted.\\nOperative Treatment of Carcinoma of the Nose. If only a part of\\none ala of the nose is affected, the carcinoma is excised by removing\\na wedge-shaped piece the entire thickness of the ala, and the defect is\\ncorrected by taking a flap from the opposite side of the nose, as advised\\nby Langenbeck, or from the face near the base of the nose (Figs. 163,", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0313.jp2"}, "306": {"fulltext": "288\\nPATHOLOGY AND TREATMENT OF TUMORS.\\n164). The wound left on the opposite side of the nose after the\\nremoval of the flap should be covered by a pavement of Thiersch\\nskin-grafts. The nasal defect after the excision of the carcinoma can\\nalso be remedied satisfactorily by taking a pedunculated flap from the\\nface, as shown in Figure 165. If the margins of the nasal apertures\\nare free, and the tumor occupies the bridge of the nose and has in-\\nvolved the bony framework, a very extensive operation becomes neces-\\nsary. With knife, chisel, and saw, the tumor and the bony framework\\nare removed to ensure complete removal of all diseased tissue. If the\\ndisease has reached the nasal cavities, extensive removal of the mucous\\nlining of the nasal passages often becomes necessary. The resulting\\ndefect often presents alarming proportions, but it can be corrected in\\na very satisfactory manner by Konig s operation (Figs. 166, a, b, c).\\nFig. 166. Konig s rhinoplasty, a: a, flap for building bridge of nose, including skin, periosteum,\\nand a thin slice of bone; b, flap used to cover flap a and to furnish integument for the entire defect; c, defect\\ncaused by excision of tumor, b a, flap a turned downward b, lower end fastened in place with catgut\\nsutures. The skin of the tip of the nose at b is left free, and to it flap b is sutured, c a, b, defects over\\nfrontal bone c, flap b, which covers the bony surface of flap a, and furnishes the cutaneous covering for the\\nentire defect, sutured in place.\\nThe reflected flap a furnishes a bridge of bone which prevents the sink-\\ning in of the nose. The defect over the frontal region caused by the\\nremoval of the flaps should be covered at once by large skin-grafts.\\nIf the entire nose has to be sacrificed, owing to the extent of the carci-\\nnoma, Thiersch s method of rhinoplasty recommends itself for restoring\\nthe lost organ. The new organ is made by taking a flap from each\\nside of the face these flaps are turned inward with the cutaneous sur-\\nface downward, and are then united in the middle line with catgut\\nsutures. A large pedunculated flap is then taken from the forehead", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0314.jp2"}, "307": {"fulltext": "CARCINOMA. 289\\nand is rotated into position and sutured in place. The two raw sur-\\nfaces brought in contact unite rapidly, and as both sides of the alse of\\nthe nose are lined by normal skin, the resulting shrinkage is moderate.\\nThe defects caused by the removal of the\\nflaps are covered at once by Thiersch\\ngrafts.\\nCarcinoma of the skin in other parts\\nof the face or the body is excised with the\\nsame thoroughness, making the incisions\\nhalf or three-quarters of an inch away\\nfrom the palpable margins of the tumor,\\nand covering the defect either by a plastic\\noperation, by skin-grafting, or by a com-\\nbination of both these procedures. In per-\\nforming primary skin-grafting it is very im- Fu; l67 ._ Rhinoplasty (after Thiersch)\\nportant to diminish the size of the wound\\nby suturing its angles and by approximating the remaining margins of\\nthe wound by the use of tension-sutures. The best material for this\\npurpose is coarse silk. The skin-grafts should be covered carefully by\\nstrips of protective silk over which an antiseptic dressing is applied, the\\nwhole being held in place by strips of adhesive plaster or by a plaster-\\nof-Paris bandage, so that the grafts may not subsequently be disturbed.\\nUnless positive indications arise, the first dressing should not be dis-\\nturbed for three days. In place of Thiersch s grafts, it may be advis-\\nable under certain circumstances to use Wolfe s grafts. Grafts not\\ndeprived of all adipose tissue should not be used, as this method of\\nskin-grafting, contrary to the assertions of Hirschberg, often results in\\nfailure.\\nMouth. Carcinoma of the mouth has the same structure as carci-\\nnoma of the skin, as the glands and the mucous membrane of this\\ncavity have an embryonic origin similar to that of the skin. Before\\nthe fourth week in the life of the human embryo there is developed\\nat the lower part of the face a broad transverse cleft this is the primi-\\ntive mouth. Developed as it is from the face, and carrying with it\\nthe covering of the face, the lining membrane of the mouth is derived\\nfrom the epiblast. The buccal part of the epiblast forms a sac that is\\nat first closed posteriorly. Not until the eighth or the ninth week\\nis a communication established between the mouth and the pharynx.\\nThe mouth and the pharynx in the embryo are two separate cavities,\\nthe first having its origin in the epiblastic layer, the second in the\\nhypoblastic layer and the visceral mesoblast. The glands in communi-\\ncation with the mouth are developed from the epiblastic lining of the\\n19", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0315.jp2"}, "308": {"fulltext": "290 PATHOLOGY AND TREATMENT OF TUMORS.\\nmouth. The mouth is covered by pavement epithelium several layers\\ndeep, the deeper or attached layer being generally columnar, while the\\nsuperficial layer presents flattened scales. In the mouth, as in the skin,\\ncarcinoma starts either in the epithelial strata of the mucous membrane\\nor in one of its glandular appendages, in the form of a hard nodule.\\nThe epithelial cells undergo fatty degeneration, so that when an ulcer\\nhas formed an atheromatous mass can sometimes be pressed from the\\ncentre of the ulcer. The base of the ulcer is indurated. The ulcer,\\ninstead of showing any disposition to cicatrize, enlarges in all directions.\\nThe superficial variety, as in the skin, manifests no disposition to\\ninvade the deep structures. The nodular variety originates in the\\ntubular mucous glands, and presents under the microscope a tubular\\nstructure. The tubules are lined with one or more layers of columnar\\nepithelial cells. This form from the very beginning penetrates the\\ntissues deeply after invading one of the maxillary bones at an early\\nstage. As a primary tumor, carcinoma of the mouth is rarely devel-\\noped in localities other than the lips, the gums, the salivary glands, the\\ntongue, the tonsil, and the palate. The labial glands are much more\\nnumerous in the lower than in the upper lip, and they are almost entirely\\nabsent about the angles of the mouth which absence may tend to\\nexplain why carcinoma affects the middle of the lower lip more fre-\\nquently than the upper lip and the angles of the mouth. Carcinoma\\nof the mouth is frequently attributed to smoking, but in the East, where\\nthis habit is most common and is carried to excess, carcinoma of the\\nlip and the mouth is very rare. This fact would seem to prove, if smok-\\ning is an etiological factor, that it is not the traumatism resulting from\\nthe pipe, but the heat, that is the active agent, as long pipe-stems are\\nused by the Orientals and the smoke is passed through water before it\\nreaches the mouth.\\nCarcinoma of the mucous membrane of the cheek is sometimes\\npreceded by a patch of leukoplakia. The influence of chronic irrita-\\ntion in producing carcinoma is well shown in carcinoma in this locality,\\nas the tumor very often corresponds in its location with the crowns of\\nprominent upper and lower molar teeth.\\nCarcinoma of the gum starts often near the stump of a carious tooth.\\nThe bone is invaded so quickly that the disease is often mistaken for a\\nprimary bone affection. Lymphatic infection is a very early and con-\\nspicuous feature when the carcinoma involves either of the maxillary\\nbones. The primary tumor is sometimes overlooked in such cases. A\\nrapid-growing glandular tumor of the neck should remind the sur-\\ngeon of the necessity of a thorough examination of the cavity of the\\nmouth. Carcinoma of the mouth with early and extensive glandular", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0316.jp2"}, "309": {"fulltext": "CARCINOMA. 291\\ninfection is a very rapidly fatal affection, the average duration of life\\nbeing not more than six months.\\nRadical operations for carcinoma of the mouth always require an\\nexternal incision. Intra-oral operations cannot be made with the requi-\\nsite degree of thoroughness. The incision must be made in a location\\nwhich affords the best access to the tumor, and in which the operation\\nwill leave the least disfigurement. If the upper maxilla is implicated,\\nthe same incisions are made as for partial or complete excision of this\\nbone. If the lower jaw has become secondarily affected, the floor of the\\nmouth is usually also extensively involved. In such cases a horseshoe-\\nshaped incision corresponding with the lower border of the jaw from\\none angle to the other will afford ample space to remove a portion of\\nthe bone and to clear out the infected glands and other soft tissues\\nrequiring removal. In cases of extensive carcinoma of the mouth recur-\\nrence is very apt to take place even after the most extensive operations,,\\nowing to the early and extensive lymphatic infection.\\nTonsil. Carcinoma of the tonsil is a comparatively rare affection.\\nOnly two or three cases have come under observation in which the\\nwriter could satisfy himself that the disease had its primary origin in\\nthis gland. In one of the cases the tumor was mistaken for a long\\ntime for primary syphilis, and the patient had been subjected to anti-\\nsyphilitic treatment for several weeks, with, of course, a negative result.\\nThe infiltration spreads very rapidly, and early lymphatic infection is\\nthe rule. The disease in the course of two or three months extends to\\nthe base of the tongue, the pillars of the soft palate, and the pharynx.\\nSalivation, pain, and dysphagia are early and distressing symptoms.\\nAs soon as the disease reaches the entrance of the larynx, hoarseness\\nand difficult breathing set in. As the disease occurs only in persons\\nadvanced in years, the diagnosis is not attended by any difficulty. The\\nmalignancy of the tumor is pronounced by the clinical course, and all\\nthat remains for the surgeon to do is to differentiate between carcinoma\\nand sarcoma. In carcinoma ulceration commences at an earlier stage\\nthan in sarcoma, and is more constantly attended by infection of the\\nlymphatic glands, which infection is exceptional in sarcoma.\\nOperative Treatment of Carcinoma of the Tonsil. The removal of a\\nmalignant tumor of the tonsil is one of the most difficult operations in\\nsurgery. At the time the operation is performed the disease has usually\\nextended far beyond the limits of the organ primarily affected. The\\ntumor must be exposed by an external incision, with or without tem-\\nporary resection of the inferior maxilla. O. Weber recommended\\ntemporary resection of the inferior maxilla at a point corresponding\\nwith the third molar. The articular end of the bone is then turned", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0317.jp2"}, "310": {"fulltext": "292\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nupward with the soft tissues. The ascending pharyngeal, lingual, facial,\\nand carotid arteries can readily be tied in this incision. Mikulicz advises\\nan external incision extending from the mastoid process to the hyoid\\nbone, after wmich the ascending ramus of the jaw is denuded of its\\nperiosteum from the insertion of the masseter muscle as high up as\\npossible, whereupon the ascending ramus of the jaw is enucleated.\\nThe tonsillar region is now freely exposed. Langenbeck recommends\\ntemporary resection of the inferior maxilla\\n(Fig. 1 68). Cheever of Boston, who recom-\\nmends an incision along the anterior border\\nof the sterno-cleido-mastoid muscle from the\\nexternal ear in a downward direction, reports\\nseveral cases operated upon successfully by\\nthis method. In two cases in which this ope-\\nration was performed by the writer he resorted\\nto Kocher s incision for the removal of the\\ntongue, and, although both operations proved\\nexceedingly difficult, he was satisfied with the\\nroom afforded by the incision.\\nIodoform-gauze drainage should be em-\\nployed both for the purpose of arresting\\nparenchymatous oozing and to afford a free\\noutlet for the primary wound-secretions. If\\ntemporary resection of the inferior maxilla is practised, the intentional\\nfracture is sutured with silver wire or with chromicized catgut after the\\nextirpation of the tumor.\\nTongue. Carcinoma of the tongue is one of the most distressing\\nof all surgical affections. Unfortunately, the tongue is rather frequently\\nthe seat of carcinoma. The\\nlingual glands are distributed\\nat the root of the tongue, on\\nthe sides, and at the apex, and\\nit is in these localities that the\\ntumor has most frequently its\\nstarting-point. Very frequently\\nthe location of the tumor cor-\\nresponds with a source of irri-\\ntation caused by a prominent\\nor carious tooth. Mechanical\\nirritation from such a source\\ncontinued for any length of\\ntime is very apt to become an influential exciting cause\\nFig. 168. External incisions\\nfor extirpation of carcinoma of the\\ntonsil a, after Langenbeck b,\\nafter Mikulicz.\\nFig. 169. Carcinoma of the tongue, showing its papillary\\nstructure; X 100 (after W. Fairlie Clarke).\\nThe propor-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0318.jp2"}, "311": {"fulltext": "m\\nCARCINOMA. 293\\ntion of female to male patients is about 1:7. In the early stages,\\nbefore ulceration has become extensive, the tumor retains on its sur-\\nface the papillary structure of the tongue (Fig. 169). Infiltration from\\nthe surface soon results in the formation of epithelial nests in the\\nunderlying vascular connective tissue. The epithelial cells are closely\\npacked in concentric layers in the\\nalveoli of the stroma (Fig. 170).\\nBesides chronic irritation, the\\nmost frequent exciting causes of\\ncarcinoma of the tongue are psori-\\nasis, leukoplakia, ichthyosis, and\\nother chronic inflammatory affec-\\ntions of the surface of the tongue\\na strong argument that chronic\\ninflammatory affections are a fre-\\nquent direct and indirect cause of\\nTT n r Fig. 170.\u00e2\u0080\u0094 Carcinoma of the tongue laminated cap-\\ncarcinoma. Usually carcinoma of 7 sule x 200 (after w Fairlie Clarke)\\nthe tongue is a rapidly fatal dis-\\nease, resulting in death within two years. Wolfler has called attention\\nto a more chronic form of carcinoma of the tongue in which a small\\nflat carcinomatous ulcer may remain in a latent condition for many\\nyears. The tumor makes its appearance at the margin, tip, or dorsum\\nof the tongue, as a firm nodule which soon begins to ulcerate in\\nthe centre. The infiltration and induration are well marked from the\\nbeginning. The primary tumor seldom or never occupies the posterior\\nthird of the organ. Glandular infiltration is an early sequence, and the\\nfloor of the mouth becomes involved at an early stage.\\nThe pain in carcinoma of the tongue is quite severe and of a sharp,\\nstinging character, extending also in the direction of the ear. The\\nsurface of the ulcer is either papillary or covered by gangrenous shreds.\\nThe induration of the base and margins of the ulcer remains through-\\nout. Profuse salivation and difficulty in swallowing and in speech are\\nconspicuous clinical features.\\nIn the differential diagnosis tuberculosis, gumma, traumatic ulcer,\\nand actinomycosis must be considered. Tuberculosis of the tongue\\noccurs, with few exceptions, only in persons suffering from pulmonary\\ntuberculosis. The tubercular sputum, coming in contact with some\\nabrasion, results in inoculation. The tubercular ulcer is covered by\\nfungous granulations, and lacks the indurated base and margins of car-\\ncinoma. Syphilitic lesions have frequently been mistaken for carci-\\nnoma, and vice versa. Gumma of the tongue is usually associated with\\nother syphilitic manifestations of the tongue or of the cavity of the mouth.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0319.jp2"}, "312": {"fulltext": "294\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe tongue itself is often deeply fissured. General hyperplasia of the\\nlymphatic glands is an indication of syphilis, while regional infection\\nspeaks in favor of tuberculosis. A gumma of the tongue is not infre-\\nquently the starting-point of a carcinoma. This complication must\\ntherefore be looked for in syphilis of the tongue. If any doubt exists\\nas to the differential diagnosis of carcinoma and syphilis, examination\\nof a section of the tumor under\\nthe microscope will clear up the\\nuncertainty. In actinomycosis of\\nthe tongue the discovery of acti-\\nnomyces under the microscope\\nwill render the diagnosis positive.\\nThe prognosis of carcinoma\\nof the tongue is always grave.\\nMany of the reported perma-\\nnent cures effected by operation\\nwere undoubtedly cases in which\\na gumma was mistaken for a\\ncarcinoma. Billroth and Kocher\\nclaim that the results after op-\\nerations for carcinoma of the\\ntongue are as favorable as those\\nafter operations for carcinoma of\\nother organs. Winiwarter s sta-\\ntistics show that the mortality\\nof extirpation of the tongue,\\nwhich formerly was very great,\\nhas been reduced to 17.6 per\\ncent. The diagnosis should be\\nmade early, and useless treat-\\nment by the application of caus-\\ntics, etc. should give way to an\\nearly and thorough operation.\\nRadical Operations for Carcinoma of the Tongue. In all operations\\nupon the tongue it is very important to disinfect the whole cavity of the\\nmouth, as advised by Billroth. The fear of hemorrhage has in the past\\ninduced surgeons to substitute for the knife and scissors the ecraseur or\\nthe galvano-caustic wire. The employment of these instruments did not\\nalways prevent hemorrhage when the tongue was amputated near its base,\\nand for this and other substantial reasons they have almost entirely been\\nabandoned. Mr. Hutchinson continues to use the ecraseur, but he has\\nfew imitators. In all operations on the tongue the organ should be\\nFig. 171. Syphilitic nodule and fissure of the tongue\\n(after W. Fairlie Clarke).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0320.jp2"}, "313": {"fulltext": "CARCINOMA.\\n295\\npierced in the middle line near the tip with a large needle armed with\\nheavy silk. With this thread, which is tied at the end, the tongue can\\nbe drawn and held in any direction during the operation. Preliminary\\nligation of one or of both lingual arteries as a prophylactic measure\\nagainst hemorrhage is seldom prac-\\ntised at the present time, and is\\nnot to be recommended. Some sur-\\ngeons employ temporary hemostatic\\nFig. 172. Temporary constriction of one-half of the\\ntongue (after Esmarch and Kowalzig).\\nFig. 173. Temporary constriction of the whole\\ntongue at its base (after Esmarch and Kowalzig).\\nmeasures during the operation (Figs. 172, 173). In applying temporary\\nconstriction the tongue is pierced in the middle at its base with a large\\nneedle armed with a long and strong silk suture. If it is the intention\\nto constrict only one side, the needle is liberated and the suture is tied\\nif the whole tongue is to be rendered bloodless, the thread is cut near\\nthe needle and the two threads are tied on opposite sides. The writer\\nhas tunnelled the base of the tongue in the middle line with a small\\npair of hemostatic forceps, and has drawn through the tunnel a small\\nrubber tube about twelve inches in length, cut it in the middle, and\\nconstricted each side by tying the rubber ligatures firmly enough to\\ninterrupt both the arterial and the venous circulation. This method\\nof elastic constriction is to be preferred to the use of silk ligatures.\\nIf the surgeon has reliable assistants, preliminary elastic constriction is\\nunnecessary, even if the entire tongue is to be removed.\\nIf the tumor is small and can be removed effectually through the\\nmouth by a wedge-shaped excision, the tongue is rendered accessible\\nby the use of Whitehead s gag. The operation through the mouth is\\napplicable when the tumor occupies the anterior third of the tongue.\\nThe line of incision should be made at least three-quarters of an inch\\ndistant from the palpable margin of the tumor. The thread with which\\nthe tongue is drawn forward is inserted in such a manner that it can be", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0321.jp2"}, "314": {"fulltext": "296\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nused as a suture after excision of the tumor (Figs. 174-177). After the\\ntongue has been drawn well forward the excision is made either with\\nFig. 174. Insertion of traction-suture\\n(after Esmarch).\\nExcision of tumor (after Esmarch).\\nthe knife or with scissors. The hemorrhage is readily controlled by\\naccurate suturing. The deep sutures should include all the tissues,\\nand if there is any tendency to inversion of the mucous membrane, this\\nFig. 176. Tying of first suture (after Esmarch).\\nFig. 177. Operation completed (after Esmarch).\\ntendency should be averted by the use of a few superficial fine catgut\\nsutures.\\nWhitehead removes the entire tongue through the mouth with\\nscissors, and immediately grasps and ties the lingual arteries. Few\\nsurgeons perform Whitehead s operation not because it is difficult and\\ncannot be done safely, but because cases which require amputation of\\nthe entire tongue are complicated by regional infection, the treatment\\nof which requires an external incision. Langenbeck makes an incision\\nfrom the angle of the mouth downward, and divides the inferior maxilla\\ntransversely in the line of the external incision (Fig. 178). The ends\\nof the bone are then drawn apart sufficiently to secure free access\\nto the base of the tongue. After completion of the amputation the\\nbone-ends are brought in apposition and are sutured with silver wire.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0322.jp2"}, "315": {"fulltext": "CARCINOMA.\\n297\\nRegnoli devised an operation, later modified by Billroth (Fig. 179),\\nby which the base of the tongue can be made freely accessible without\\ndividing the inferior maxilla. The cavity of the mouth is opened by a\\nhorseshoe-shaped incision corresponding with the lower border of the\\njaw; the cavity of the mouth\\nbeing opened, the tongue is\\ndrawn forward through the in-\\ncision sufficiently to bring its\\nbase within easy reach. More\\nrecently, Kocher devised an\\nincision by which the base of\\nthe tongue is reached from the\\nside without dividing the jaw\\n(Fig. 180). This incision is com-\\nmenced below the ear, and is\\ncarried along the anterior mar-\\ngin of the sterno-cleido-mastoid\\nmuscle about five inches, when\\nit is directed forward, and by a\\nsmall turn upward is made to terminate near the symphysis of the chin.\\nThe flap of skin is then raised as far as the lower border of the jaw, and\\nthrough this space the base of the tongue is reached. The tongue is\\nthen drawn through the incision and is amputated in the usual manner.\\nFig.\\n78. Amputation of the tongue by Langenbeck s\\nmethod.\\nFig. 179.\u00e2\u0080\u0094 Amputation of the tongue according\\nto Regnoli-Billroth.\\nFig.\\n-Kocher s incision in amputation of the\\ntongue.\\nKocher s incision affords the surgeon an excellent opportunity to remove\\nall the submaxillary and submental lymphatic glands, but does not expose\\nthe base of the tongue as freely as the Regnoli-Billroth method. From\\nexperience the writer is satisfied that the Kocher method is well adapted\\nfor partial removal of the tongue, but when the entire organ is to be", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0323.jp2"}, "316": {"fulltext": "298 PATHOLOGY AND TREATMENT OF TUMORS.\\namputated the Regnoli-Billroth method deserves the preference. After\\nthe tongue has been drawn well forward, before making the amputation,\\nit has been the habit of the writer to insert on each side of the base of\\nthe tongue an additional traction-suture, with which to control the\\nstump later. This is an exceedingly important precaution. After\\ndividing the tongue by one stroke of the knife as far as the median\\nline, the lingual artery is grasped and tied. The lingual artery on the\\nopposite side is dealt with in a similar manner after the amputation has\\nbeen completed. The parenchymatous oozing is moderate, and is con-\\ntrolled by suturing the stump. It is advisable to remove as much of\\nthe floor of the mouth as necessaiy, and all the infected lymphatic\\nglands, before the tongue is amputated. The writer always resorts to\\npartial anesthesia in performing the operation, for the purpose of\\nsecuring the patient s co-operation in preventing the entrance of blood\\ninto the larynx. The two traction sutures are brought out of the\\nmouth, and are used in fixing the stump in proper position for a day\\nor two after operation. The wound is covered with adhesive iodoform\\ngauze or with Whitehead s benzoe mixture. The external wound is\\nclosed except at a point best adapted for drainage. If necessary, the\\npatient is nourished for a few days by introducing food into the stomach\\nthrough an elastic tube or by rectal feeding. A saturated solution of\\nboric acid should be used frequently as a gargle or mouth-wash. Care-\\nful attention in the after-treatment is of great importance in the preven-\\ntion of acute pulmonary complications. The functional results are\\nsatisfactory after complete extirpation of the tongue. It has been\\nascertained that the criminals in Persia who were formerly punished by\\ncutting out of the tongue recovered speech sufficiently to make them-\\nselves understood. The same has been observed after amputation of\\nthe entire tongue for carcinoma. The function of deglutition is pre-\\nserved almost to perfection.\\nParotid. Carcinoma of the parotid gland does not occur in persons\\nless than forty years of age. Carcinoma of the salivary glands is\\nnotoriously malignant. The acinous variety begins as a proliferation of\\nthe columnar epithelia of an isolated embryonic lobule of the gland\\n(Fig. 181). The stroma is usually scanty in this variety. The tumor\\ngrows rapidly and gives rise to early lymphatic infection. Weber\\ndescribed a form of carcinoma of the parotid that closely resembles\\nhard carcinoma of the breast. The tubular variety begins in the distal\\nbranches of the salivary duct, in the form of epithelial pearls of colum-\\nnar epithelial cells which arrange themselves in the form of tubules,\\nwhich multiply and grow into the substance of the gland. A rapid-\\ngrowing tumor of the parotid gland in a person fifty or more years", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0324.jp2"}, "317": {"fulltext": "CARCINOMA.\\n299\\nFig. 181. Adenomatous stage of a cancer of the\\nsubmaxillary gland X 35\u00c2\u00b0 (after D. J. Hamilton) a,\\nsection of a normal acinus b, an acinus distended with\\nproliferating epithelium other parts of the gland were\\ncompletely cancerous.\\nof age is, with very few exceptions indeed, a carcinoma. The capsule\\nof the gland is perforated at an early stage, when the tumor involves\\nthe overlying skin and the neigh-\\nboring organs. The external\\near, the malar bone, and the\\nascending ramus of the inferior\\nmaxilla are frequently impli-\\ncated. In two cases that have\\ncome under the writer s obser-\\nvation paralysis of the facial\\nnerve existed at the time the\\noperation was performed. Re-\\ngional infection extends to the\\ndeep lymphatics of the neck.\\nExtirpation of the Parotid\\nGland. Extirpation of the par-\\notid gland was first performed in\\nAmerica in 1804 by the father\\nof J. Collins Warren. Brainard\\nof Chicago performed the opera-\\ntion a number of times, and\\nstrongly maintained its feasibility. Konig advises in the aged a\\npartial excision of the gland, with a view of preventing facial paral-\\nysis if the tumor is not large. The writer is of the opinion that\\npartial removal of the parotid gland for carcinoma is an unjustifiable\\nand unsurgical procedure, as recurrence is sure to take place, and the\\nrecurrent tumor grows more rapidly than the primary growth. Carci-\\nnoma of the parotid gland indicates complete removal of the gland with\\nall other infected tissues, and is always followed by permanent facial\\nparalysis. The writer has removed the parotid gland for carcinoma\\nsix times without a death, and has never observed serious consequences\\nfrom the facial paralysis. In one case there was removed, in addition to\\nthe tumor, the entire external ear in another, the malar bone and part\\nof the superior maxilla and in a third, the ascending ramus of the in-\\nferior maxilla with the parotid. The overlying skin is generally found\\naffected, and must be excised with the tumor. Preliminary ligation\\nof the external or common carotid artery is unnecessary, as the external\\ncarotid artery can be ligated in the wound toward the completion of the\\noperation. Liston and Dieffenbach recommended intracapsular enucle-\\nation. Roser removed the carcinomatous parotid gland piecemeal\\n(morcellement).\\nThe capsule of the gland should invariably be removed with the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0325.jp2"}, "318": {"fulltext": "300 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor. If a large area of skin has to be excised, the part to be\\nremoved should be included between two elliptical incisions, the lower\\nangle of the ellipse corresponding with the point where the external\\ncarotid artery is to be ligated. The temporal artery is ligated on the\\ndistal side and is secured by compression-forceps on the proximal side.\\nThe whole mass is carefully dissected all around the dissection must\\nbe extended to the styloid process of the temporal bone. As soon as\\nthe external carotid artery comes in view it is isolated and is grasped\\nwith a pair of hemostatic forceps, the tumor is removed, and the arteiy\\nis tied. The wound-surface being large, it is necessary to cover it by\\na plastic operation, which can be done by taking a pedunculated flap\\nfrom the forehead or the scalp. The scalp defect is then covered with\\nThiersch s grafts. In the case in which the writer had to remove the\\nexternal ear with the parotid a little opening was made in the large\\nskin-flap, this opening corresponding with the location of the external\\nmeatus, and thus the function of hearing was preserved almost to\\nperfection.\\nIf the skin over the tumor can be preserved, the writer exposes the\\nparotid gland by a curved incision, with the convexity directed down-\\nward, extending from the mastoid process to near the malar prominence,\\nturns this flap upward, and then proceeds to remove the tumor as has\\nbeen described. The results after this operation compare favorably\\nwith those of removal of the breast for carcinoma. If the deep cervical\\nglands are infected, the incision must be extended downward along\\nthe anterior border of the sterno-cleido-mastoid muscle. Carcinoma\\nof the parotid gland should be removed as early and as thoroughly as\\npossible, and the patient must be made to understand that the price he\\npays for a radical operation includes invariably a permanent facial\\nparalysis.\\nThyroid. Carcinoma of the thyroid gland is very rare in the\\nUnited States. Malignant disease of this gland is usually associated\\nwith adenoma or with miasmatic struma, and is consequently more\\nprevalent in localities where these affections are endemic. Carcinoma\\nof the thyroid gland presents an additional interest from the fact that\\nsuch tumors are by no means limited to the thyroid gland. Accessory\\nthyroid glands are quite frequently found in the neighborhood of the\\nthyroid, but thyroid tissue has a much more diffuse distribution in\\ndifferent parts of the body. It has been found in the bronchial glands,\\nin the lungs, and in the bones in cases where the thyroid was enlarged,\\nand its presence in these situations has been regarded as an example\\nof metastasis. According to Piana, thyroid tissue occurs close to the\\naortic arch in the dog. The hyoid glands of Zuckerkandl and Kadyi,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0326.jp2"}, "319": {"fulltext": "CARCINOMA.\\n301\\nFig. 182. Microscopical ap-\\npearance of pulsatile tumor of the\\nskull (after Morris).\\nwhich are well described by Streckeisen, consist of remains of the\\nthyroid duct and of gland-tissue, and may become the seat of malig-\\nnant as well as benign tumors.\\nHeterotopic tumors composed of thyroid tissue are excessively rare.\\nMorris in 1880 described a case of pulsatile tumor of the skull in which\\nit was shown under the microscope that the\\ntumor was composed of thyroid tissue (Fig.\\n182). Coats reported a similar case. Gussen-\\nbauer found such a tumor in the vertebrae.\\nThat such a matrix should occasionally serve as\\na starting-point of carcinoma should be remem-\\nbered when a primary carcinoma is found in\\ntissues normally devoid of epithelial cells.\\nCarcinoma of the thyroid gland is met with\\nmost frequently in persons from thirty to fifty\\nyears of age. The tumor infiltrates the gland-\\ntissue, and soon perforates the capsule and\\nextends to the surrounding tissues, rendering\\nthe tumor immovable. Extension in the direction of the trachea gives\\nrise to hoarseness and dyspnea. Destruction of the recurrent laryngeal\\nnerves results in paralysis of the vocal cords. Wolfler describes a\\nmalignant adenoma of the thyroid gland a tumor which under the\\nmicroscope exhibited the same appearances as an adenoma, but which\\nclinically pursued the same course as carcinoma. Histologically he\\nrecognizes three varieties 1. Alveolar carcinoma; 2. Cylindrical-celled\\ncarcinoma; 3. Squamous-celled carcinoma.\\nCarcinoma of the thyroid usually proves fatal within a year. It\\nstarts most frequently in a pre-existing miasmatic struma or adenoma.\\nIf a goitre that has remained stationary for a long time commences to\\nincrease rapidly in size without any apparent cause, it is more than prob-\\nable that it has become the seat of a carcinoma, either by the tissues\\ncomposing the pre-existing pathological product having undergone malig-\\nnant transformation, or from the development of a carcinoma from a\\nseparate matrix of embryonic cells within or in the immediate vicinity of\\nthe infective swelling or the benign tumor. Kaufmann recommended as\\na means of early and positive diagnosis puncture of the tumor and exam-\\nination under the microscope of fragments of tissue removed in this way.\\nExtirpation of the Thyroid Gland for Carcinoma. The only surgical\\ntreatment of carcinoma of the thyroid gland is early and thorough excis-\\nion. The removal of a carcinomatous tumor of this gland is a much\\nmore difficult task than the enucleation of an adenoma or a cyst, as the\\ntumor has usually perforated the capsule of the gland before the opera-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0327.jp2"}, "320": {"fulltext": "302\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ntion is undertaken,\\nnecessitates\\nThe excision of a carcinoma of the thyroid gland\\nA\\nligation of numerous and large veins (Figs. 183, 184)\\nFig. 183. Tumor of the right lobe of the thyroid\\ngland, showing ramification of superficial veins\\n(after Kocher).\\nFig. 184. Schema showing points of ligation of\\nlarge veins in extirpation of thyroid tumors (after\\nKocher).\\ncurved transverse incision with the convexity directed downward will\\nafford the best access to the base of the tumor. The large veins should\\nbe divided between a double ligature. A very useful instrument in\\nmaking the dissection is Kocher s director (Fig. 185).\\nVenous hemorrhage is more to be feared than arterial\\nhemorrhage, and is more difficult to control. Injury to\\nthe recurrent laryngeal nerve has frequently happened\\nduring operations for malignant disease of the thyroid.\\nPermanent paralysis of the vocal cord on the same side\\nis a constant result of this accident. If the trachea\\nhas become involved, it is generally opened during the\\noperation, and a tracheal cannula should be inserted at\\nonce.\\nThe results of operations for malignant disease of the\\nthyroid gland have not been very encouraging. Local\\nrecurrence is the rule, even if the infected lymphatics are\\ncarefully removed with the tumor. The operation, how-\\never, is one of great palliative value, and is the only means\\nof preventing death from suffocation. In operating for\\nmalignant disease of the thyroid the whole gland should\\nbe removed, as it is much better for the patient to run the risk of\\nFig. 185.\u00e2\u0080\u0094 Kocher s\\ndirector.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0328.jp2"}, "321": {"fulltext": "CARCINOMA,\\n3\u00c2\u00b0;\\nbecoming later the subject of cachexia strumipriva than to take the\\nchances of an early local recurrence.\\nMammary Gland. The greatest interest centres in carcinoma of the\\nmammary gland, owing to the great frequency with which this organ is\\nFig. 186. From carcinoma of mammary gland, showing infiltration of connective-tissue spaces with\\ncarcinoma-cells connective-tissue endothelia can be seen in places lining the connective-tissue spaces\\nX 250 (after Ziesing).\\naffected. The frequency of carcinoma as compared with other tumors\\nof the breast is very great, as Billroth found in 440 tumors of the breast\\nthat only in 1 8 per cent, were the tumors of a non-malignant character.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0329.jp2"}, "322": {"fulltext": "304\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nFig. 187. Acinous carcinoma of mammary gland X no, reduced one-third (Surgical Clinic, Rush\\nMedical College, Chicago) a, connective-tissue stroma; tumor-parenchyma c, blood-vessels in stroma;\\nd, wandering carcinoma-cells e, area where recent hemorrhage has occurred f, blood-pigment g, shrink-\\nage in hardening.\\nHistological Varieties. The histological structure of a carcinoma of\\nthe mammary gland depends on the type of cells of which it is com-\\nff^lPW\\nFig. 188. Alveolar carcinoma of breast (after Kbnig) a, alveoli filled with epithelial cells; b, empty alve-\\noli c, stroma infiltrated in places by small round cells.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0330.jp2"}, "323": {"fulltext": "CARCINOMA,\\n305\\nposed and the amount and arrangement of its stroma. The embryonic\\nmatrix from which it develops is always derived from the epiblast, but\\nFig. 189. Tubular carcinoma in cystic tumor of the breast natural size (Surgical Clinic, St. Joseph s\\nHospital, Chicago) a, tumor b, pedicle c, cavity of cyst d, normal gland-tissue e, adipose tissue f 3\\npin supporting tumor.\\nthe morphology of the cells is determined by the part of the gland\\nwhich the matrix represents. The product of tissue-proliferation rep-\\nresents either the acinous or the duct portion of the gland.\\n\\\\i\\n^f\\nv--\\nWm\\nup\\nFig. 190.\u00e2\u0080\u0094 Section from tumor shown in Figure 191 X 185 a, alveolated stroma infiltrated in some places\\nby small cells; b, columnar epithelial cells filling tubular spaces.\\nAcinous Variety. In this variety the cells are packed in the alveoli\\nof the stroma very much in the same manner as in carcinoma of the\\n20", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0331.jp2"}, "324": {"fulltext": "306\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nskin (Fig. 1 8?). If the alveoli are large, we speak of alveolar carci-\\nnoma, although the stroma of all carcinomatous tumors presents an\\nalveolated structure (Fig. 188). If the parenchyma of the tumor pre-\\ndominates greatly over its connective-tissue stroma, the tumor is soft and\\nvery vascular, corresponding with what was formerly called enceph-\\naloid or medullary cancer. If the tumor is hard and nodulated,\\nit answers to what is still being described as scirrhus. If the cellular\\nelements or the stroma, or both, undergo such extensive colloid degen-\\neration that the tumor is largely composed of colloid material, it has\\nbeen customary to call such a tumor a colloid cancer. In acinous\\ncarcinoma of the mammary gland the cells infiltrate the connective-\\ntissue spaces around the primary growth, and the tumor increases in\\nsize (Fig. 186).\\nTubular Variety. Tubular carcinoma frequently takes its starting-\\npoint in a pre-existing cystic disease of the ducts of the gland. The\\ncells are either columnar or resemble columnar cells which line duct-\\nspaces or infiltrate the connective-tissue stroma (see Plate 5). Tubular\\ncarcinoma is less malignant than the acinous variety. In one case the\\nwriter found in the breast of a woman thirty-five years old a tubular\\ncarcinoma which had existed for six months, and during this time it\\nhad reached the size of a walnut. The skin over the tumor remained\\nunaffected, and the nipple was not retracted. Distinct fluctuation was\\nfelt. The cyst was excised. On laying it open a small quantity of\\nmucoid material escaped. The\\ninterior of the cyst was occupied\\nby a pedunculated papillary tu-\\nmor (Fig. 189). Dr. Mellish,\\nwho examined the tumor and\\nmade the drawings, traced its\\npedicle to the orifice of a duct-\\nlike tract in the gland-tissue.\\nThis blind tract could be fol-\\nlowed to the depth of about a\\nquarter of an inch into the\\nsubstance of the gland. There\\nis no doubt that the tumor\\ndeveloped from the wall of a\\npre-existing duct, and that it\\ncaused by its presence in-\\ncreased secretion and retention of the secretions which produced the\\ncyst. Sections of the tumor showed a well-marked alveolated struc-\\nture of its stroma, its spaces filled with columnar epithelial cells.\\nFig. 191. Tubular form of carcinoma of the breast infil\\ntration of the stroma by small round cells (after Konig).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0332.jp2"}, "325": {"fulltext": "CARCINOMA. 307\\nIn typical tubular carcinoma the tubular arrangement is preserved\\nin the new portions of the tumor. The membrana propria, however, is\\ndefective in many places and permits the infiltration of the stroma by\\nnew cells (Fig. 191).\\nEtiology. Very little is known concerning the exciting causes of car-\\ncinoma of the breast. It occurs most frequently in women past thirty-\\nfive years of age the soft variety is more frequent in young persons, and\\nthe hard variety in persons advanced in years. The rarity of the occur-\\nrence of carcinoma in men points to the frequently-recurring hyperemia\\nof the mammary gland in females during pregnancy, lactation, and\\nmenstruation as an important etiological factor. That pregnancy and\\nlactation are important causes is shown from the fact that in carcinoma\\nof the breast in the female the proportion of the unmarried to the mar-\\nried, according to Bryant, is 1 3 according to Baker, of 260 cases,\\n23 per cent, occurred in single and 72 per cent, in married women, and\\n4 per cent, in widows. In a small percentage of cases the disease had\\nevidently a traumatic origin. Antecedent lesions of the breast, abscess,\\nfissure of the nipple, and eczema appear to have acted as exciting\\ncauses or to have furnished besides the essential tumor-matrix. Occa-\\nsionally an adenoma undergoes malignant transformation. The etio-\\nlogical relation between eczema of the nipple and carcinoma of the\\nbreast is now generally recognized. In a case that came under the\\nwriter s observation the eczema preceded the carcinoma by over five\\nyears, and during this time no evidences of the carcinomatous nature\\nof the primary skin affection could be detected by the most careful\\nand frequently-repeated examinations.\\nIn 1874, Sir James Paget read a paper in which he discussed for the\\nfirst time the connection of eczema of the areola of the breast with\\ncarcinoma, basing his remarks on fifteen cases which had up to that\\ntime come under his personal notice. Some of his remarks on this\\nsubject are quoted: The patients were all women various in age,\\nfrom forty to sixty or more years, having in common nothing remark-\\nable but their disease. In all of them the disease began as an eruption\\non the nipple and areola. In the majority it had the appearance of a\\nflorid, intensely red, raw surface, very finely granular, as if nearly the\\nwhole thickness of the epidermis were removed like the surface of\\nvery acute diffuse eczema or like that of an acute balanitis. From such\\na surface, on the whole or greater part of the nipple and areola, there\\nwas always a copious, clear, yellowish, viscid exudation. The sensa-\\ntions were commonly tinglings, itching, and burning, but the malady\\nwas never attended by disturbance of the general health. I have not\\nseen this form of eruption extend beyond the areola, and only once", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0333.jp2"}, "326": {"fulltext": "308 PATHOLOGY AND TREATMENT OF TUMORS.\\nhave seen it pass into a deeper ulceration of the skin after the manner\\nof a rodent ulcer. In some of the cases the eruption has presented the\\ncharacteristics of an ordinary chronic eczema, with minute vesications,\\nsucceeded by soft, moist, yellowish scabs or scales and constant viscid\\nexudation. In some it has been like psoriasis, dry, with a few white\\nscales desquamating, and in both these forms, especially the psoriasis,\\nI have seen the eruption spreading far beyond the areola in widening\\ncircles, or with scattered blotches of redness covering nearly the whole\\nbreast But it has happened that in every case which I have been\\nable to watch cancer of the mammary gland has followed within at the\\nmost two years, and usually within one year. The formation of cancer\\nhas not in any case taken place first in the diseased part of the skin.\\nIt has always been in the substance of the mammary gland, beneath or\\nnot far from the diseased skin, and always with a clear interval of appar-\\nently healthy tissue.\\nIn view of the fact that eczema of the nipple is so constantly fol-\\nlowed by carcinoma, and as the disease appears to resist all kinds of\\nlocal treatment, Paget is in favor of early operative removal of the dis-\\neased breast as the only known prophylactic measure against carcinoma\\nfrom this source.\\nThin, who studied Paget s disease of the nipple from a histological\\nstandpoint, found first the skin of the nipple eczematous. The inflam-\\nmatory process creeps then along the mucous membrane of the milk-\\nducts. Bryant estimates that carcinoma of the breast is hereditary in\\n10 per cent, of all cases. Sprengel traced a hereditary influence in\\nthirteen out of 109 cases.\\nSymptoms and Diagnosis. The acinous variety of carcinoma, by far\\nthe most frequent, commences as a hard nodule in the substance of the\\nbreast, most frequently near the periphery of the organ. If the tumor\\nstarts in an accessory mammary gland, it usually occupies primarily\\nthe base of the axillary space. The tumor is nodulated, and a certain\\ndegree of fixity can be detected almost from the beginning.\\nTubular carcinoma starts more commonly nearer the nipple. As the\\ntumor increases in size it approaches the surface the skin is drawn\\ninward, and soon becomes discolored in the centre a condition which\\nprecedes ulceration. In soft tumors nodulation is less marked than in\\nthe hard variety, and the tumor closely resembles a sarcoma. Exten-\\nsive fatty degeneration of the centre of the tumor and contraction of\\nthe stroma at this point leads to a depression which is often noticeable\\non the surface of the skin. Retraction of the nipple accompanies a\\nsimilar condition, and is therefore most constant and well marked in\\nhard carcinoma. It is the result of cicatricial contraction of the stroma,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0334.jp2"}, "327": {"fulltext": "CARCINOMA.\\n309\\nA serous or sanguineous\\nwhich exerts traction upon the milk-ducts\\nfluid can sometimes be pressed from the nipple, especially in cases oi\\nsoft tumors. Soft tumors grow rapidly, being most malignant; the\\nlocal infection spreads rapidly, the stroma being scanty, and the cells\\nundergo early degenerative changes, especially of a colloid charac-\\nter. The tumor is soft, fluctuating, and resembles closely a subacute\\nabseess or a rapid-growing sarcoma. Mr. Heath reports such a case\\nA few months before the examination the* patient, a married woman\\ntwenty-four years of age, noticed in the left breast a swelling the size\\nFig. 192. The lymphatics from the nipple to the axilla, placed upon the axillary vein, whence they\\nmount to the under part of the clavicle, passing through an opening to terminate in the angle of the conjoined\\njugular and subclavian veins of the right side, at the lower part of the neck (after Astley Cooper) a, the\\nnipple, with two absorbents from it passing upon the fourth rib, and then dividing into numerous branches\\nwhich cover the intercostal spaces up to the third and down to the fifth rib they then mount to the third rib,\\nto the axillary vein ib), and pass on the inner side of that vein under the clavicle (e), where they are con-\\ntinued, through the opening, into the angle of the jugular and subclavian veins d, the subclavian artery\\ne, e, axillary plexus of nerves.\\nof a hen s egg. The tumor developed rapidly without pain, and occa-\\nsionally blood flowed from the nipple. A little later, in consequence\\nof the large size of the breast and the copious discharge of blood from\\nthe nipple, she consulted Mr. Heath, who evacuated about a pint of a\\nthin bloody fluid and injected tincture of iodine. This treatment was\\nrepeated on two other occasions. A few months later the breast was", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0335.jp2"}, "328": {"fulltext": "3io\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nremoved. At this time there was at the site of puncture a fungous\\ngrowth through which bloody, offensive fluid was escaping.\\nSimmonds has shown that colloid degeneration cannot occur inde-\\npendently of epithelial cells. When the cells undergo this process the\\nstroma can take part, and in this manner greater or lesser portions of\\nrapid-growing carcinoma are transformed into colloid material. In\\nthe atrophic form of carcinoma the stroma is very abundant, and the\\ntumor in the central part shrinks because of the partial or total disap-\\npearance of the epithelial cells by fatty degeneration and because of\\nthe shrinkage of the massive stroma, which in itself favors fatty degen-\\neration by causing pressure and by diminishing the blood-supply. In\\nnearly all cases which come under the notice of the surgeon glandular\\ninfectioii has already occurred. It may be impossible to detect the\\nenlarged glands through the intact skin,\\nespecially in obese women, but their ex-\\nistence can generally be demonstrated at\\nthe operation.\\nThe relation of the lymphatics to the\\nmammary gland and their location and\\ndistribution are well shown in Figures\\n192, 193.\\nCareful anatomical researches made by\\nHeidenhain have shown the existence of\\na dense network of lymphatics underneath\\nthe mammary gland in the adipose tissue,\\nbetween it and the fascia of the pectoralis\\nmajor muscle. He attributes the fre-\\nquency with which local recurrence has\\nfollowed the removal of the carcinoma-\\ntous mammary gland to incomplete re-\\nmoval of the pectoralis fascia. In all\\ncases this fascia should be removed thor-\\noughly, which can only be done by taking\\naway the superficial fibres of the muscle.\\nIn cases in which the diseased breast is\\nattached to the muscle, the muscle should\\nbe removed completely. Stiles fully con-\\nfirms the views expressed by Heidenhain\\nby his own investigations. The latter\\nauthor has also traced a connection be-\\ntween the submammary lymphatics and the lymphatics accompanying\\nthe internal mammary artery.\\nFig. 193. Shows the lymphatics (a)\\nof Figure 192 passing under the blood-\\nvessels (b), the axillary vein (c), the artery,\\nacross four of the upper ribs, joining with\\nthe anterior, entering the angle of the\\njugular and subclavian of the right side\\nat d (after Astley Cooper).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0336.jp2"}, "329": {"fulltext": "CARCINOMA.\\n311\\nThe lymphatic glands nearest the mammary gland usually become\\naffected first, when the regional infection extends in the direction of\\nthe apex of the axillary space. The glandular tumors are often more\\nnumerous than the normal glands, and some of them are tumors which\\nhave developed in the lymphatic vessels. The enlargement of the\\nlymphatic glands belonging to the brachial lymphatics produces\\noedema of the arm a condition which becomes aggravated by press-\\nure of the tumors upon the axillary vein. Lymphatic enlargement\\nusually takes place along the greater pectoral muscle, but, as pointed\\nout by Astley Cooper, if the tumor is situated on the sternal side of\\nthe nipple the supraclavicular glands become involved by way of\\nthe internal mammary lymphatics. Metastasis takes place most fre-\\nquently in the liver; next in frequency come the lungs, the pleura,\\nand the brain. Torok and Wittelshofer have found metastasis in the\\nbones of the skull. Metastatic tumors of the long bones frequently\\nresult in pathological fracture. Carcinoma of the vertebrae resembles\\nclinically spondylitis. Billroth and Konig have observed metastasis\\nmost frequently in connection with slow-growing hard carcinoma,\\nwhich corresponds with the results of the writer s observations.\\nIn the hard variety the ulcer is at first superficial, and extends\\nprimarily more toward its periphery than in the direction of the tumor.\\nFig. 194. Carcinoma of the breast.\\nIn soft carcinoma the superficial ulceration often gives rise to central\\nsloughing of a considerable portion of the tumor this sloughing, upon\\nseparation of the gangrenous part, leaves a crater-like excavation.\\nInfection with pus-microbes hastens the destructive process, and the\\npresence of putrefactive bacilli in the dead tissues causes putrefaction,", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0337.jp2"}, "330": {"fulltext": "312\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwhich is the source of the offensive odor which characterizes the dis-\\ncharge from soft carcinoma of the breast. Patients who have remained\\nin good health until ulceration begins soon become cachectic from\\nthe absorption of septic material from the surface of the tumor and\\nfrom the inflamed tissues. Pain may be almost entirely absent in\\nsoft carcinoma of the breast, the disease resembling in this respect\\nsarcoma. In the hard variety the pain, of a shooting or lancinat-\\ning character, is always present after the tumor has attained a cer-\\ntain size, but is variable in its intensity it is always intermittent,\\nand is apt to be aggravated during the night and after active\\nexercise.\\nA rapid-growing tumor of the breast is a malignant tumor. To\\ndetermine whether the enlargement of the breast is caused by an infec-\\nd\\nin\\n%ff\\nS^\\nFig. 195. Adenoma of the breast X 75 (Surgical Clinic, Rush Medical College, Chicagol a, massive\\nconnective-tissue stroma b, gland-ducts cut transversely c, gland-ducts cut obliquely; d, cystic dilatation\\nof duct.\\ntive swelling or by a tumor requires often a very careful examination.\\nA subacute suppurative mastitis often resembles in its signs and symp-\\ntoms a malignant tumor. The clinical history must be investigated\\ncarefully and all possible sources of infection be ascertained. If any", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0338.jp2"}, "331": {"fulltext": "CARCINOMA.\\n3 J 3\\n-v\\n\u00e2\u0096\u00a0z -a\\n.r o\\ns\\nU\\nSS^-\\na\\nJ\\nU T3", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0339.jp2"}, "332": {"fulltext": "314 PATHOLOGY AND TREATMENT OF TUMORS.\\ndoubt remain, an opinion should not be given until after an exploratory\\npuncture has been made.\\nTuberculosis of the breast often presents itself as a multiple affec-\\ntion, which is not the case in carcinoma. An adenoma without cystic\\ndegeneration hardly ever exceeds in size a walnut. Cystoma forms\\nvery slowly, fluctuates on palpation, and upon deep pressure offers a\\nsense of elastic resistance. It is important to distinguish between sar-\\ncoma and carcinoma before an operation is undertaken, as the operative\\nprocedure will depend to a certain extent on the diagnosis. Sarcoma,\\nas a rule, grows more rapidly than the hard variety of carcinoma. It\\nappears as a smooth tumor, and it is seldom complicated by infection\\nof the axillary glands. It occurs in persons of all ages, while carci-\\nnoma is seldom met with in women less than thirty years of age.\\nThe examination of a section taken from the tumor under the\\nmicroscope will enable the surgeon to make a differential diagnosis\\nbetween adenoma (Fig. 195), carcinoma, and sarcoma. In adenoma\\nthe stroma is massive and the epithelial cells are limited to the space\\ninside the membrana propria. A glance at Figure 196 will be sufficient\\nto distinguish carcinoma from an adenoma. The epithelial cells here\\nare limited to no one particular place, but are found everywhere and\\nin direct contact with the vascula7 r connective tissue.\\nRound-celled sarcoma of the breast, so far as the appearances of the\\ntumor are concerned, very closely simulates the soft form of carcinoma.\\nUnder the microscope it is distinguished from the latter by the absence\\nof a well-marked alveolar stroma, by the more uniform distribution of\\nthe cells, and by the sarcoma-tissue forming a part of the wall of the\\nnew blood-vessels (Fig. 197). The displacement of the gland-tissue by\\ntraction and by projecting parts of the tumor in carcinoma distinguishes\\nthis tumor from all other pathological products. Paget aptly says\\nMoreover, mere indurations do not involve the skin, do not invade or\\ninfiltrate it, or produce in it any puckering or dimpling, as by drawing\\na part of it toward their own mass. In this, indeed, I think there may\\nbe an almost unfailing diagnostic sign.\\nAnother important diagnostic feature of carcinoma that distin-\\nguishes it from all other tumors is its peculiar dissemination through\\nthe lymphatics of the skin after the tumor has reached the surface.\\nBillroth has likened this to the manner of dissemination of papular\\nexanthemata. Nodules appear in the skin in the vicinity of a carci-\\nnomatous ulcer, and feel like shot under the epidermis. They rapidly\\nincrease in number in all directions. The lymphatic channels are impli-\\ncated, and the whole surface, if the disease spreads rapidly, presents\\nan erysipelatous appearance. So long as the nodules remain isolated,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0340.jp2"}, "333": {"fulltext": "CARCINOMA, 315\\nYelpeau called this condition squirrhe disseminee ou pustideux, and\\nwhen the nodules become united into a board-like mass, squirrhe en\\nmasse.\\nCicatricial contraction is a prominent feature of this form of sec-\\nondary carcinoma of the skin. The lymphatic vessels play here a\\nmore important part in the dissemination of the carcinoma than do the\\nlymphatic glands. Carcinoma of the superficial lymphatics appears to\\nbe, if the expression be allowed, a carcinomatous lymphangitis. In\\nsome cases the deep carcinoma becomes adherent to the chest-wall and\\ncontinues to contract, but at the same time continues to extend after\\nreaching the gland in the opposite side. The chest-wall becomes fixed\\nand respiration becomes difficult. The whole wall of thorax on the\\naffected side is rendered immovable, board-like this condition was called\\nby Velpeau cancer en cuirasse. Cancer en cuirasse is not a distinct\\nanatomico-pathological or clinical form of carcinoma, as was formerly\\nasserted, but is always the residt of the extension of a glandidar carci-\\nnoma to the lymphatics of the skin. The writer has never observed it as\\na primary affection. It is a rather frequent complication of neglected\\ncarcinoma or of recurrent carcinoma of the breast, and is another form\\nof regional infection, occurring later than regional infection through the\\ndeep lymphatic glands. When the tumor has reached this stage it is\\nusually inoperable. Recurrence is almost sure to follow most exten-\\nsive operations. Infection of the superficial lymphatics of the skin\\nappears often in such an acute form that the temperature rises several\\ndegrees above normal, and in a few weeks the whole side of the chest\\nbecomes involved. New nodules appear every day, and the skin during\\nthe acute stage presents an erysipelatous blush.\\nIn the rudimentary mammary gland in men occur nearly all the\\ntumors that have been observed in the female, especially carcinoma.\\nSchuchhardt recently collected 277 cases of carcinoma of the breast in\\nmales. When carcinoma develops in the male breast, it follows the\\nsame clinical course as in the female. Regional and general infection\\noccur with equal frequency, and the disease proves fatal in about the\\nsame length of time as in the female.\\nPrognosis. Birkett estimated the average duration of life of patients\\nsuffering from carcinoma of the breast, and upon whom no operation\\nis performed, as being three and a half years. The duration of the\\ndisease is affected very much by the age and the constitution of the\\npatient, the course being slower in the older and less plethoric patients.\\nAstley Cooper s estimate is a fair one namely, two years for the full\\ndevelopment of the disease, and from six months to two years longer\\nfor a fatal termination. In some instances, particularly in the aged.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0341.jp2"}, "334": {"fulltext": "316 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe disease pursues a very slow course, extending over a period of\\nfrom six to fifteen years. In a case of pathological fracture of the\\nupper part of the femur in a woman seventy-five years of age the writer\\naccidentally discovered a small firm tumor in the left breast. On com-\\nmunicating this information to the patient she stated that she had first\\ndiscovered a small lump in the breast twenty years previously. In this\\ncase, as in many other cases which finally terminate in metastasis, the\\ntumor remained in a latent condition for twenty years.\\nThe malignancy of carcinoma of the breast appears to diminish with\\nadvancing age. Soft carcinoma, observed most frequently in the young,\\nleads to a fatal termination much more rapidly than the hard variety.\\nThe local infection progresses more rapidly, and the tumor attains a\\nlarger size, in the soft than^in the hard variety. Patients suffering from\\nthe soft form of carcinoma of the breast are frequently carried off by\\nsome acute chest complication, and the autopsy reveals secondary\\ntumors in the lung and the pleura. Tumors which have undergone\\ncolloid degeneration do not result in early regional infection they\\npursue a comparatively benign course.\\nIt is interesting to know what has been gained in the duration of\\nlife by operative treatment. Birkett estimates that patients who have\\nbeen subjected to operative treatment live, on an average, four years,\\nwhile the duration of life in those not operated on is three and a half\\nyears. Sibley, in 78 cases not operated on and in 63 operated on,\\nascertained that the latter lived one year and nine months longer\\nthan the former. Patients operated upon by Paget and Volkmann\\nlived one year and two and a half months longer than those treated\\nupon an expectant plan. According to Winiwarter, patients not ope-\\nrated on live 32.9 months, and those operated on 39.3 months. A\\ncertain percentage of those patients subjected to operative treatment\\nremain free from a recurrence. Winiwarter ascertained that most of\\nthe relapses that is, 82.4 per cent. occur within three months after\\nthe operation. Relapses, however, may occur as late as ten years after\\noperation. The extensive statistics of Winiwarter, Billroth, Oldekop,\\nEsmarch, Henry, Breslau, Fischer, and Dennis show conclusively that\\noperations undertaken before axillary infection has taken place yield\\nthe best results. Since surgeons have made it a rule to clear out the\\naxilla in every case of carcinoma of the breast the results are becoming\\nbetter. Dennis secured a permanent result in 25 per cent, of his cases.\\nThe average percentage of cases in which no recurrence takes place in\\nthe hands of other operators is, however, much less. The mortality\\nof the operation under the influence of antiseptic measures has been\\nreduced to from 5 to 7 per cent. The writer is confident that when the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0342.jp2"}, "335": {"fulltext": "CARCINOMA. 317\\npublic has become educated in reference to the necessity of early\\noperations, and the profession recognizes the importance of carrying\\nthe incisions far beyond the palpable tumor and the infected glands,\\nthe percentage of permanent recoveries will be increased greatly, and\\nthe mortality of the operation, by a strict adherence to aseptic meas-\\nures, will become reduced to I or 2 per cent\\nTreatment. The palliative measures in inoperable cases of carci-\\nnoma consist of such measures and palliative operations as have been\\ndescribed under the head of Palliative Treatment of Carcinoma. The\\ncontraindications to a radical operation are Extreme old age meta-\\nstatic tumors local or regional extension of the disease beyond the\\nlimits of a justifiable radical operation the coexistence of other dis-\\neases which would in themselves tend to destroy life in a short time.\\nIt is useless to emphasize what is now insisted upon by all practical\\nsurgeons that a radical operation should be performed before regional\\ninfection has taken place. A radical operation should be performed as\\nsoon as a diagnosis has been made. The diagnosis should be made\\npositive either before or at the time of operation. Upon the differential\\ndiagnosis between adenoma and carcinoma depends the thoroughness of\\nthe operation. An adenoma is removed by enucleation a carcinoma\\ndemands the removal of the entire breast. The removal of the entire\\nmammary gland for adenoma is unwarranted the removal of a carci-\\nnoma of the breast without removing the entire organ is almost sure\\nto be followed by an early recurrence. If an unequivocal diagnosis of\\ncarcinoma is made, it is not only necessary to remove the entire breast,\\nbut all the connective and adipose tissue and lymphatic glands from\\nthe margin of the breast to the very apex of the axilla should be\\nremoved with the breast. The extent of a radical operation is reached\\nby removing at the same time such parts of the pectoral muscles and\\nthe latissimus dorsi as may be deemed necessary. The removal of the\\nentire upper extremity, as suggested by McGraw, and the resection of\\nnumerous ribs when the tumor has invaded the chest-wall, are beyond\\nthe limits of prudent surgery.\\nThe field of operation should be prepared the evening before the\\noperation by scrubbing with warm water and potash soap, shaving, and\\nthe energetic use of a 1 1000 solution of corrosive sublimate. The\\nuse of alcohol or of ether is useful in removing infectious material\\nfrom the appendages of the skin. A compress of aseptic gauze wrung\\nout of the sublimate solution should be applied, the moisture being-\\nretained by applying over the compress an impermeable fabric like\\ngutta-percha paper, mackintosh, or oiled silk. The hands of the\\noperator and his assistants are carefully disinfected, and the instru-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0343.jp2"}, "336": {"fulltext": "3i8\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nments, ligatures, and sutures are sterilized by boiling for ten minutes\\nin a I per cent, solution of carbonate of soda. No antiseptics are to\\nbe brought in contact with the wound. Gauze sponges should take\\nthe place of marine sponges. The chest of the patient should be\\nraised slightly during the operation, and the body should be inclined\\ntoward the opposite side.\\nUnless the position of the tumor furnishes a contraindication, the\\nincision should be made in such a manner as to include with the nipple\\nan elliptical piece of skin, and should be carried along the border of\\nthe pectoralis major to the apex of the axilla (Fig. 198). The necessity\\nof removal of an extensive area of skin was strongly emphasized by S.\\nW. Gross. He made a circular incision around the breast and made\\nno attempt to close the wound. This course should be pursued if the\\noverlying skin is extensively involved, but if sufficient healthy skin\\nremains, it is better to preserve enough to cover the wound. The\\nhemorrhage which freely follows immediately the incision is made\\nshould be controlled by pressure a duty incumbent upon the assist-\\nIncision for carcinoma of the breast (after Esmarch).\\nant. The spurting arteries are then secured with compression-forceps,\\nwhich must be relied upon as a hemostatic until the tumor and the\\naxillary contents are removed, when every bleeding point is carefully\\ntied with aseptic catgut. The breast with the pectoral fascia should\\nbe dissected out first, but should be allowed to remain in connection\\nwith the axillary glands. The large wound-surface is now covered\\nwith a compress of gauze during the dissection of the axillary space.\\nIf the carcinoma has extended beyond the capsule of the gland at its\\nbase, parts of the pectoralis major and minor and the serratus magnus\\nand latissimus dorsi muscles may require removal but such extensive", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0344.jp2"}, "337": {"fulltext": "CARCINOMA.\\n3 J 9\\nexcision of muscular tissue as has recently been advocated by Halsted\\nappears superfluous to the writer.\\nThe guide to the axilla is the border of the pectoralis major in front\\nand the latissimus dorsi behind. It is advisable to approach the axilla\\nfrom the front. The skin, the superficial fascia, and the panniculus\\nadiposus are reflected on each side sufficiently to expose the border\\nof both these muscles. After clearing the border of the pectoralis\\nmajor the space between this muscle and the pectoralis minor is\\ninspected carefully, as a chain of enlarged lymphatics is frequently\\nfound in this locality. If the entire chain of glands can be removed\\nby retracting the great pectoral muscle, this part of the operation is\\ncompleted. If this cannot be done, the pectoral muscle is divided\\ntransversely as far as necessary, and after clearing out the axilla it is\\nsutured with a row of buried catgut stitches.\\nFig. 199. Dissection of the axillary space in operation for carcinoma of the breast (after Esmarch).\\nThe next thing to be done is to clear the border of the lesser pec-\\ntoralis muscle, which at the same time serves as a guide to the axillary\\nvessels, which are the next landmarks to be sought for. The axillary\\nvein can usually be found without any particular difficulty by making\\na blunt dissection with the finger, with Kocher s director, or with blunt-\\npointed scissors. Before anything is done in the apex of the axillary\\nspace the large vessels must be well exposed to avoid unintentional injury,\\nwhich is unlikely to occur if the vessels are exposed and are followed", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0345.jp2"}, "338": {"fulltext": "320 PATHOLOGY AND TREATMENT OF TUMORS.\\nwith tlie requisite care. The space in front of the axillary vessels is\\nnext cleared out; and it is here that the chain of glands must often be\\nfollowed and removed as far as the upper border of the first rib. This\\npart of the operation must be done slowly and carefully. Rupture of\\nglands by pressure or by traction must be avoided. The dissection\\nhere must be made with the aid of blunt instruments. A number\\nof small veins emptying into the axillary vein from below should\\nbe tied close to the axillary before being cut. Glands are often\\nfound attached to the vein, and their separation without injury to the\\nvein requires patience and careful work (Fig. 199). If the vein is\\nincorporated in a mass of carcinomatous glands and cannot be isolated,\\nthe part connected with the tumor should be removed between two\\ncatgut ligatures. This alternative, fortunately, does not present itself\\nfrequently, and resection of the vein must be avoided whenever\\npossible. Small wounds of the axillary veins can safely be closed by\\nlateral ligatures or by suturing, thus preserving the lumen of the\\nvessel.\\nThe space behind the axillary vessels, which next claims the atten-\\ntion of the surgeon, is cleared out in the same careful manner as the\\nanterior space. When this has been done the dissection is continued\\nin a downward direction. All spurting points are secured by hemo-\\nstatic forceps. The preservation of the coraco-brachialis and of other\\nsmaller nerves traversing the axillary space, as recommended by\\nKuster, is practised only when the regional infection is slight. In the\\nmajority of cases it is better to excise them with the axillary contents\\nthan to run the risk of making an incomplete operation by preserving\\nthem.\\nThe removal of the string of glands in the direction of the sub-\\nscapular artery often necessitates ligation of this vessel and its accom-\\npanying vein. If the disease is at all extensive, a considerable portion\\nof the serratus magnus muscle must be removed. The tumor, the adja-\\ncent tissues, and the axillary contents are to be removed in one continuous\\nmass. All attempts at enucleation of infected glands will surely be fol-\\nlowed by a speedy recurrence. Crushing or teasing of carcijiomatous\\nglands will be followed by traumatic dissemination of the carcinoma.\\nAs soon as the tumor and the axillary contents have been removed all\\nbleeding points must be ligated. Careful hemostasis is an essential pre-\\nrequisite to an ideal wound-healing.\\nThe wound inflicted by an operation of this extent is a very large\\none, and considerable parenchymatous oozing will occur after the patient\\nrallies from the immediate effects of the operation and the anesthetic.\\nIf the wound is sutured throughout, accumulation of a considerable", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0346.jp2"}, "339": {"fulltext": "CARCINOMA.\\nPlate 7.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0347.jp2"}, "340": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0348.jp2"}, "341": {"fulltext": "CARCINOMA. 321\\nquantity of blood and serum is almost sure to follow, often giving\\nrise to painful tension, necessitating an early change of the dressing,\\nthe removal of one or more sutures, and the insertion of secondary\\nsutures.\\nOrdinary tubular drainage is very unsatisfactory in preventing the\\naccumulation of blood in the wound. The lumen of the tube becomes\\nblocked by a blood-clot, and the fluid that escapes is at the sides, and\\nnot through the tube. Bergmann overcame these difficulties by pack-\\ning the wound with iodoform gauze, which he removes on the second\\nor third day, then closing the wound by secondary sutures. He and\\nothers have obtained excellent results by this treatment. The sutures\\ncan be inserted at the completion of the operation, but they are not\\ntied until the gauze tampon is removed. In hospital practice this\\nmethod of wound-treatment yields excellent results and is not attended\\nby any additional risks of infection, but in general practice it is better\\nto suture the wound and to drain with iodoform gauze. A strip of\\ngauze folded upon itself several times should extend from the apex of\\nthe axilla to the most dependent part of the wound, where it is brought\\nout through a separate incision about two inches in length. The wound\\nis then sutured throughout. On the second or the third day the gauze\\ndrain is removed. In closing the wound the deep sutures of silk or of\\nsilkworm-gut are placed about an inch apart, and over them the skin is\\nunited accurately with a continued suture of fine catgut (PL 7, Fig. 1).\\nAfter washing the surface with a solution of corrosive sublimate or of\\ncarbolic acid and drying it carefully, a copious antiseptic hygroscopic\\ndressing should be applied. The line of suturing is dusted with a\\npowder of iodoform and boric acid (1:5) until the sutures are buried\\nunder the powder. Eight layers of iodoform gauze are applied next to\\nthe wound, and over the iodoform gauze a large thick compress of\\nsterilized gauze. Absorbent cotton is used as a filter over and around\\nthe gauze, including also the shoulder. The dressing is retained by\\na wide roller composed of several layers of gauze, and the arm is\\nconfined to the side of the chest with the same roller bandage (PL 7,\\nFig. 2).\\nThe first dressing should not be changed for two or three days,\\nwhen the gauze drain is to be removed, unless copious oozing saturates\\nthe dressing. When the outer dressing becomes simply stained at the\\nend of the first twelve or twenty-four hours, the part stained should be\\ndusted with iodoform and be covered with a thick compress of absorb-\\nent cotton retained by an additional bandage.\\nThe deep sutures are removed at the end of eight or ten days. At\\nthis time only the superficial part of the catgut suture remains. If, not-\\n21", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0349.jp2"}, "342": {"fulltext": "322\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwithstanding the strictest antiseptic precautions, infection has occurred,\\nas will be indicated by a rise in the temperature on the second or the\\nthird day, no time should be lost in removing the dressing and some if\\nnot all of the sutures, and in establishing additional points of drainage.\\nAntiseptic irrigation frequently repeated, and a compress kept moist\\nwith a saturated solution of acetate of aluminum, will then constitute\\nthe most important measures in the after-treatment.\\nIf after the completion of the operation the wound cannot be su-\\ntured, the margins should be brought as close together as possible\\nwith tension-sutures, and the remaining surface should be paved with\\nThiersch s grafts. The results of skin-grafting performed under such\\ncircumstances are very encouraging. Skin-grafting enables the surgeon\\nto secure primary healing of the wound under one or two dressings a\\ngreat gain in the management of such cases.\\nIn a case recently under his care the writer resorted successfully\\nto a plastic operation to remedy the resulting defect. The breast\\nand skin on the opposite side were undermined, and with a flap\\n(Fig. 200) taken from the abdomen the wound was readily closed.\\nFig. 200. Fig. 201.\\nFigs. 200, 201. Plastic operation after excision of carcinoma of the breast.\\nThe opposite breast was mobilized so that it occupied a position\\nnear the sternum (Fig. 201). With the exception of a slight mar-\\nginal necrosis the flap survived, and the wound healed by primary\\nintention.\\nAfter every operation for carcinoma of the breast it is important that\\nthe surgeon or the family physician should examine the patient every", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0350.jp2"}, "343": {"fulltext": "CARCINOMA. 3 2 3\\ntwo or three months to determine whether or not a local recurrence\\nhas taken place. It is not a good policy to leave this matter to the\\npatient or to her friends. The patient should know as little as pos-\\nsible about the object of these examinations. The first nodule that is\\ndiscovered should be removed at once. This removal can usually be\\ndone with the aid of a local anesthetic. Every local recurrence should\\nbe met promptly by a thorough removal. The writer has repeatedly\\nperformed three and four operations for slight recurrence in the same\\npatient, and has been able in this way to postpone the fatal termination,\\nand in a few instances has gained complete control over the disease.\\nCEsophagns. Carcinoma of the alimentary canal below the soft\\npalate is composed of tissue derived from the hypoblast. The prevail-\\ning type of the epithelial cells of the tumor is the columnar. The\\npharynx is very seldom affected by carcinoma. The oesophagus, on\\nthe contrary, is quite frequently the seat of carcinoma. About half\\nof the cases occur in the lower third, about one-third in the middle\\nthird, and the balance higher up. Mackenzie s observations led him\\nto formulate different conclusions in reference to the part of the oesoph-\\nagus most frequently affected. He based his statistics on ioo cases.\\nOf these, 44 involved the upper third, 28 the middle third, and 22 the\\nlower third. As Mackenzie was a throat specialist, it is to be expected\\nthat he was consulted more frequently by patients who suffered from\\ncarcinoma of the upper part of the oesophagus, which would explain\\nthe discrepancy existing between the statistics gathered by the general\\nsurgeon and those quoted by specialists in reference to the favorite seat\\nof carcinoma of the oesophagus. All surgeons agree in the statement\\nthat cicatricial stenosis affects more frequently the upper, and carcinoma\\nthe lower, part of the oesophagus.\\nCarcinoma of the oesophagus appears in two different pathological\\nforms (1) the soft variety, which leads to early ulceration and perfora-\\ntion (2) the hard form, which results in the formation of a circular strict-\\nure. The circular stricture seldom involves more than an inch of the\\noesophageal tube. Not infrequently perforation into the trachea, the pos-\\nterior mediastinum, or the pleura takes place. The writer saw in Von\\nZiemssen s clinic a case which was frequently presented before the class\\nto demonstrate the existence of a communication between the oesoph-\\nagus and the trachea. A few moments after the patient drank a few\\ntablespoonfuls of milk he was attacked by a violent fit of coughing\\nwhich did not cease until the milk he had swallowed was expectorated.\\nThe post-mortem showed a carcinoma of the oesophagus that had per-\\nforated into the trachea. In some instances a fatal termination takes\\nplace from hemorrhage by perforation of the carcinoma into one of", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0351.jp2"}, "344": {"fulltext": "324 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe large blood-vessels. In some cases the disease results in death\\nwithout having produced any symptoms of obstruction. In the major-\\nity of cases, however, the first thing that attracts the patient s attention\\nis that he is not able to swallow solid food. This difficulty gradually\\nincreases until only liquids can be swallowed, and finally the obstruction\\nbecomes complete. The food that is swallowed is not ejected imme-\\ndiately, a variable interval elapsing until the food is regurgitated. One\\nof the results of the obstruction is a dilatation of the oesophagus above\\nthe stricture in cases of long-standing circular stricture the oesophagus\\nbecomes dilated into a large pouch holding a teacupful or more. The\\nfood is not vomited, but is regurgitated, and is ejected unchanged. As\\nsoon as the tumor interferes with deglutition marasmus very rapidly\\nsets in, and death follows in a few weeks. Pain in the region of the\\ntumor is slight or is entirely absent.\\nIn the differential diagnosis between cicatricial stenosis and carci-\\nnoma of the oesophagus it is necessary in the first place to inquire care-\\nfully into the history of the case. Cicatricial stenosis usually develops\\nafter destruction of the mucous membrane by the swallowing of lye or\\nof other caustic an accident which occurs more frequently in children\\nthan in adults. Cicatricial stenosis occurs most frequently in children\\nand young adults carcinoma of the oesophagus is seldom met with in\\npersons less than fifty years of age. A gradually increasing stenosis\\nof the oesophagus in persons advanced in life, in whom the clinical history\\ndoes not reveal the existence of the usual causes of cicatricial stricture, is\\nwith very few exceptions indeed caused by a carcinoma. The existence\\nof the obstruction must be demonstrated by the use of the olive-pointed\\noesophageal bougie. The largest size is to be used first to determine the\\nseat, and then the smaller points to ascertain the extent, of the stricture.\\nNo force must be used in passing the instrument through the stricture.\\nDisregard of this advice has repeatedly resulted in perforation of the\\noesophagus and death from immediate and remote complications caused\\nby this accident. The writer has personal knowledge of two such cases\\nin one the perforation was followed by fatal hemorrhage, in the other\\nby septic peritonitis. Dilatation of a carcinomatous stricture is contra-\\nindicated, as it not only aggravates the local conditions, but is also\\nattended by the risk of perforation. The use of elastic tubes is not\\nattended by the danger of perforation, and if the stricture is permeable\\nthey are used to introduce into the stomach liquids and finely-divided\\nfood suspended in liquids. A small rubber tube inserted into the\\nstomach from one of the nostrils can be retained and used for stomach-\\nfeeding. As soon as stomach-feeding is impossible even with the aid\\nof elastic oesophageal tubes, a gastrostomy should be performed. This", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0352.jp2"}, "345": {"fulltext": "CARCINOMA.\\nPlate 8.\\nWitzel s method of performing gastrostomy. 2. Witzel s operation, showing tube buried by sutures.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0353.jp2"}, "346": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0354.jp2"}, "347": {"fulltext": "CARCINOMA. 325\\noperation should not be postponed too long. As a rule, patients are\\nloath to accept this the last alternative to prolong their lives, and con-\\nsequently frequently postpone the operation until it is too late.\\nGastrostomy. Fenger s incision has been rendered obsolete by the\\nmany recent improved methods of establishing an external gastric fistula\\nin cases of oesophageal obstruction. The operation that has found more\\nfavor with the profession than any other is Witzel s (PI. 8, Figs. 1, 2).\\nOne of the great difficulties to overcome in gastric feeding through an\\nexternal fistula was the escape of food through the fistula after its intro-\\nduction into the stomach. Witzel devised an operation that appears to\\nanswer all requirements better than any other. The abdomen is opened,\\nunder strict antiseptic precautions, through the left rectus muscle, a\\nlittle to the left of the median line and a little below the tip of the\\nxiphoid cartilage. The stomach is identified, and its anterior wall is\\nbrought well forward into the wound. A compress of gauze is packed\\naround the projecting part of the stomach, and in its anterior wall there\\nis made an opening large enough to insert a rubber tube a little larger\\nthan an ordinary lead pencil. The tube, about 6 inches in length, is\\nthen so inserted that its end projects well beyond the mucous surface\\nof the stomach. There is then made in the anterior wall of the stomach\\na vertical groove deep enough to receive the rubber tube, when the\\nserous surfaces are stitched together over and below the tube, so as\\nto prevent the escape of fluid from the opening in the stomach into the\\nperitoneal cavity. The tube is buried in this manner to the extent of\\ntwo inches, when the stomach is fastened by stitches in the upper angle\\nof the incision, and the balance of the wound is closed by suturing.\\nMikulicz modified Witzel s operation by stitching the anterior wall\\nof the stomach around the sutures over the tube to each side of the\\nexternal incision before closing the wound up to the fistulous opening.\\nThis should invariably be done, as it affords an additional safeguard\\nagainst the escape of stomach-contents into the peritoneal cavity.\\nIf the patient is very much debilitated, stimulants and liquid food\\nmay be introduced at once into the stomach through the rubber tube.\\nThe distal end of the tube after feeding is either tied or compressed by\\na suitable clamp. The fistula established in this manner is oblique, and\\nthe internal opening is closed by a valve-like action of the upper part,\\nwhich, even when the tube is removed, effectually prevents the escape\\nof stomach-contents. Witzel recommends that after a few weeks the\\nrubber tube be removed, and be inserted only when the patient feeds\\nhimself. The patient should masticate and insalivate the solid food\\nbefore he pours or injects it into the stomach. The great mortality\\nwhich has attended this operation so far is due to the fact that in the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0355.jp2"}, "348": {"fulltext": "326 PATHOLOGY AND TREATMENT OF TUMORS.\\nmajority of cases in which death resulted from the operation the patients\\nhad postponed it too long. If this operation is to prolong life, it must\\nbe performed in time, before the patient s strength has been reduced to\\nthe lowest ebb.\\nStomach. Carcinoma of the stomach, which is by no means a\\nrare affection, occurs most frequently in persons from thirty to sixty\\nyears of age. Sutton refers to a case in which the patient, a girl, was\\nonly thirteen years old. The youngest patient that has come under\\nthe writer s observation suffering from this disease was a man twenty-\\nfive years old. The pylorus is the part of the stomach most frequently\\nimplicated. Lebert found the disease here in 5 1 per cent, of the cases\\nhe examined, and Brinton, Gussenbauer, and Winiwarter have shown\\nthat the proportion of cases in which the pylorus is affected is still\\ngreater they estimate it at 60 per cent. As all parts of the mucous\\nmembrane of the stomach are freely supplied with tubular glands, the\\nhistological structure of carcinoma of the stomach mimics tubular\\nglands. Sections from new parts of the tumor show under the micro-\\nscope a tubular structure (see Fig. 140).\\nThe character of the structure of the tumor is determined by the\\nrelative amount of epithelial cells to the stroma. If the parenchyma\\nof the tumor largely preponderates over the stroma, the tumor grows\\nrapidly, ulcerates early, and soon implicates the entire thickness of the\\nwall of the stomach. These are the cases in which hemorrhage or per-\\nforation frequently terminates life at an early stage. In the hard variety\\nof carcinoma of the stomach, found most frequently at the pyloric end,\\nthe tissues become infiltrated slowly and to a limited extent. The\\ncircumference of the entire pylorus becomes implicated in the form of\\na ring-like, circular induration. The connective-tissue stroma contracts,\\nand the lumen of the pylorus is progressively narrowed until finally it\\nbecomes impermeable to the passage of food from the stomach into\\nthe duodenum. In other cases the disease infiltrates the wall of the\\nstomach very extensively, but no contraction of the stroma takes place.\\nThese are the cases in which during life, although the pylorus may\\nshow extensive disease, symptoms of obstruction do not occur. In\\ncarcinoma of the cardiac end of the stomach a circular carcinomatous\\nstricture presents the same clinical evidences as carcinoma of the\\noesophagus, and requires the same treatment. In carcinoma of the\\nstomach located between the cardiac and pyloric ends the symptoms\\nare often very vague. Vomiting at irregular periods after meals,\\nhematemesis, indigestion, progressive marasmus, and in some cases\\na palpable tumor, suggest the existence of a malignant tumor in this\\npart of the stomach. Circular constricting carcinoma of the stomach", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0356.jp2"}, "349": {"fulltext": "CARCINOMA. 3V\\ngives rise to a clinical picture that is almost typical. Vomiting of\\nunchanged or partly-digested food in from two to four hours after\\nmeals, attended by a sense of relief, gradual dilatation of the stomach,\\nin advanced cases reaching as far as the pubes, and progressive emacia-\\ntion, characterize the case. If the carcinoma appears in the form of\\na narrow constricting ring, it is often impossible to recognize the tumor\\nby external palpation. If the tumor attains larger dimensions, it can\\nbe felt usually a little below the level of the normal pylorus, espe-\\ncially after the stomach has been emptied of its contents by the use of\\nthe elastic stomach-tube. Hemorrhage is sometimes profuse, and even\\nfatal if a large vessel, such as the pyloric branch of the hepatic artery,\\nhas been eroded by the carcinoma. In pyloric obstruction the retention\\nof food leads to fermentation, which aggravates existing indigestion and\\nends in causing dilatation of the organ.\\nThe only disease which is likely to be mistaken for pyloric carci-\\nnoma is cicatricial stenosis of the pylorus. Cicatricial stenosis is the\\nresult of the healing of an antecedent ulcer in this locality, and the\\ncondition occurs, as a rule, in younger persons than does carcinoma.\\nThis form of obstruction is found more frequently in the female than\\nin the male. The absence of a palpable tumor should not influence\\nus in deciding in favor of the existence of a cicatricial stenosis, as fre-\\nquently no tumor can be detected externally in cases of circular con-\\nstricting carcinoma of the pylorus. Free muriatic acid is frequently\\nabsent in carcinoma of the stomach, but this circumstance is no unfail-\\ning test for malignant disease, as this acid may be absent in obstruction\\ncaused by non-malignant disease, and may be present during the early\\nstage of carcinoma. The occurrence of vomiting in from one to three\\nhours after meals in persons more than fifty years of age should excite\\nsuspicion of carcinoma. If the vomited material is mixed with\\ngrumous blood, presenting the appearance of coffee-grounds, if the\\nvomiting is followed by a sense of great relief, and if the symptoms\\ndo not yield within a short time to the usual treatment, it is very proba-\\nble that the patient is suffering from carcinoma of the stomach, although\\nno palpable tumor may be present.\\nInflation of the stomach after evacuating the organ by the use of\\nthe stomach-tube is the most reliable and safest way by which to deter-\\nmine the presence and extent of dilatation. The area of tympanites\\nwill at least approximately correspond with the size of the stomach.\\nIf the large curvature of the stomach reaches the umbilicus, the organ\\nhas become dilated. During the examination for a tumor of the\\nstomach the patient should be placed in the dorsal recumbent position\\nwith the chest elevated and the legs and thighs flexed. Succussion", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0357.jp2"}, "350": {"fulltext": "328 PATHOLOGY AND TREATMENT OF TUMORS.\\nafter the introduction of a small quantity of fluid into the stomach\\nsuggests very strongly the existence of dilatation (Bouchard).\\nCarcinoma of the stomach, with few exceptions, proves fatal within\\na year. Perforation into adjacent viscera, duodenum, and transverse\\ncolon may prolong life by creating a new outlet for the stomach-con-\\ntents into the intestinal canal. If perforation into the free peritoneal\\ncavity takes place, death from peritonitis usually ensues. Death from\\nrecurring hemorrhages follows the erosion of an artery of considerable\\nsize. In most instances of carcinoma of the pylorus the immediate\\ncause of death is inanition resulting from the suspension of digestion\\ncaused by mechanical obstruction.\\nMetastasis occurs in connection with carcinoma of the stomach.\\nWhen the carcinoma reaches and involves the peritoneal coat of the\\nstomach, regional dissemination often takes place by the dispersion of\\ncarcinoma-cells or fragments of tissue over the adjacent serous surfaces.\\nIn this way the great omentum often becomes extensively infected.\\nThe lymphatic glands in the gastro-hepatic omentum are infected in\\nmore than two-thirds of the cases. The lumbar, cervical, and medias-\\ntinal lymphatic glands are occasionally the seat of regional infection.\\nTreatment. Careful attention to the diet and the use of the siphon\\nstomach-tube in the cases in which dilatation from pyloric obstruction\\nhas taken place are to be relied upon in the conservative treatment of\\ncarcinoma of the stomach. The internal administration of salol and\\nbismuth affords relief when the obstruction has given rise to catarrhal\\ninflammation of the gastric mucous membrane. The observation that\\ncarcinoma of the pyloric orifice of the stomach is frequently very limited\\nin extent, and that patients succumb not so much to the malignant dis-\\nease as to the effects caused by the mechanical obstruction, has induced\\nsurgeons to desist from operations for the removal of the carcinomatous\\npylorus.\\nPylorectomy. The first experimental pylorectomies on dogs were\\nmade in 1810 by Merem. Parts of the stomach were removed for\\nother indications than carcinoma by Torelli and Esmarch. Accurate\\nexperimental investigations concerning the feasibility of pylorectomy\\nfor carcinoma were made by Gussenbauer, Winiwarter, and Kaiser.\\nThe pylorus was removed for the first time for disease by Pean.\\nBillroth made the first successful pylorectomy. The success of the\\noperation has not been what was expected from it. In 66 cases death\\noccurred soon after the operation in 50. Only in a few cases was life\\nprolonged for any considerable length of time. One of Wolfler s cases\\nlived three and a half years after the operation. That the operation has\\nnot yielded better results is due to the fact that the local extension of", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0358.jp2"}, "351": {"fulltext": "CARCINOMA.\\n329\\nthe tumor and the regional infection were such as to require very exten-\\nsive operations, to the immediate effects of which many of the patients\\nsuccumbed and for the same reasons, in those that survived the imme-\\ndiate effects of the operation the disease returned soon afterward. In\\nthe fifteen cases of abdominal section made by the writer for carcinoma\\nof the stomach the disease was found too extensive and regional infec-\\ntion too diffuse to warrant pylorectomy in all the cases but one, and in\\nthis one the circular carcinomatous stricture of the pylorus had resulted\\nin such great impairment of the strength of the patient as to preclude\\nthe advisability of resorting to a pylorectomy.\\nSurgeons have gone too far in the radical treatment of carcinoma\\nof the pylorus. In the writer s estimation the operation is warranted\\nonly if the disease remains limited to the organ primarily affected, and\\nif the patient is strong enough to resist the immediate effects of the\\noperation. The stomach is washed out immediately before the opera-\\ntion. If the organ is thoroughly emptied before the operation, there is\\nhardly any need for the different mechanical devices (Fig. 202, A, b, c, d)\\nFig. 202. Intestinal and stomach clamps a, after Rydygier b, after Billroth c, after Hahn\\nHeineke.\\nafter\\nwhich have been employed for the purpose of preventing the escape\\nof duodenal and stomach-contents. Catch-forceps of special construc-\\ntion (Figs. 203, 204) have also been employed for the same purpose.\\nFor the prevention of the escape of intestinal contents nothing equals\\nin efficiency and ease of application the elastic constrictor. A small\\nrubber tube about a foot in length is drawn through a buttonhole made", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0359.jp2"}, "352": {"fulltext": "33\u00c2\u00b0\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwith a pair of hemostatic forceps in the mesentery near its attachment\\nto the bowel. This tube is tied with sufficient firmness to prevent the\\nescape of intestinal contents. It is not in the way of the operator, and\\nit is less likely to inflict unintentional injury to the bowel or the adjacent\\nFig.\\n-Intestinal forceps (after Gussenbauer).\\nFig. 204.\u00e2\u0080\u0094 Intestinal forceps (after Kiister).\\nparts than the different kinds of clamps or forceps. Sterilized gauze\\nshould be packed around and on the sides of the part to be resected,\\nto absorb any fluid that might escape during the operation.\\nFig. 205. Resection of the pylorus after Billroth-Wolner 1, location and direction of visceral incisions;\\n2, suturing: a, occlusion-sutures b, circular sutures.\\nThe abdomen is usually opened in the median line, below the tip\\nof the xiphoid cartilage, far enough to secure free access to the pylorus.\\nBillroth prefers an oblique incision below and parallel to the right\\ncostal arch. The mesenteric attachment of the part to be resected", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0360.jp2"}, "353": {"fulltext": "CARCINOMA.\\n33*\\nshould be tied in small sections with fine braided silk. The lumen of\\nthe stomach is made to correspond with the oblique section of the\\nduodenum by closing a part by Czerny-Lembert sutures before it is\\njoined with the duodenum. The junction between duodenum and\\nstomach is made with the same kind of sutures. The suturing is done\\nin steps as the excision wound is enlarged. This method affords a\\nbetter opportunity to coaptate the parts properly, and is attended by\\nless hemorrhage, than if the excision were made at once.\\nRydygier diminishes the size of the opening in the stomach from\\nthe larger instead of from the smaller curvature of the stomach (Fig.\\nFig. 206. Resection of the pylorus (after Rydygier) a, location and direction of incisions b, sutures.\\n206, b). Canalization difficulties are less likely to follow the operation\\nif the duodenum is united with the greater curvature of the stomach\\naccording to the Billroth-Wolfler op-\\neration than when it is attached to\\nthe lesser curvature, as recommended\\nby Rydygier. The difficulties expe-\\nrienced in uniting the duodenum with\\nthe stomach when a large part of this\\norgan has to be removed have led\\nBillroth to combine pylorectomy with\\ngastro-enterostomy in the operative\\nremoval of large carcinomatous tu-\\nmors of the pyloric portion of the\\nstomach (Fig. 207). The resected\\nends of the stomach and duodenum\\nare closed by a double row of su-\\ntures, and a communication is established between the anterior wall\\nof the stomach and the lower part of the duodenum or the upper part\\nof the jejunum by making in each of these organs a longitudinal slit\\nat least two inches in length and uniting them by Czerny-Lembert\\nsutures. Tuholsky of St. Louis is an ardent advocate of this operation,\\nbut he advises that it should be done a deux temps.\\nFig. 207. Resection of the pylorus with gastro-\\nenterostomy (after Billroth).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0361.jp2"}, "354": {"fulltext": "332 PATHOLOGY AND TREATMENT OF TUMORS.\\nGastroenterostomy The limited success of pylorectomy induced\\nWolfler to devise an operation for the relief of patients suffering from\\npyloric carcinoma too far advanced for a radical operation. This opera-\\ntion is called gastro-enterostomy, and consists in establishing between\\nthe stomach and the upper part of the intestinal canal a communica-\\ntion, thus excluding permanently from the gastro-intestinal canal the\\naffected part. The stomach is prepared for the operation in the same\\nmanner as for pylorectomy. It is advisable to wash out the stomach\\ndaily at least for two days before the operation, and to nourish the\\npatient during this time exclusively by rectal feeding. The intestinal\\ncanal should be cleared of its contents by a mild laxative or a high\\nrectal enema. In one instance the writer performed this operation\\nwithout an anesthetic. The only pain which the patient complained of\\nwas produced by making the external incision. The handling of the\\nstomach and the intestines, the visceral incisions, and the suturing\\nappeared to cause little or no pain.\\nIf no contraindications exist, chloroform should be used in perform-\\ning this as well as other operations on the gastro-intestinal canal, in\\npreference to ether, as the use of chloroform is attended and followed\\nby less retching and vomiting than is the case when ether is used.\\nThe abdomen is opened by a straight incision in the median line ex-\\ntending from the xiphoid cartilage to the umbilicus. The upper part\\nof the intestinal tract, at a point about twelve inches below the pyloric\\norifice of the stomach, is brought forward into the wound with the\\nanterior wall of the stomach.\\nFig. 208.\u00e2\u0080\u0094 Formation of valve to prevent entrance of Fig. 209.\u00e2\u0080\u0094 Implantation of duodenum into jejunum\\nstomach-contents into duodenum (after Wolfler). and jejunum into stomach (after Wolfler).\\nGastro- enterostomy after Wolfler. Wolfler intended to prevent the\\nentrance of bile into the stomach, and of stomach-contents into the\\nduodenum, by forming a valve by uniting the right half of the opening\\nin the bowel with the intact stomach-wall, and only the left half with\\nthe margin of the opening in the stomach (Fig. 208). The same object", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0362.jp2"}, "355": {"fulltext": "CARCINOMA.\\n333\\nFiG. 2io. Gastro-enterostomy (after Liicke).\\nis attained if the bowel is completely divided at the junction of the\\nduodenum with the jejunum, and the proximal end is implanted into\\nthe jejunum and the jejunum into an\\nopening in the anterior wall of the stom-\\nach, as shown in Figure 209. Liicke\\nreversed the position of the bowel as\\nrecommended by Rockwitz, in order to\\nbring the peristaltic action of the intes-\\ntine in accord with the movements of\\nthe stomach (Fig. 210).\\nIn making the communication be-\\ntween the stomach and the intestines\\nlarge enough, some allowance must be\\nmade for cicatricial contraction of the\\nopening. The visceral incision should be at least two inches in length.\\nThe stomach and the bowel should be united behind by sero-muscular\\nsutures before the visceral incisions are made, as recommended by\\nLauenstein. After the incisions have been made the deep sutures are\\napplied all around, when the incision is completed by a row of super-\\nficial sutures in front and on the sides.\\nGastro-enterostomy after Senn. The writer has made fifteen gastro-\\nenterostomies by substituting in part for the sutures plates of decal-\\ncified bone with a central perforation at least two inches in length and\\nthree-quarters of an inch wide. The intestine is brought into the\\nRockwitz position and is united with the stomach behind by a row of\\nsero-muscular sutures. An incision two inches\\nin length is made in the stomach and the duo-\\ndenum the plates are then inserted, and are\\nbrought into proper position by making trac-\\ntion on the fixation-sutures the lateral sutures,\\narmed with needles, are now passed through\\nall the tissues except the peritoneum, and\\nthe terminal sutures are brought out at the\\nangles of the visceral wounds. An assistant\\ncoaptates the wounds, and the lower fixation-\\nsuture is tied with sufficient firmness to bring\\nthe parts in apposition without endangering\\ntheir blood-supply by strangulation next the terminal sutures are tied,\\nand finally the superficial fixation-sutures. Before tying the last suture\\nthe margins of the wound must be carefully brought well between the\\nplates to prevent eversion. All the sutures are cut close to the knot.\\nThe union is completed by stitching the serous surfaces over the\\nFiG.21\\nMoist perforated decal-\\ncified bone-plate.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0363.jp2"}, "356": {"fulltext": "334\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nanterior margins of the plates, thus completing the ring of superficial\\nsutures (Fig. 212).\\nThe results following the use of the bone plates in performing\\ngastro-enterostomy for carcinoma have been most encouraging. The\\nEnsiform process\\nriculus.\\nAscending- colon. X\\nicus._$BFjf\\nIleum\\nWs Jejunum.\\nk\\nFlG. 212. Method of performing gastro-enterostomy (illustration after Von Baracz).\\nunion between the parts interposed between the plates can be hastened\\nby free scarification. Since using plates with a perforation at least two\\ninches in length the writer has seen no ill results from cicatricial con-\\ntraction. In one case of pyloric carcinoma in a man thirty years of\\nage, the patient, who was brought to the hospital on a stretcher, ema-\\nciated to a skeleton, gained sixty-five pounds in weight after operation,\\nresumed his occupation, that of a butcher, worked for a year and\\na half, and then gradually sunk from the effects of the carcinoma. In\\nanother case, that of a man seventy years of age, emaciated to an\\nextreme degree, the patient recovered sufficient strength to conduct\\nhis business for over a year after the operation. In a number of", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0364.jp2"}, "357": {"fulltext": "CARCINOMA.\\n335\\ninstances the patients lived for three, four, and eight months in comfort\\nand ease a sufficient recompense for the risk assumed in subjecting\\nthemselves to a gastroenterostomy. In the majority of cases of\\npyloric carcinoma the surgeon will have to content himself with making\\na gastroenterostomy until by improved diagnostic resources we will\\nbe able to recognize carcinoma of the stomach early enough to warrant\\na more frequent recourse to a radical operation by pylorectomy or by\\npartial gastrectomy.\\nIntestines. Carcinoma is more frequent in the lower than in the\\nupper part of the intestines. Of every ioo cases, 75 occur in the rec-\\ntum of the remainder, 23 would be localized in the large bowel and\\n2 in the small intestine, including the ilio-cecal valve, and would prob-\\nably be distributed in the following manner Small intestine and ilio-\\ncecal valve, 2 cecum, 2 hepatic flexure of colon, 3 splenic flexure\\nof colon, 4; sigmoid flexure, 10; intermediate segments of colon, 4\\n(Sutton). Carcinoma of the intestines represents in its minute struct-\\nure the glandular appendages of the mucous membrane lining the\\nintestinal canal (Fig. 213). The irregular tubules are lined with cylin-\\nFig. 213.\u00e2\u0080\u0094 Cylindrical-celled carcinoma of the intestine; X 128 (after Hauser) above, elongated and\\ndistended granular spaces; below, without a sharp border, these tubules terminate in irregular carcinoma-\\nalveoli. The black points indicate cells undergoing karyokinesis.\\ndrical cells. In the periphery of the tumor the cells which have parted\\nfrom the parent soil and have escaped through the imperfect membrana", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0365.jp2"}, "358": {"fulltext": "336 PATHOLOGY AND TREATMENT OF TUMORS.\\npropria infiltrate the surrounding connective-tissue spaces, and the new\\ncells which they produce arrange themselves again in tubular shape,\\nthe pre-existing connective tissue becoming the stroma of that part\\nHi\\n.,1,;\\n.VA\\nI\\nFig. 214. Periphery of cylindrical-celled carcinoma of the cecum; X no (Surgical Clinic, Rush\\nMedical College, Chicago): a, rows of carcinoma-cells in connective-tissue spaces; b, intervening con-\\nnective tissue.\\nof the tumor. The section represented in Figure 214 was taken from\\nthe periphery of a circular constricting carcinoma of the cecum. The\\ntumor had produced intestinal obstruction.\\nThe parenchyma and the stroma of intestinal carcinoma are very\\napt to undergo colloid degeneration. Regional and metastatic infection\\noccurs earlier and more constantly than in squamous-celled carcinoma.\\nCarcinoma of the intestines is seldom recognized, or even suspected,\\nbefore the tumor has produced symptoms of obstruction. Chronic\\nobstruction from this cause is frequently attended by diarrhea, a symp-\\ntom which frequently leads patient and physician into errors in diag-\\nnosis.\\nAcute obstruction is caused either by the affected segment of the\\nintestine becoming invaginated or by a suddenly-developed paretic con-\\ndition of the bowel above the seat of obstruction. Great hypertrophy\\nof the muscular coat of the bowel above the obstruction is usually\\nassociated with chronic obstruction, and an acute attack is initiated\\nwhen compensatory hypertrophy no longer keeps pace with the increas-\\ning mechanical impediment or when the narrowed part of the bowel\\nbecomes impermeable by impaction of some foreign substance or of a\\nhardened fecal mass. In cases of acute intestinal obstruction in per-\\nsons advanced in years the existence of a malignant intestinal tumor\\nshould be borne in mind. As in the pylorus, carcinoma of the intestine\\noccurs either as a diffuse tumor attaining considerable size or as a cir-\\ncular constriction. The former variety is more liable to ulceration and", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0366.jp2"}, "359": {"fulltext": "CARCINOMA. 337\\nperforation the latter gives rise to intestinal obstruction. In the con-\\nstricting variety the tumor involves the entire circumference of the\\nbowel, and by constriction of its stroma the lumen of the bowel is\\ngradually reduced in size. The bowel on the distal side becomes\\nmuch smaller in size, while on the opposite side of the constriction it\\nbecomes distended and all its coats are hypertrophied to some distance\\nfrom the seat of obstruction. The catarrhal inflammation caused by\\nthe accumulation of feces and the greatly increased peristaltic action\\ncause the frequent liquid discharges, which are taken only too often by\\nthe superficial observer as an indication of the absence of a mechanical\\nobstruction. Chronic intestinal obstruction caused by a carcinoma is\\nattended by intermittent paroxysmal pain which is referred to the region\\nof the umbilicus, irrespective of the anatomical location of the tumor.\\nOperative Treatment. Unless the tumor has given rise to a palpable\\nswelling, the surgeon has seldom an opportunity to perform a radical\\noperation until symptoms of chronic or acute intestinal obstruction\\nset in. In making a laparotomy for intestinal obstruction the surgeon\\nmust be prepared to meet with such a condition. A radical operation\\nis indicated if the carcinoma has not passed beyond the limits of the\\nbowel and the patient s strength is adequate to resist the immediate\\neffects of an enterectomy. If the patient has become prostrated from\\nthe effects of the intestinal obstruction, it is advisable to resort to the\\nformation of an artificial anus above the obstruction, and to postpone\\nthe operation until his strength has been recuperated sufficiently.\\nEnterostomy. If the tumor occupies the ilio-cecal region, a tem-\\nporary artificial anus is established in the right inguinal region by\\nbringing into the wound the first distended knuckle of the small intes-\\ntine that presents itself. The intestine is united with the peritoneum\\nof the external incision, and the bowel is opened by a transverse\\nincision about an inch in length. If the carcinoma is located below\\nthe sigmoid flexure, a sigmoidostomy in the left groin is made. These\\noperations are indicated in cases in which \u00c2\u00a3he obstruction is acute and\\nthe patient s general condition does not permit of an operation requiring\\nmore time.\\nEnterectomy. The removal of a malignant tumor of the intestine\\nrequires an enterectomy. The removal of a limited segment of the\\nbowel for malignant disease, if the patient s strength has not been too\\nmuch exhausted and no regional infection has occurred, is a legitimate\\nprocedure, and is often followed by a permanent cure. The operation\\nshould not be undertaken if extensive malignant adhesions have formed\\nor if the lymphatic glands have become extensively infected. The\\nbowel on each side of the tumor should be constricted with a piece of\\n22", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0367.jp2"}, "360": {"fulltext": "33%\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nrubber tubing passed through an opening made in the mesentery near\\nits attachment to the bowel (Fig. 215). Before the incisions through\\nFig.\\n215. Separation of mesentery from bowel (after\\nKocher).\\nFig. 216. Circular suture and folding of mesen-\\ntery after enterectomy (after Kocher).\\nthe bowel are made the mesentery should be tied in small sections with\\nfine silk. The bowel sections are made somewhat obliquely at the\\nexpense of the convex side, and the ends are at once united with a\\ndouble row of sutures. The mesentery corresponding with the section\\nof bowel removed should not be excised, but be folded upon itself, and\\nthe ligatured margin should be sutured as shown in Figure 216. If\\nthe lumina of the bowel-ends do not correspond in size, the smaller end\\nFig. 217.\\n-Restoration of the continuity of the bowel after resection of the cecum for carcinoma, with the\\naid of perforated decalcified bone-plates.\\nis cut more obliquely. If the difference in size is too great to be equal-\\nized by this method, as after excision of the cecum, both ends are\\nclosed, and the continuity of the bowel is restored by lateral anasto-\\nmosis, by suturing, or with the aid of perforated decalcified bone-plates.\\nThe use of decalcified perforated bone-plates to restore the continuity\\nof the bowel has been resorted to by the writer in three cases of resec-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0368.jp2"}, "361": {"fulltext": "CARCINOMA.\\n339\\ntion of the cecum for carcinoma, and in every instance this method\\nof approximation proved eminently successful (Fig. 217).\\nIntestinal Anastomosis. If the carcinoma, by the promotion of car-\\ncinomatous adhesions with neighboring organs or by extensive regional\\ninfection through the lymphatic channels, has advanced beyond the\\nlimits of a radical operation, an intestinal anastomosis should be made.\\nThis operation consists in establishing a fistula between the bowel\\nabove and below the tumor.\\nA B\\nThe operation can be done\\nby making in the respective\\nparts of the bowel an incis-\\nion four inches in length,\\nas advised by Abbe, and\\nthe union is effected by a\\ndouble row of silk sutures.\\nA single row of sutures\\nmight prove all-sufficient,\\nbut as a matter of safety a\\ndouble row is preferable.\\nThe same object can be\\naccomplished in a shorter\\ntime and with a greater de-\\ngree of security by substi-\\ntuting for the inner row of sutures perforated decalcified bone-plates\\n(Fig. 218). The anastomotic opening should correspond in size with\\nthe lumen of the bowel.\\nThe use of the Murphy button would be attended by great danger\\nin such cases, as the button would be just as likely to fall into the blind\\nend of the bowel on the proximal side of the obstruction as into the\\nopposite side. Besides, it has been shown by Keen and others that\\nthe opening, small in the beginning, is apt to become contracted beyond\\nthe limits of its requirements in a comparatively short time.\\nRectum.. Carcinoma of the rectum occurs more frequently than\\ncarcinoma of the remaining portion of the intestinal canal, its greater\\nfrequency here being probably accounted for by the rectum being\\nmore often the seat of benign growths, of chronic inflammatory affec-\\ntions, and of prolonged irritations from different sources. The histo-\\nlogical structure of most of the rectal carcinomata presents a tubular\\narrangement of the cells, surrounded and enclosed by a connective-tissue\\nstroma which in the soft variety of tumors is exceedingly scanty, and\\nin the hard, constricting variety is very abundant and compact (Fig.\\n219). In the rapidly infiltrating form the rectal tube becomes indurated\\nFig. 218. Intestinal anastomosis with the aid of perforated\\ndecalcified bone-plates in the operative treatment of inoperable\\ncarcinoma of the bowel (after Esmarch) A, plates in situ\\nb, operation completed.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0369.jp2"}, "362": {"fulltext": "34o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nand the surface ulcerates, but its lumen is not much reduced in size.\\nIn the circular constricting form the constricting ring is very dense and\\nthe lumen of the bowel is rapidly diminished in size. This is the form\\nFig. 219. Cylindrical-celled carcinoma of the rectum X 480 (Surgical Clinic, Rush Medical College, Chicago)\\na, connective-tissue stroma b, atypical tubules of carcinoma; c, cylindrical epithelial cells.\\nof rectal carcinoma that produces obstruction and is most favorable to\\noperative treatment, owing to the limited extent of the tumor and the\\ndilated condition of the bowel above the obstruction, permitting the\\nbowel to be drawn down after removal of the carcinomatous part.\\nThe writer has already referred to a case that came under his obser-\\nvation of carcinoma of the rectum in a boy eighteen years of age. Car-\\ncinoma of the rectum, however, with few exceptions is a disease of\\nadvanced life. According to Hildebrandt s statistics, 16 per cent, of\\nrectal carcinomata occur in persons less than forty years old, 54 per\\ncent, in persons forty to sixty years of age, and 30 per cent, in persons\\nfrom sixty to eighty years old. The carcinoma is located most fre-\\nquently in the lower third of the rectum. The stagnation of feces\\naggravates the ulcerative process and produces at the same time a\\ncatarrhal proctitis above the tumor. Local extension takes place in\\nthe direction of the connective tissue outside of the rectum, in advanced\\ncases rendering the rectum as immovable as though it were held in", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0370.jp2"}, "363": {"fulltext": "CARCINOMA. 341\\na vise. Regional infection takes place in the rapid-growing variety\\nat an early stage, and extends in the direction of the chain of sacral\\nand lumbar lymphatic glands. In advanced cases the regional infec-\\ntion occasionally includes the inguinal glands. Metastasis of different\\norgans hastens the fatal termination. The statement has already been\\nmade that cylindrical carcinoma gives rise earlier and more constantly\\nto metastasis than does carcinoma representing epiblastic tissue.\\nSymptoms and Diagnosis. Carcinoma of the rectum is not attended\\nby much suffering until the tumor by its size or by constriction gives\\nrise to obstruction. A sense of weight and an aching feeling in the\\nsacral region, usually attributed to rheumatism or hemorrhoids, is\\nabout all the patient complains of during the early stages. The dis-\\ncharge of a little blood and mucus, and constipation alternated by\\ndiarrhea, are the symptoms which usually induce the patient to seek\\nmedical advice under the belief that he is suffering from piles. Patients\\ngiving such a clinical history slwuld always be subjected to a thorough\\nrectal examination. Digital exploration is more to be relied upon in\\nconducting this examination than the use of the different kinds of rectal\\nspecula. The patient should be brought into the exaggerated lithotomy\\nposition. With the right index finger well lubricated the rectum is\\nexplored, and unless the carcinoma involves the first part of the rectum\\nthe tumor is discovered without any difficulty. In the constricting\\nvariety the lower end of the tumor with the constricted lumen feels\\nvery much like an enlarged lacerated cervix uteri. The size of the\\nlumen and the mobility of the affected part are now determined, after\\nwhich careful search should be made for enlarged lymphatic glands in\\nthe sacral fossa. If the tumor has infiltrated the rectal wall without\\nhaving produced contraction, the rectum feels like a firm, unyielding\\ncylinder with points of ulceration of its mucous lining.\\nIn cicatricial stenosis of the rectum, the only condition liable to be\\nmistaken for carcinoma, the stricture is usually near the anus, infiltra-\\ntion of the rectal wall is less marked, any considerable enlargement of\\nthe sacral glands is absent, and the stricture is often multiple, which\\nlatter is not the case in carcinoma. Should any doubt exist as to the\\ndifferential diagnosis between these two rectal affections, a fragment of\\ntumor-tissue should be removed and sections of it be examined under\\nthe microscope.\\nIndications for a radical operation are absence of paraproctitic infil-\\ntration and of extensive lymphatic infection, and a sufficient accessibility\\nof the tumor to enable the surgeon to remove all the diseased tissue\\nby a radical operation. Opposite conditions must be regarded as posi-\\ntive contraindications to any radical measures.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0371.jp2"}, "364": {"fulltext": "342\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nPalliative Operations. In inoperable cases of carcinoma of the rec-\\ntum the surgeon can do a great deal to alleviate the suffering of the\\npatient by establishing an artificial anus in the left inguinal region.\\nRemoval of the carcinomatous tissue projecting into the lumen of\\nthe bowel by scraping, and linear rectotomy, for the purpose of ame-\\nliorating the symptoms due to\\nobstruction, have become, for\\nsubstantial reasons, obsolete\\nmeasures. If the carcinoma\\nproduces obstruction, an arti-\\nficial anus will benefit the\\npatient in two ways it will\\nexclude from the fecal circula-\\ntion the diseased part of the\\nrectum, and at the same time\\nwill establish a free outlet for\\nthe intestinal contents. If an\\nartificial anus is made under\\nsuch circumstances, it should\\nbe made with a view of com-\\npletely interrupting the fecal\\ncirculation and thus affording\\nabsolute rest for the excluded\\npart of the bowel. Maydl s colostomy (Fig. 220) will answer these\\nrequirements to perfection. An incision four inches in length is made\\nabout two inches above Poupart s ligament, halfway between the symphy-\\nsis pubis and the anterior superior spinous process of the ilium, parallel\\nwith the fibres of the external oblique muscle. The muscular layers are\\nseparated as far as possible by the use of blunt instruments. The trans-\\nversalis fascia and the peritoneum are incised to the extent of the external\\nwound. Some care is now necessary to recognize, seize, and bring for-\\nward into the wound in proper position the sigmoid flexure. As soon\\nas the proper loop has been found the mesentery near the bowel is tun-\\nnelled with a hemostatic forceps, and a glass tube four\\ninches in length, the size of an ordinary lead pencil,\\ncovered by several layers of gauze, is drawn through\\nthis opening with the forceps. The glass tube serves\\nas a bridge for the prolapsed loop of the bowel.\\nThe two limbs of the bowel are now sutured together\\non each side by two sero-muscular sutures under-\\nneath the bridge (Fig. 221). Next, the prolapsed\\nloop is sutured at its base to the parietal peritoneum\\nby at least six points of suture, to prevent the escape of intestinal\\nFig. 220. Maydl s inguinal colostomy.\\nFig. 221. Maydl s co-\\nlostomy, showing the posi-\\ntion of the bridge and the\\nsutures underneath it.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0372.jp2"}, "365": {"fulltext": "CARCINOMA. 343\\nloops. If the symptoms are urgent, the base of the loop is surrounded\\nby a ring of absorbent cotton fastened to the bowel and the skin by\\ncollodion the bowel is then, at the most prominent part, divided trans-\\nversely to the extent of at least two inches. If the symptoms are not\\nurgent, it is much safer to postpone the opening of the bowel for two\\nor three days, until the peritoneal cavity has become shut out by\\nadhesions all around. If this course is adopted, an ordinary antiseptic\\ndressing is applied, taking the precaution that the intestinal loop should\\nnot be subjected to harmful pressure. On the second or third day the\\ndressing is removed, the collodion ring is applied, and the bowel is\\nincised as indicated above. It is advisable to keep the bridge in place\\nfor at least a week or two, in order to secure at a point opposite to it\\nthe formation of an efficient spur. Complete section of the bowel at\\nthis time is recommended by some but it is not necessary, as the spur,\\nif well developed, will direct all the intestinal contents away from the\\nlower part of the bowel, and the bowel on the distal side can be flushed\\nfrom time to time as may appear necessary.\\nExtirpation of the Rectum for Carcinoma. Extirpation of the carci-\\nnomatous rectum is now generally made through the sacral route. A\\nlong time ago, Kocher recommended removal of the coccyx as a pre-\\nliminary step to the removal of the lower part of the rectum. Encour-\\naged by the success attending the removal of the rectum from this\\ndirection, surgeons have become bolder and have sacrificed parts of\\nthe sacrum for the purpose of securing better access to the diseased\\nrectum. The resection, temporary or permanent, of a part of the pos-\\nterior bony wall of the pelvis has\\nenabled surgeons to extend the\\nfield of radical operations upon the\\nrectum for malignant disease.\\nThe different points where the\\nsacrum has been divided in the\\noperation for extirpation of the\\nrectum are shown in Figure 222.\\nAs is the case with similar ope-\\nrations in other parts of the body,\\nthe application of the principle of\\nSacral resection as a preliminary Fig. 222.\u00e2\u0080\u0094 Resection of sacrum in extirpation of\\nStep tO extirpation Of the rectum -ct m for carcinoma: .after Kraske; after\\nr r cardenheuer b, after Volkmann, Rose.\\nhas been carried too far. It ap-\\npears to the writer unjustifiable to carry the resection of the sacrum as\\nfar as has been done by Volkmann and Rose. The simple removal of\\nthe coccyx will often suffice in affording ample room for the removal", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0373.jp2"}, "366": {"fulltext": "344 PATHOLOGY AND TREATMENT OF TUMORS.\\nof the lower part of the rectum, and Kraske s operation will usually\\naccomplish all that could be desired in the removal of a carcino-\\nmatous rectum when the disease is within the limits of a justifiable\\noperation.\\nThe patient should be prepared for a number of days for the opera-\\ntion by dieting, laxatives, warm baths, and colonic irrigation, so as to\\nsecure for the part, as nearly as can be done, an aseptic condition.\\nImmediately before the operation the lower part of the rectum should\\nbe flushed thoroughly with Thiersch s solution, and the external sur-\\nface should be scrubbed thoroughly with warm water and potash soap,\\nand later be disinfected with a solution of corrosive sublimate or of\\ncarbolic acid. After the patient is under the influence of an anesthetic\\nhe is placed face down upon a low table or a cot, the pelvis is elevated\\nby placing under it pillows covered by rubber sheeting, and the thighs\\nand the legs are flexed. This position diminishes the amount of venous\\nhemorrhage, and the abdominal organs gravitate toward the chest,\\nleaving the pelvis comparatively empty. An incision is then made in\\nthe median line from the centre of the sacrum to the verge of the anus.\\nThe coccyx is enucleated, and the lower two sacral vertebrae are isolated\\nfrom the soft tissues by the use of the knife and the periosteal elevator.\\nThe sacrum is then divided transversely between the last two foramina\\nwith a large chisel and a mallet. All hemorrhage is then carefully\\narrested. After this step of the operation minute details as to the\\nimmediate arrest of hemorrhage by the use of hemostatic forceps must\\nbe carried out. By careful dissection between tissue-forceps the rectum\\nis reached. As soon as this has been done cutting instruments should\\nbe used sparingly. The rectum should be enucleated rather than\\nexcised. Connective-tissue bands and muscles are isolated before they\\nare cut. The proximal end of the tumor should be reached first. If\\nthe rectum has to be removed high up, the peritoneal cavity is opened\\ncarefully, and prolapse of intestines, as well as the entrance of blood\\ninto the peritoneal cavity, is prevented by packing the opening with\\ngauze sponges well secured in a hemostatic forceps. When healthy\\ntissue is reached, a strip of gauze is tied around the rectum sufficiently\\ntight to prevent escape of intestinal contents, after which the bowel is\\ndivided below transversely. The bowel is then drawn downward,\\nand the diseased segment is separated by a careful dissection. If pos-\\nsible, the external sphincter muscle is preserved. The course to be\\npursued now depends on how far the rectum has to be removed in a\\ndownward direction. If the distal end can be preserved, the surgeon\\ncan select one of two procedures. The proximal end can be united\\nwith the distal end by circular enterorrhaphy. Owing to the absence", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0374.jp2"}, "367": {"fulltext": "CARCINOMA. 345\\nof a peritoneal investment in the lower end, this procedure has not\\nyielded good results. Hochenegg has suggested that the proximal\\nend should be invaginated into the distal end and be sutured to a cir-\\ncular denudation at the anus. The results after this procedure have\\nbeen more satisfactory than those after the first-named method. If the\\nlower part of the bowel has to be removed, the resected end is drawn\\ndownward and is attached to the external skin by sutures. The bowel\\nend must be ruffled so as to diminish its lumen before it is attached\\nthis can be done with a circular purse-string suture of catgut. In\\neither of these procedures the cavity of the wound is packed with\\niodoform gauze, over which the external wound is sutured except at\\nfrom one to three places, where the gauze is brought out to the sur-\\nface. The patient should be given a liquid diet for a few days, and\\nsmall doses of opium to constipate the bowels temporarily. If no con-\\ntraindications arise, the gauze should remain for at least a week. At\\nthis time the whole wound-surface is covered by a pavement of active\\ngranulations that will guard against infection later. The wound pre-\\nsenting such a condition heals in a remarkably short time.\\nIf the rectum is amputated high up and the resected end cannot be\\nbrought down, a sacral anus is established by suturing the bowel into\\nthe upper angle of the external incision. The writer has pursued this\\ncourse a number of times, and believes that an artificial anus in this\\nlocality has a number of advantages not possessed by an artificial anus\\ndevoid of a proper sphincter muscle lower down. Should the wound\\nsuppurate, enough sutures are removed to secure free drainage. In\\nthis event the dry dressing must give way to frequent antiseptic irriga-\\ntions and to a compress of gauze kept moist with a saturated solution\\nof acetate of aluminum or of boric acid.\\nIf the carcinoma returns, little is to be expected from another ope-\\nration, as the local recurrence is usually accompanied by extensive\\ninfiltration and lymphatic infection. The formation of an artificial anus\\nin such cases is never indicated, as the recurring carcinoma does not\\ncause constriction of the bowel, but extends to the\u00c2\u00abpelvic connective\\ntissue.\\nLiver. Primary carcinoma of the liver is extremely rare. Riesen-\\nfeld, Klebs, and von Bergmann do not believe in the primary origin of\\ncarcinoma of the liver. In 1885, Harris of London collected 19 cases\\nof primary carcinoma of this organ. In 6000 postmortems made by\\nVirchow the liver was found to be the seat of carcinoma in 95 of\\nthese; the disease was secondary in 90, and primary in 5. Two cases\\nof carcinoma of the liver have been subjected to operative treatment.\\nIn von Bergmann s case the tumor was located in a pedunculated lobe", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0375.jp2"}, "368": {"fulltext": "346 PATHOLOGY AND TREATMENT OF TUMORS.\\nof the liver, which was excised with the tumor. The patient recovered\\nand remained in good health a year after the operation. Luecke\\noperated successfully in two stages on a similar case, and the patient\\nwas free from recurrence at the expiration of two years. It is only\\nin such isolated and favorable cases that operative treatment is indi-\\ncated.\\nTesticle. Carcinoma as compared with sarcoma of the testicle is\\nan exceedingly rare affection. Sometimes it engrafts itself upon the\\nbasis of an antecedent benign tumor or an inflammatory affection. The\\nd\\nm\\na\\nFig. 223.\u00e2\u0080\u0094 Carcinoma and tuberculosis of the testicle X 85 (Surgical Clinic, Rush Medical College,\\nChicago) a, stroma of carcinoma b, alveolus packed with carcinoma-cells c, focus of caseous degenera-\\ntion; d, miliary tubercles in carcinoma-tissue.\\nsection from which the illustration (Fig. 223) was taken was derived\\nfrom a testicle that had been tubercular for a long time and had only\\nrecently commenced to increase rapidly in size. This specimen refutes\\nthe assertion made by Rokitansky, that tuberculosis and carcinoma\\nexclude each other. There can be no doubt in this case that the tuber-\\ncular epididymitis was the primary and carcinoma the secondary affec-\\ntion. Sutton has never seen a tubular carcinoma of the testicle. That", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0376.jp2"}, "369": {"fulltext": "CARCINOMA.\\n347\\nsuch a carcinoma occasionally, although rarely, occurs is shown by\\nFigure 224. Langhans never saw hard, but always soft, carcinomata\\nof this organ. He believes that the tumor starts from the epithelial\\ncells lining the seminiferous tubules. He also calls attention to the\\ntransformation of an adenoma of the testicle into a carcinoma.\\nFrom a diagnostic point of view it is important to remember that\\ntuberculosis almost always begins in the epididymis, and carcinoma in\\ni\\nJgk\\n:v#\\n--49\\nFig. 224. Tubular carcinoma of the testicle; X 270 (after Karg and Schmorl). The tumor is composed\\nof long, solid streaks of large epithelial cells (a). The nuclear structures cannot be seen, as the chromatin\\nhas been affected by the hardening solution, Miiller s fluid. The stroma (i) is scanty and is rich in cells.\\nthe testicle proper. As carcinoma of this organ is always soft, it is\\nliable to undergo cystic degeneration an occurrence which still further\\ncomplicates the diagnosis. The regional infection extends along the\\nlymphatics of the cord and from the cord to the iliac fossa. The tumor\\nmay attain the size of an adult s head.\\nEarly removal of the testicle with its envelopes and the cord as far\\nas it can be followed is the only operation that promises a permanent\\nresult. Kocher has observed cases in which the disease did not recur\\nfor four and a half, eight and a half, and ten and a half years after\\noperation.\\nPenis. Carcinoma of the prepuce and of the glans penis is observed\\nin men past fifty years of age. Kaufmann estimates that one-third of all", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0377.jp2"}, "370": {"fulltext": "348\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nthe cases occur during the sixth decennium. Occasionally the tumor\\noriginates in Tyson s glands. Such a case is referred to by Tyson.\\nUsually the tumor commences in the epithelial layer of the skin and\\nof the glans penis, and presents itself as a cauliflower tumor with great\\ninduration at its base. The surface ulcerates early, and is usually the\\nseat of a very offensive discharge.\\nThe histological structure of carcinoma of the penis (Figs. 225, 226)\\nresembles essentially squamous-celled carcinoma of the skin in other\\nlocalities. Paget saw in a number of cases carcinoma of the penis pre-\\nceded by balanitis. In other cases the disease starts in a pre-existing\\nFig. 225. Squamous-celled carcinoma of the penis X 150 (after Perls) to the right, normal skin to the\\nleft, proliferating epithelial projections with numerous cancer-nests.\\ninflammatory lesion of a more circumscribed nature. Injuries sustained\\nduring coitus, during masturbation, and by friction of the clothing may\\nfurnish the exciting causes in other cases.\\nIt was formerly doubted that carcinoma of the penis could give rise\\nto regional infection. Kaufmann and Gussenbauer have shown that\\ncarcinoma of this organ pursues the same course as carcinoma of the\\nskin in other localities namely, that regional infection occurs, as a rule,\\nlate, but that it is sure to ensue if the disease is allowed to pursue its\\nown course. The writer has seen regional infection much more fre-\\nquently in carcinoma of the penis than in carcinoma of the lip. The\\ninguinal glands on both sides eventually become involved a fact which\\nhas led to the conviction that it is necessary in most cases to resort at\\nonce to clearing out of the inguinal glands in all cases of carcinoma\\nof the penis in which a radical operation is performed.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0378.jp2"}, "371": {"fulltext": "CARCINOMA. 349\\nAmputation of the Penis for Carcinoma. If the carcinoma is limited\\nto the prepuce, and no evidences of lymphatic affection are present, the\\norgan should be amputated behind the corona glandis. The penis is\\nconstricted at its base with a rubber cord or tube to render the opera-\\ntion bloodless. The section through the penis should be made with\\nthe knife in such a manner as to secure for the stump a cutaneous\\ncovering. The writer generally makes an oval anterior flap with which\\n*0m\\nFig. 226. Papillary carcinoma of penis X 10 (after Karg and Schmorl). Between the enlarged papillae,\\ncovered by thickened layers of epithelial cells, are found infiltrations of epithelial cells which in the vascular\\nconnective tissue show distinct cancer-nests.\\nto cover the corpora cavernosa. The mucous membrane of the ure-\\nthra is stitched to this flap and to the adjacent skin. The dorsalis penis\\nartery is ligated. The hemorrhage from the corpora cavernosa, at first\\nprofuse, yields to compression, hot water, and the sutures. A small\\ndressing held in place with a number of strips of adhesive plaster fin-\\nishes the operation. Rest for a few days in bed must be enforced.\\nThe suturing of the flap and the urethra should be done with fine cat-\\ngut sutures, so as to obviate the necessity of removing them.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0379.jp2"}, "372": {"fulltext": "350 PATHOLOGY AND TREATMENT OF TUMORS.\\nIf the body of the penis is affected by extension of the primary\\ntumor of the prepuce or the glans penis, the organ should be amputated\\nclose to the pubes, and at the same time the inguinal glands on both\\nsides should be removed. The amputation is made with the knife and\\nin the manner just described, but an outlet for the urethra is established\\nin the perineum, as first recommended by Thiersch. The urethra is\\nisolated, is brought out through a small buttonhole behind the\\nscrotum, and is firmly anchored to the skin with a few sutures. In a\\ncase that recently came under the writer s observation the disease had\\nextended along the penis and had involved the mons veneris as well as\\nthe glands in both inguinal regions. In this case the entire penis, part\\nof the mons veneris, and both testicles were removed, and the posterior\\npart of the scrotum was utilized as a covering for the enormous wound.\\nThe incision was extended on both sides the whole length of Poupart s\\nligament, and was joined over the large femoral vessels by a vertical\\nincision reaching to the apex of Scarpa s triangle. The whole chain\\nof glands on each side was removed with the penis in one continuous\\npiece. The urethra was stitched to the margins of a small opening in\\nthe perineum. The shock from the operation required active treatment\\nby stimulants. The patient rallied in the course of six hours and made\\nan excellent recovery. Three months after the operation he returned\\nto the hospital greatly improved in general health, but with a recurrence\\nin the left groin. A second operation was performed, and a section of\\nthe internal saphenous vein was removed with the carcinomatous tissue\\nby which it was surrounded. Six months after since the second opera-\\ntion there were no signs of further recurrence.\\nOvary. Carcinoma of the ovary occurs after the period of puberty\\nas a comparatively rare affection as a primary tumor, in cystic tumors,\\nand as the result of extension by contiguity of a carcinoma of an\\nadjacent organ. Olshausen describes papillary carcinoma of the ovary\\nas a primary tumor. The same author makes the statement that Klebs\\nand Spencer Wells first called attention to this form of carcinoma of\\nthe ovary. The carcinoma appears as a malignant form of papillary\\nor proliferating cystoma. Marchand has shown that this form of cystic\\ntumor of the ovary gives rise to metastasis. In one case of papillary\\ncyst of the ovary in a woman thirty-five years of age the writer found\\nthe tumor extensively adherent to the anterior abdominal wall. The\\ntumor was, however, completely removed, and the patient made a good\\nrecovery. Six months later she again entered the hospital, and upon\\nexamination quite an extensive carcinoma was found in the scar just\\nbelow the umbilicus. A considerable portion of the entire thickness\\nof the abdominal wall, and including the whole scar, was resected. She", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0380.jp2"}, "373": {"fulltext": "CARCINOMA. 351\\nrecovered without any untoward symptoms, but died a few months\\nlater from diffuse carcinosis of the peritoneum. Pfannenstiel and\\nOlshausen have seen carcinoma develop in the scar following lapa-\\nrotomy for the removal of non-malignant ovarian tumors, and attribute\\nits origin to implantation of epithelial cells from the tumor upon the\\nwound-surfaces. In one of the cases reported by Pfannenstiel several\\nyears after the removal of a small simple cystic tumor of the ovary a\\ntypical adenocarcinoma developed in the abdominal scar. He came to\\nthe same conclusion as Olshausen, that the development of the carci-\\nn\\nFig. 227.\u00e2\u0080\u0094 Carcinoma of the ovary; X 75 (Surgical Clinic, Rush Medical College): a, scanty connective-\\ntissue stroma; b, nests of epithelial cells; c, small colloid cysts; d, blood-vessel.\\nnoma was referable to the cystic tumor that epithelial cells from the\\nbenign cystoma became detached and implanted either in the abdom-\\ninal cavity or in the wound, and eventually developed into a carcinoma.\\nHe is of the opinion that the last process did not follow immediately\\nupon the epithelial deposit, but that first an adenoma developed, and\\nfrom that a carcinoma sprang.\\nRokitansky described a case of carcinoma of the ovary that started\\nin a corpus luteum.\\nThe occurrence of carcinoma in cysts, and the resemblance anatom-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0381.jp2"}, "374": {"fulltext": "352 PATHOLOGY AND TREATMENT OF TUMORS.\\nically of the carcinomatous and adenomatous proliferating cysts of the\\novary, make it very difficult to distinguish, from the naked-eye appear-\\nances of certain cysts of the ovary, between malignant and non-malig-\\nnant tumors. From a histological standpoint this difficulty is increased\\nbecause endothelial tumors of a malignant character are included by\\nsome authors under the head of carcinoma. Endothelioma, which was\\nfirst described by Birch-Hirschfeld as carcinoma of the lymphatics, con-\\nstitutes a tumor composed of tissue derived from the mesoblast, and it\\nwill again be referred to in the section on Sarcoma. Carcinoma as a\\nprimary tumor of the ovary undoubtedly originates, as does adenoma,\\nin a remnant of the fetal ducts (Fig. 227). The stroma is alveolated\\nand is usually scanty the cells are numerous, filling the alveoli and\\ninfiltrating the stroma. The tumor is soft and grows rapidly. Colloid\\ndegeneration affecting both the parenchyma and the stroma of the\\ntumor results in the formation of cysts. Diffuse carcinosis of the peri-\\ntoneum takes place when the tumor perforates the capsule of the ovary.\\nTumor-cells and fragments of tumor-tissue are disseminated over the\\nperitoneal surfaces by the peristaltic action of the intestines these\\ncells and fragments of tissue become implanted at different places,\\nand establish in this manner independent centres of tumor-growth\\neverywhere.\\nAscites is often the first symptom which induces the patient to seek\\nmedical advice. Ascites in the female occurring independently of the\\nexistence of organic disease of the liver, heart, or kidneys indicates the\\nexistence of either peritoneal tuberculosis, malignant disease of the\\novary, or a movable solid tumor of the uterus or the ovaries. If the\\npatient is advanced in years, the possibility of the primary affection\\nbeing of a malignant character is greatly increased. Carcinoma of the\\nuterus is exceedingly prone to extend to the ovaries. Winckel records\\na case in which, a year and a half after amputation of the cervix for\\ncarcinoma, the disease made its appearance in one of the ovaries, while\\nno local recurrence had taken place.\\nMany gynecologists are opposed to radical measures in the treat-\\nment of carcinoma of the ovary. This sense of helplessness on the\\npart of the surgeon when confronted by such a case has been created\\nlargely by the unfavorable experience of late operations. Usually,\\nbefore a laparotomy is made, the disease has extended from the ovary\\nto the adjacent organs. The broad ligament is often extensively impli-\\ncated. The adherent omentum frequently shows evidences of extensive\\ninvolvement, and sometimes diffuse miliary carcinosis is present. If the\\ngeneral condition of the patient is such as to warrant an exploratory\\nincision, this should always be done, if for no other purpose than to", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0382.jp2"}, "375": {"fulltext": "CARCINOMA. 353\\nmake a positive diagnosis. It is just possible that the ascites and the\\nother conditions which have induced the surgeon to make a diagnosis\\nof carcinoma may have been produced by other pathological conditions\\nwhich are within reach of successful treatment by direct measures.\\nThe patient should therefore be given the benefit of the doubt by a\\nresort to an exploratory incision. It appears that temporary relief and\\nprolongation of life have been obtained in cases in which the disease\\nreturned later. The writer can recall at least three instances in which,\\nby the removal of a carcinomatous tumor of the ovary with extensive\\nadhesions, great relief was afforded and life was prolonged for from six\\nmonths to a year. If the disease is limited in extent, the success of an\\noperation should be the same as in operations for carcinoma of other\\norgans similarly situated. If the attachments are such that the removal\\nof the tumor would place the life of the patient in imminent danger,\\nthe operator should go no further, and should close the wound after\\nhaving made a positive diagnosis.\\nUterus. Carcinoma of the uterus was known to the ancient\\nauthors, and has been described elaborately by Hippocrates, Celsus,\\nGalen, ^Etius, and others. In more recent times animated discussions\\nhave been carried on in regard to its starting-point. Cancroid, papil-\\nlomatous carcinoma, scirrhus, and medullary carcinoma of the uterus\\nhave been regarded as distinct varieties of carcinoma. The histo-\\ngenetic origin of carcinoma of the uterus, like that of carcinoma of\\nother mucous surfaces, can be traced either to a matrix of embryonic\\ncells in the epithelial lining or to a matrix representing the glandular\\nappendages of the uterus.\\nHistogenesis and Histology. The cauliflower excrescences of the\\ncervix uteri, or the papillomatous variety of carcinoma, have been recog-\\nnized for a long time as one of the most common malignant tumors\\nof the uterus. How much confusion has existed in separating the\\nmalignant from the benign papillary tumors is evidenced from a de-\\nscription of them by Virchow in 1851\\nOne must distinguish three different papillary tumors of the os\\nuteri the simple, such as Frerichs and Lebert have seen the cancroid\\nand the cancerous the first two forms together constitute the cauli-\\nflower growth. This begins as a simple papillary tumor, and at a later\\nperiod passes into cancroid. At first one sees only on the surface\\npapillary or villous growths, which consist of very thick layers of\\nperipheral, flat, and deeper cylindrical epithelial cells, and a very fine\\ninterior cylinder formed of a scanty stroma of connective tissue with\\nlarge vessels. The outer layer contains cells of all sizes and stages\\nof development, some of them forming great parent structures with\\n23", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0383.jp2"}, "376": {"fulltext": "354\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nendogenous corpuscles. The vessels are for the most part colossal,\\nvery thin-walled capillaries, which form either simple loops at the apices\\nof the villi, between the epithelial layers, or toward the surface develop\\nnew loops in constantly increasing number, or, lastly, present a retic-\\nulate branching. At the beginning of the disease the villi are simple\\nand close pressed, so that the surface appears only granulated, as\\nClarke describes it: it becomes cauliflower-like by the branching of\\nthe papillae, which at last grow out to fringes an inch long, and may\\npresent almost the appearance of a hydatid mole. After the process\\nhas existed for some time on the surface, the cancroid alveoli begin to\\nform deep strings between the layers of the muscular and the con-\\nnective tissue of the organ. In the early cases I saw only cavities\\nsimply filled with epithelial structures but in Kiwisch s case there\\nwere alveoli on whose walls new papillary branching growths were\\ngrowing a kind of proliferous arborescent formation.\\nIt will be seen from this description that the cauliflower excrescences\\nin the two conditions distinguished by Virchow illustrate the usual\\nclinical course of the most malignant growths of the cervix uteri.\\nThe growths which he calls simple papillary tumors represent the\\nsame form of carcinoma of the skin. The outgrowth of the papillary\\nexcrescences is always attended by infiltration of the deeper structures\\n(Fig. 228). The tumor is composed of enlarged papillae covered by\\nFig. 228. Papillary cancer of the cervix: pavement epithelium of the external os section, natural size\\n(after Pozzi).\\nsquamous epithelial cells in greatly thickened layers. The enlarged\\npapillae form the branching projections. The tumor begins in that part\\nof the cervix that is below the vaginal insertion, after it starts from\\ncylindrical epithelium which has invaded the surface. It remains for", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0384.jp2"}, "377": {"fulltext": "CARCINOMA.\\n355\\na long time local, but later local and regional infection is sure to take\\nplace, extending to the vagina, the body of the uterus, the pelvic con-\\nnective tissue, and the lymphatic glands.\\nJ-\\nm\\n%0\u00c2\u00a5m\\nr\\nHPI*\\n2\\nifi*\\nk: ^\u00c2\u00a7jb\\nFig. 229. Carcinoma of the cervix uteri X 12 (after Karg and Schmorl): vertical section through the\\ncarcinomatous anterior lip of the cervix. The carcinoma commenced in the vaginal portion of the cervix.\\nThe mucous membrane of the cervical canal is completely destroyed. The tumor projects from the cervical\\ncanal, in the form of cauliflower excrescences (a), beyond the level of the squamous cells (c) of the anterior\\nlip; at other points it infiltrates, in the form of solid strings of cells and nests of cells, the vascular mus-\\ncularis {d) remnants of uterine glands lined with cylindrical cells.\\nIn other cases the carcinoma appears as an induration without any\\npapilliform projections. Ulceration in the centre of the growth takes\\nplace at an early stage, and continues to spread toward the periphery\\nas well as in the direction of the base of the ulcer. These are the cases\\nwhich correspond with the flat, squamous-celled carcinoma of the skin.\\nCarcinomata originating in the mucous membrane of the cervical", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0385.jp2"}, "378": {"fulltext": "356\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nFig. 230. Uterine gland, showing very early malignant overgrowth of the columnar epithelium at a and b\\n(after Boyce). (Obj. 1 inch, with eye-piece.)\\n\u00e2\u0080\u0094b\\n5\\nFig. 231. Cylindrical-celled carcinoma from the upper part of the cervix, invading the fundus X 150\\n(after Cornil) m, e, hypertrophied glands of the body of the uterus, like those of chronic metritis t, en-\\nlarged glandular cavity, the walls showing many layers of epithelium b, adjacent gland-wall in a similar\\nstate v, vessels c, connective tissue.\\nFig. 232. Cylindrical-celled carcinoma of the body of the uterus, extending from the cervix X 150\\n(after Cornil) c, c, connective tissue; a, cavity full of cells, the external layer being cylindrical: these cells\\nhave a tendency to become detached from the wall, well seen at o f, cavity with mucous cells, and larger\\ncells in mucous degeneration.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0386.jp2"}, "379": {"fulltext": "CARCINOMA.\\n357\\ncanal begin in the glands, and are composed of cylindrical cells\\narranged in tubular form in a stroma very variable in its relative\\nproportions to the parenchyma of the tumor (Fig. 229). Primary car-\\ncinomata of the mucous membrane of the cervical canal and of the\\nuterine cavity histologically resemble each other almost perfectly.\\nThe structure is in imitation of the mucous glands. The starting-point\\nof the tumor is in a matrix of embryonic cylindrical epithelial cells that\\npre-exists in one of the glands or in their immediate vicinity, or that is\\nformed later in these localities by post-natal causes. Boyce had an\\nopportunity to study the incipient stage of a tumor with such an origin\\n(Fig. 230). The illustration represents a complete uterine gland, the\\nmouth of which (a) is stopped by an epithelial overgrowth of the\\ncolumnar lining, and on whose wall (at b) a plaque of proliferated epi-\\nthelium has formed in the midst of typically columnar cells. It is\\nthe beginning of a cancerous change which elsewhere in the uterus\\nhas advanced to completeness. Where the change is complete the\\nglands have been converted into solid epithelial cylinders these,\\ntogether with the prolife rating epithelium on the surface, have branched\\ndeeply into the stroma (Fig. 231).\\nFig. 233. Carcinoma of the uterine mucous mem-\\nbrane, circumscribed form (after Pozzi).\\nFig. 234. Carcinoma of the uterine mucous mem-\\nbrane, diffuse form (after Pozzi).\\nCylindrical-celled carcinoma is much more malignant than the squa-\\nmous-celled variety. Carcinoma of the cervical canal creeps along the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0387.jp2"}, "380": {"fulltext": "358 PATHOLOGY AND TREATMENT OF TUMORS.\\nmucous membrane into the cavity of the uterus. The intra-uterine\\nFig. 235. Primary carcinoma of the uterus; X 120 (after Pozzi) b, b, lobules of the tumor; m, lobules\\nshowing empty spaces, which are either transverse sections of vessels or cavities filled with cells in mucous\\ndegeneration n, smaller alveoli of the tumor. Nearly all these epithelial cells have a tendency toward\\nisolation by the walls of the vessels that enclose them.\\npart of the tumor presents under the microscope a structure similar to\\nthat of the primary tumor (Fig. 232).\\nmm\\nFig. 236. Primary carcinoma of the uterine body X 300 (after Cornil) a, numerous layers of stratified\\nepithelium, the deepest being cylindrical e, e, cells with karyokinesis t, muscular tissue of the uterus, on\\nwhich the cylindrical cells are directly implanted.\\nPrimary carcinoma of the body of the uterus is a much rarer affec-\\ntion than carcinoma of the cervix. Clinically, carcinoma of the uterine\\ncavity presents itself in two forms, the circumscribed (Fig. 233) and the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0388.jp2"}, "381": {"fulltext": "CARCINOMA. 359\\ndiffuse (Fig. 234). In the circumscribed form the tumor often attains\\nconsiderable size before it breaks down, and frequently it assumes a\\npolypoid shape. In the diffuse variety the mucous membrane is ex-\\ntensively involved from the beginning, and the disease infiltrates the\\nmuscular tissues in all directions, resulting in a uniform pear-shaped\\nenlargement of the body of the uterus.\\nThe structure of a primary carcinoma of the uterine mucous mem-\\nbrane, like that of a carcinoma of the cervical canal, is usually in imita-\\ntion of the uterine glands. Cylindrical cells are arranged in a tubular\\nform in an alveolated stroma (Fig. 235). The cylindrical cells are\\narranged in the tubules in one or more layers. If the layers are\\nnumerous, the cells most distant from the matrix become flattened and\\nresemble squamous or pavement epithelium (Fig. 236). Mucous and\\ncolloid degeneration leads to dilatation of the tubules and the formation\\nof cysts of small size. The stroma often undergoes similar changes.\\nThe infiltration of the cervix and body of the uterus imparts to the\\naffected organ that characteristic hardness with which the surgeon\\nbecomes so familiar as an important point in differential diagnosis.\\nThe formation of large tumors is rendered impossible by the destruc-\\ntive ulceration which sets in at an early stage and continues in a pro-\\ngressive manner. In the papillary form the copious vegetations slough\\noff, leaving large ulcerating defects.\\nEtiology. Schroeder ascertained that 33 per cent, of all women who\\ndie of carcinoma succumb to carcinoma of the uterus. The only organs\\nmore frequently affected by carcinoma are the stomach and the mam-\\nmary gland. Wagner estimated that of all persons who die of carci-\\nnoma, in one-fourth of them the uterus is the seat of the disease.\\nFrom these statistics it is evident that the uterus is one of the organs\\nwhich presents, next to the stomach, conditions, congenital or other-\\nwise, most favorable to the development of carcinoma. The fifth\\ndecennium is the time of life most predisposed to the affection. A\\ncloser study of the statistics shows that the first five years after the\\ncessation of menstruation furnish the largest contingent of cases. An\\nhereditary predisposition was traced, according to different authors, in\\nfrom 7.6 to 1 3 per cent. Winckel called special attention to the frequent\\noccurrence of carcinoma of the uterus in tubercular families another\\nproof of the fallacy of Rokitansky s assertion that tuberculosis and\\ncarcinoma do not occur in the same person at the same time. Carci-\\nnoma occurs more frequently in married than in single women, and\\nmore frequently in sterile women than in those who have given birth to\\nchildren. Of the women who have borne children, those who have\\npassed most frequently through childbed are most disposed to card-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0389.jp2"}, "382": {"fulltext": "360 PATHOLOGY AND TREATMENT OF TUMORS.\\nnoma of the uterus. Difficult or instrumental deliveries and abortions\\nappear to exert an etiological influence. These different etiological\\ninfluences have been studied by Winckel on the hand of an extensive\\nclinical material that came under his own observation. There can be\\nno question that trauma, inflammatory affections, and benign tumors,\\nwhich are so frequently found in the cervix, constitute an important\\nelement in the production of carcinoma. The most important cause,\\nhowever, to explain the frequency with which carcinoma selects this\\nlocality, is the fact that in the embryo the squamous epithelium of the\\nsinus urogenitalis blends with the cylindrical epithelium of Miiller s\\nducts at the external os of the cervix. It is at the point of junction of\\nthe epithelial cells of different embryonal origin and of different shape\\nand function that carcinoma most frequently takes its starting-point.\\nEmbryonal cells are here in excess or they are displaced, and become\\nlater the essential tumor-matrix.\\nThe reasons why carcinoma of the cervix appears in preference after\\nthe menopause are the same as Thiersch has advanced for carcinoma\\nof the lip. The shrinking submucous connective tissue loses at this\\ntime its physiological resistance, thus opening pathways for invasion by\\nepithelial cells. Emmet has called attention to laceration of the cervix\\nas a cause of carcinoma. The writer is strongly inclined to believe\\nthat a laceration of the cervix may not only act as an exciting cause,\\nbut that, in addition, it may furnish the essential matrix of embry-\\nonic epithelial cells. It is not difficult to understand that during the\\nhealing of a laceration of the cervix new embryonal cells may become\\nburied in the scar-tissue in an immature state, and remain in this con-\\ndition, constituting a tumor-matrix of post-natal origin. E. Martin\\nbelieves that acute infectious lesions of the vagina and the uterus, like\\ngonorrhea, have an influence in the causation of uterine carcinoma an\\nopinion which receives the support of Winckel and others.\\nSymptoms and Diagnosis. The symptoms which point to the exist-\\nence of carcinoma of the uterus are (1) hemorrhage, (2) profuse and\\noften very fetid vaginal discharge, (3) pain, (4) dysuria, and (5) rectal\\ntenesmus.\\nIf the patient has not ceased to menstruate, menstruation is profuse\\nand prolonged. Greater significance attaches, however, to the occur-\\nrence of hemorrhage between the menses. Bleeding during the interval,\\noccurring spontaneously or provoked by active exercise, by the use of\\nthe vaginal syringe, or by coitus, in a woman past thirty-five years of\\nage is very suggestive of the existence of a carcinoma of the uterus,\\nand should induce the medical attendant to make a thorough examina-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0390.jp2"}, "383": {"fulltext": "CARCINOMA. 361\\ntion. The occurrence of hemorrhage after the menopause has a similar\\ndiagnostic significance.\\nA profuse watery discharge, stained at times with blood, is one of\\nthe earliest external evidences of papillary carcinoma of the cervix.\\nThe discharge is often very irritating, producing excoriation of the\\nexternal genital organs, and often a catarrhal vaginitis. When the dis-\\nease has advanced to extensive ulceration, or the papillary excrescences\\nhave become gangrenous, the discharge is always exceedingly fetid and\\nprofuse at this time it also frequently contains fragments of cast-off\\ntumor-tissue.\\nThe pain, of a dull, aching, burning, or lancinating character, is\\nreferred most frequently to the back, the lower part of the abdomen,\\nthe hips, the iliac regions, and the thighs.\\nThe retention of secretions in the uterine cavity by the blocking of\\nthe cervical canal by the tumor-tissue causes expulsive pains. If the\\ncarcinoma presses upon the bladder or has reached this organ by\\nextension, urinary disturbances set in, varying in intensity from a desire\\nto pass the urine more frequently than usual to the involuntary escape\\nof urine through a fistula produced by destruction of the posterior\\nbladder-wall by the tumor. The function of the rectum is disturbed\\nby pressure or by the extension of the disease from the uterus to the\\nrectum.\\nConstipation, tenesmus, and the escape with the feces of mucus or\\nof mucus stained with blood are some of the indications showing the\\nexistence and extent of uterine carcinoma. If the disease has extended\\nto the pelvic connective tissue or the peritoneum, it presents many\\nsymptoms and signs of parametritis and pelvic peritonitis affections\\nwhich must be excluded carefully in the differential diagnosis. Exten-\\nsive local and regional infection is indicated further by great oedema of\\none or both lower extremities, caused by compression or thrombosis\\nof one or more of the large veins in the pelvis, by ascites, by tympan-\\nites, and by carcinoma of the external genitals. Metastatic tumors in\\ndistant parts of the body would indicate that general infection has taken\\nplace.\\nIt is unfortunate that the onset of the disease is so insidious, as\\npatients, as a rule, consult the physician only after the disease has\\nmanifested itself by symptoms which belong to its advanced stages.\\nUnless discovered accidentally in the examination for obscure pelvic\\naffections, carcinoma of the uterus presents itself to the surgeon in the\\nmajority of cases in its advanced stages. As most if not all of the\\nsymptoms that have been detailed may be simulated by benign tumors\\nof the uterus and by inflammatory affections involving this organ and", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0391.jp2"}, "384": {"fulltext": "3\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nits appendages, a reliable diagnosis must rest upon a thorough exam-\\nination.\\nIn advanced cases, when the lower segment of the uterus is the seat\\nof fungous masses or of a deep excavation with an infiltration of stony\\nhardness at its base extending from the uterus to the parauterine con-\\nnective tissue on both sides, completely immobilizing the organ, a\\npositive diagnosis can be made by the mere touch of the finger. It is\\ndifferent in cases in which the disease is limited to perhaps one lip of\\nthe cervix, or where the disease originated primarily in the mucous\\nmembrane of the uterine cavity. In such cases it is sometimes exceed-\\ningly difficult to differentiate between chronic inflammatory affections,\\nbenign tumors, and carcinoma.\\nLaceration of the cervix with hypertrophy of one or more of its\\nlips, and ectropion of the cervical mucous membrane with erosion, have\\nfrequently been mistaken for carcinoma. A hypertrophic lip of the\\ncervix covered by papillary erosions presents to the palpating finger on\\npassing it lightly over the surface a velvety softness, while on deeper\\npressure the hypertrophied tissues feel uniformly dense, but lack the\\nstony hardness of carcinoma\\n(Fig. 237). The carcinomatous\\ncervix feels not only hard but\\nnodulated, and if ulceration has ^H\\ntaken place the surface of the t*l\u00c2\u00a3\\nA\\nFig. 237. Broad erosions of both lips of\\ncervix, with numerous glandular openings\\n(after Winckel).\\nFig. 238. Papillary carcinoma of cervix limited almost\\nentirely to the anterior lip (after Winckel).\\nulcer is uneven and hard (Fig. 238). If the disease involves both lips\\nat the same time and is limited in extent, the opening of the cervical\\ncanal is then surrounded by a ring-like induration of great firmness\\nthat does not yield on attempting to insert the tip of the index finger\\nFi g- 239)-\\nRetention-cysts of the external os of the cervical canal might be", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0392.jp2"}, "385": {"fulltext": "CARCINOMA,\\n363\\nmistaken for carcinoma, as on palpation they feel quite firm, but lack\\nthe induration so characteristic of carcinoma, and on deep pressure a\\nFig. 239.\u00e2\u0080\u0094 Papillary carcinoma of both lips of the\\ncervix (after Winckel).\\nFig. 240. Large retention-cysts of both lips of\\nthe cervix (after Winckel).\\nsense of elastic resistance is produced. These cysts are also usually\\nmultiple, while carcinoma extends from one centre (Figs. 241, 242).\\nFig. 241. Beginning cancer of the cervix, ulcer-\\native form (after Pozzi).\\nFig. 242. Cancer of the cervix, nodular form\\n(after Pozzi) fi, zone of intact pavement epithe-\\nlium cancerous nodule a, external os c, cervix.\\nIn doubtful cases a diagnosis must be made by the use of the micro-\\nscope. A small fragment of tissue near the margin of the supposed\\ntumor is removed, and from it sections are made. In carcinoma the\\nsection will show atypical proliferation of epithelial cells in the form of\\nsolid cylinders and epithelial nests in the vascular stroma. In papillary\\nerosions the section will show an increase of glandular structure, but\\nthe epithelium is separated from the submucous vascular connective\\ntissue by the membrana propria. No epithelial cells are found in direct\\ncontact with vascidar connective tissue.\\nPrimary carcinoma of the body of the uterus is very rare, and espe-\\ncially so in women less than fifty years of age. It is attended by\\nenlargement of the uterus, profuse and often fetid vaginal discharge,\\nand fitful attacks of hemorrhage. As some of these symptoms attend\\nadenomatous disease of the mucous membrane, it is often necessary to", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0393.jp2"}, "386": {"fulltext": "364 PATHOLOGY AND TREATMENT OF TUMORS.\\nremove with the sharp curette fragments of tissue for examination\\nunder the microscope. In adenoma the epithelial cells will be found to\\noccupy their normal relative position to the basement membrane, while\\nin carcinoma the epithelial cells, almost always of the cylindrical variety,\\nwill be found in and among the vascular structures and arranged in a\\ntubular form (Fig. 243). Retained placental tissue and myoma of the\\nuterus undergoing sloughing are conditions which might lead to errors\\nFig. 243. Atypical columnar epithelioma derived from uterine glands (after Boyce) a, the cancer-cylinder.\\n(Obj. inch, without eye-piece.)\\nin diagnosis, and they must be considered carefully in making a differ-\\nential diagnosis between primary carcinoma of the body of the uterus\\nand other intra-uterine affections.\\nSupravaginal Amputation of the Cervix Uteri for Carcinoma. The\\nfirst supravaginal excision of the cervix uteri for carcinoma was made\\nby Osiander. The operation was later perfected by C. J. M. Langen-\\nbeck and by Schroeder. This operation should be restricted to cases\\nof carcinoma beginning upon the vaginal portion of the cervix and in\\nwhich the disease has not extended to the body of the uterus. Sur-\\ngeons are not agreed as to the value of this operation in the treatment\\nof uterine carcinoma. The combined statistics representing cases from\\nthe practice of a number of able surgeons show a mortality of about\\n1 1.5 per cent. Some of the ardent advocates of this operation claim\\nthat in nearly half of the cases the carcinoma did not return after\\noperation. Such a statement, however, must be accepted with a good", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0394.jp2"}, "387": {"fulltext": "CARCINOMA.\\n365\\nFig. 244.\u00e2\u0080\u0094 Schroeder s supravaginal ampu-\\ntation of the cervix for carcinoma, showing the\\nextent of the excision and the ligature of the\\nlower branch of the uterine artery (after Pozzi).\\ndeal of allowance. On the contrary, the champions of hysterectomy\\nunderrate the value of this operation. Common sense would dictate\\nthat in a limited carcinoma of the ex-\\nternal os it is no more necessary to\\nremove the entire uterus than it would\\nbe to extirpate the whole of the lower\\nlip in a beginning carcinoma of the\\nlip. Here as elsewhere the surgeon\\nmust show good sense and judg-\\nment in selecting the cases for par-\\ntial and those for complete removal\\nof the uterus for carcinoma. Schroe-\\nder s operation is the one that prom-\\nises the best results in well-selected\\ncases.\\nThe uterus is drawn down to the\\nvulva by a pair of vulsellum forceps,\\nand a strong loop of thread is passed\\nthrough and above each of the lateral\\nculs-de-sac (Fig. 244). These loops\\nserve to draw the parts down and\\nto compress the uterine artery. The cervix is then isolated, through\\na circular incision made at the vaginal insertion, as far as the internal os.\\nSpirting vessels are at once tied. The dissection is made as far as\\npossible by the use of blunt instruments, to guard against wounding\\nthe bladder or the rectum or opening unintentionally the peritoneal\\ncavity. The anterior portion of the cervix is removed first, when the\\nvaginal mucous membrane is stitched to the mucous membrane of the\\ncervical canal. The same is done after the amputation of the posterior\\nhalf of the cervix. Schroeder has excised with the cervix the upper part\\nof the vagina when the disease had extended in that direction. Some\\nsurgeons employ no sutures after amputation of the cervix, but follow\\nthe use of the knife by that of the cautery (Koeberle) or of chloride of\\nzinc (Van de Warker). If all the diseased tissue can be removed\\nand these are the cases which are adapted for supravaginal amputa-\\ntion it is advisable to suture the vaginal mucous membrane to the\\nmucosa of the cervical stump, as otherwise a stenosis or a complete\\nobliteration of the cervical canal may become a source of trouble and\\nan indication for more operating in the future. The writer has seen at\\nleast two cases of supravaginal amputation of the cervix for carcinoma\\nin which the suturing was omitted, and in which complete obstruction\\nby cicatricial contraction gave rise to great pain during the menstrual", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0395.jp2"}, "388": {"fulltext": "3 66\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nperiod, as all the menstrual discharge escaped into the peritoneal cavity,\\ncausing repeated attacks of pelvic peritonitis. In on\u00e2\u0082\u00ac of these cases\\nremoval of the uterine appendages disclosed both of the tubes greatly\\ndistended, the lumen at the fimbriated extremity having become greatly\\nnarrowed by firm adhesions, the remnants of repeated attacks of cir-\\ncumscribed peritonitis.\\nVaginal Hysterectomy for Carcinoma of the Uterus. C. J. M. Langen-\\nbeck in 1813 made the first complete vaginal hysterectomy for carci-\\nnoma. Sauter and Dubourg appear next in the list of surgeons who\\nundertook this operation. Vaginal hysterectomy was revived and per-\\nfected in 1878 by Czerny. A radical operation for carcinoma of the\\nuterus involving more than the cervix and limited to the uterus can be\\nperformed with less difficulty and greater safety by the vaginal than\\nby the abdominal route. Freund s abdominal hysterectomy for carci-\\nFiG. 245. Vessels of the uterus: uterine and utero-ovarian arteries (after Pozzi).\\nnoma has been replaced almost entirely by vaginal hysterectomy. Strict\\nantiseptic precautions are necessary when the abdominal cavity is to be\\nopened in the removal of a carcinomatous uterus. The vagina and the\\nexternal genitals should be disinfected in the usual manner, and if the\\ncarcinoma has ulcerated extensively, a preliminary scraping is neces-\\nsary for the purpose of removing necrosed infected tissue that would\\nescape the ordinary means of disinfection. The patient should undergo", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0396.jp2"}, "389": {"fulltext": "CARCINOMA.\\n3^7\\nFig. 246.\u00e2\u0080\u0094 Vaginal hysterectomy first step, opening the posterior cul-de-sac and suture of the peritoneum\\nto the vaginal mucous membrane (after Martin).\\nFig. 247.\u00e2\u0080\u0094 Vaginal hysterectomy second step, ligation of the uterine artery (after Martin).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0397.jp2"}, "390": {"fulltext": "368 PATHOLOGY AND TREATMENT OF TUMORS.\\npreparatory treatment as for laparotomy for a number of days. Bladder\\nand rectum should be emptied before the operation is commenced.\\nThe patient must be placed in the lithotomy position, the thighs being\\nwell separated and properly immobilized. Hegar s speculum and re-\\ntractors, made for this special purpose, are best adapted for securing\\naccess to the uterus. The modern improved technique of vaginal\\nhysterectomy has special reference to the prevention and arrest of\\nhemorrhage. The principal vessels concerned in this operation are\\nwell shown in Figure 245. The uterus is secured and drawn down to\\nthe vulva in the same manner as in supravaginal amputation of the\\ncervix. The operation is commenced by opening the cul-de-sac of\\nDouglas by a curved incision behind the cervix at its junction with\\nthe vagina, when the vaginal mucous membrane is sutured to the\\nperitoneum (Fig. 246). The suturing arrests the parenchymatous and\\nvenous hemorrhage completely. The next step (Fig. 247) consists in\\nligating the uterine artery on both sides en masse. The left index\\nfinger is inserted through the wound, and the exact location of the\\nartery is ascertained by the pulsations then, with a large curved needle\\narmed with strong silk, the artery is included in a mass of tissue at\\neach angle of the wound and is secured by drawing the ligature tightly.\\nThe cervix is then drawn backward and downward, and, by an incis-\\nion at a safe distance from the palpable margin of the tumor, the circular\\nincision is completed, the point of the knife being directed against the\\ncervix to avoid wounding the bladder. The dissection between the\\nbladder and the cervix is made chiefly by the use of the finger and\\nof blunt instruments. Hemorrhage is arrested by points of suture\\non the cut surface of the tissues. The uterus is now retroverted suf-\\nficiently to bring the broad ligaments within easy reach, when they are\\ntied in three parts. The uterus is now, by means of scissors, severed\\nfrom all attachments, including the peritoneal reflection between it\\nand the bladder, which attachment so far has been reserved to guard\\nagainst infection. Prolapse of the intestines is prevented by elevating\\nthe pelvis or by means of a large sponge well secured in long hemo-\\nstatic forceps.\\nThe wound should be closed on each side by one or two sutures,\\nleaving an opening in the centre for an iodoform-gauze drain. If\\novaries or tubes present conditions requiring operative treatment, they\\nshould be removed otherwise it is better to limit the operation to the\\nremoval of the uterus. If the bladder or the rectum should be injured\\nduring the operation, the visceral wound must be sutured. After com-\\npletion of the operation the vagina is lightly packed with iodoform\\ngauze. The packing and dressing should not be removed for from", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0398.jp2"}, "391": {"fulltext": "CARCINOMA.\\n369\\nthree to five days unless hemorrhage or infection demands earlier\\ninterference. Ligation of the broad ligaments and blood-vessels is the\\nFig. 248. Bowed forceps for compression of the broad ligaments in vaginal hysterectomy (after Doyen).\\ncorrect surgical way in which to prevent and arrest hemorrhage in\\nvaginal extirpation of the uterus.\\nPean has substituted for the ligature long compression-forceps\\n(Fig. 248). After detaching the cervix much in the same way as has\\nbeen described, the broad ligament near the uterus is grasped with\\nlong, slightly curved catch-forceps, as shown in Figure 249. The for-\\nceps are prevented from un-\\nlocking by tying the handles\\ntogether with a strip of gauze.\\nAfter removal of the uterus\\nthe vagina is packed with gauze\\nand the forceps are incorpo-\\nrated in the external antiseptic\\ndressing. The forceps are re-\\nmoved at the end of the second\\nday.\\nMany surgeons have adopt-\\ned Pean s method of control-\\nling hemorrhage in vaginal\\nhysterectomy by permanent\\nforceps pressure, but the pro-\\ncedure is open to a number\\nof serious objections which do\\nnot apply to the use of the\\nligature, the most important\\nbeing insecurity against second-\\nary hemorrhage from slipping of the forceps and inability to carry out\\naseptic precautions to the required extent. The writer has always relied\\non the ligature, and has had no reason to change his views concerning\\nits superiority over the forceps in the permanent arrest of hemorrhage\\nin vaginal hysterectomy.\\nExtirpation of the carcinomatous uterus through the sacral route\\n24\\nFig. 249. Vaginal hysterectomy application of- for-\\nceps and section of the base of the broad ligament (after\\nPean).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0399.jp2"}, "392": {"fulltext": "37\u00c2\u00b0\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwas first practised by Hochenegg and is strongly endorsed by Czerny.\\nThe sacral resection is made in the same way as advised by Kraske for\\nextirpation of carcinoma of the rectum. The sacral operation would\\ncertainly appear to present great advantages when the lymphatic glands\\nand the connective tissue behind the uterus have become infected, as it\\nsecures better access to the retro-uterine tissues than does the vaginal\\noperation.\\nExtraperitoneal enucleation, first practised by the older Langenbeck,\\nand recently revived by Frank and Lane, has no future in the operative\\ntreatment of carcinoma of the uterus.\\nIn inoperable cases of carcinoma of the cervix and uterus and as\\nsuch should be considered all cases in which, from the extent of the\\ndisease, complete removal of all infected tissues cannot be effected by\\neither vaginal or sacral hysterectomy the removal of fungous masses\\nwith a sharp spoon, followed by thorough cauterization with the\\nPacquelin cautery, constitutes an important palliative measure.\\nExternal Female Genital Organs. Carcinoma of the external gen-\\nital organs of the female is a comparatively rare affection. Its primary\\nstarting-point may be either the\\nlabium majus, the labium minus,\\nor the clitoris. Among 7479\\nwomen suffering from carci-\\nnoma, Winckel found that the\\nvulva was the primary seat of the\\ndisease in 72, or about 10 per\\ncent, of all the cases. The tu-\\nmor begins as a firm nodule in\\nthe skin, with an indurated base.\\nThe tumor is covered at first\\nby thickened layers of epithelial\\ncells, which in the centre of the\\ngrowth soon disappear by ulcera-\\ntion. Carcinoma of the vulva,\\naccording to Klob and Winckel,\\nis always composed of squamous\\nepithelial cells. As soon as ul-\\nceration has occurred, the oppo-\\nsite surface with which the tumor\\nmay come in contact is often\\nsimilarly affected. The tumor\\ndoes not attain any considerable\\nsize, as the older portions are destroyed by ulceration. The tumor\\nFig. 250. Carcinoma of the labium majus (after\\nWinckel). The tumor is incised vertically, showing the\\nappearance of its interior. The surface is nodulated,\\nand on one side is a fringe of hair derived from the\\nlesser labium.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0400.jp2"}, "393": {"fulltext": "CARCINOMA.\\n371\\nrepresented in Figure 250 was removed by Winckel. In another case\\nthe same authority satisfied himself that the carcinoma had originated\\nin a congenital wart of the clitoris. The transformation of a wart of\\nthe lesser labium into a carcinoma is well shown in Figure 251.\\nLymphatic infection is an early occurrence in carcinoma of the\\nclitoris and vulva. A case of primary carcinoma of the clitoris in a\\nwoman sixty years of age came under the writer s observation six\\nmonths from the time the tumor was discovered. Both greater labia\\nwere involved, and very extensive regional infection had taken place in\\nboth groins. In this case an oval flap was made by carrying a curved\\nincision the whole length of Poupart s ligament on both sides, and then\\nacross the lower border of the mons veneris. This flap was reflected\\nin an upward direction to a point where the femoral vessels pass under-\\nneath Poupart s ligament. An incision was then made downward to\\nthe apex of Scarpa s triangle on both sides. After reflection of the\\ntriangular flaps the whole chain of lymphatics was dissected out, being\\nlater removed with the mass containing the primary tumor and both\\nFig. 251. Cancerous transformation of the epithelium of the labium majus (after Boyce) a, normal epithe-\\nlium b, warty condition; c, malignant change. (Obj. inch, without eye-piece.)\\nthe greater labia in one piece. The hemorrhage was controlled by\\ncompression and by hemostatic forceps during the operation. The\\nexcision had to be carried to the margin of the meatus and to the lesser\\nlabia on the sides. The oval flap was then drawn downward and\\nstitched to the upper margin of the meatus, and the wounds caused by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0401.jp2"}, "394": {"fulltext": "372 PATHOLOGY AND TREATMENT OF TUMORS.\\nexcision of the labia were closed by stitching the lesser labia to the\\nskin. The remaining parts of the wounds were closed in the usual\\nmanner. Primary healing of all the wounds on the right side took\\nplace a slight suppuration interfered with the healing of the wound\\nbelow Poupart s ligament on the opposite side. The patient left the\\nhospital three weeks after the operation, and three months later was\\nreported as being free from recurrence.\\nThe only effective treatment of carcinoma of the external genital\\norgans of the female is free excision. Large defects can be covered by\\nsliding of the skin, and very large wounds heal in the most satisfactory\\nmanner. If the disease has resulted in infection of the inguinal glands,\\nall the glands should be removed with the primary tumor in one con-\\ntinuous mass. This removal can be effected by extending the incision\\njust below Poupart s ligament as far as the anterior superior spinous\\nprocess, and joining it by a vertical incision extending from the femoral\\ncanal to the apex of Scarpa s triangle.\\nBye. Malignant tumors in the interior of the eye are sarcomata.\\nThe conjunctiva in rare instances is the seat of carcinoma. The tumor\\nulcerates early, and generally comes under the observation of the sur-\\ngeon before extensive local or regional infection has occurred. Perfor-\\nation of the eyeball takes place at the junction of the cornea and the\\nsclerotic, as resistance to cell-invasion here is less than in the sclerotic\\nor the cornea. Regional infection takes place through the pre-auricular\\nand submaxillary lymphatics. The diagnosis should always be con-\\nfirmed by examination of sections of the tumor under the microscope,\\nas a positive diagnosis justifies the only radical treatment in such cases\\nenucleation, with clearing out of all the orbital contents.\\nBladder. Primary carcinoma of the bladder is a rare affection. It\\nis more common in men than in women. It occurs as a sessile, indu-\\nrated, ulcerating tumor or as a papillary growth. The latter form\\noccurs often as a transformation of a benign papilloma into a car-\\ncinoma.\\nVillous carcinoma (Zottenkrebs) was first described by Rokitansky.\\nIt appears clinically as a projecting growth from mucous or other free\\nsurfaces. The villous growth consists, in its stem, of a fibrous struct-\\nure, on which villous tufts are borne, as buddings or sproutings of the\\nstem or its branches. The same kind of tumors are found in the\\ninterior of proliferous cysts. In some tumors the main stem is short\\nand thick, and the buds aggregated in a cluster and nearly round in\\nothers the stem is delicate and long, branching into secondary and\\ntertiaiy tubes or offshoots. The blood-vessels are large, with thin and\\nimperfect walls, resembling colossal capillaries.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0402.jp2"}, "395": {"fulltext": "CARCINOMA. 373\\nOccasionally the urethra is the starting-point (Fig. 252). If in the\\nfemale the urethra is primarily affected, the radical operation should be\\npreceded by the formation of a suprapubic fistula. After this has been\\nFig. 252. Primary carcinoma of the urethra in the female (after Winckel) a, urethra; b, fundus of the\\nbladder.\\nestablished the entire urethra and the base of the bladder should be\\nexcised and the opening in the bladder be closed permanently. This\\noperation has been performed successfully by Pawlik and Oviatt.\\nCarcinoma of the bladder frequently selects that part of the bladder-\\nwall corresponding to the insertion of the ureters. Secondary carci-\\nnoma of the bladder from extension of the tumor from the prostate\\ninvades the base of the bladder; after the growth has reached the\\nvesical mucous membrane it becomes diffuse, often blocking the orifice\\nof the urethra with masses of tumor-tissue. After ulceration has set in\\nshreds of carcinomatous tissue are often voided with the urine. The\\nulceration usually extends in the course of time over the entire surface\\nof the tumor (Fig. 253).\\nThe most prominent symptoms of carcinoma of the bladder are\\nhemorrhage, frequent desire to urinate, and great pain after evacuation", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0403.jp2"}, "396": {"fulltext": "374\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nof the bladder. Microscopical examination of fragments of tissue\\nvoided with the urine or removed in the eye of the catheter will often\\nprove of great value in making a positive diagnosis. In women an\\nincision through the vesico-vaginal septum, and in men a suprapubic\\ncystotomy, will enable the surgeon to make a positive diagnosis, and\\nwill also afford relief by establishing a permanent fistula. If the car-\\ncinoma is superficial, removal after opening the bladder should be\\nattempted. If the tumor involves the anterior wall or fundus of the\\nbladder, the indication is for a radical operation by excision of the entire\\nthickness of the bladder-wall beyond the limits of the tumor through\\nan abdominal incision. If the carcinoma is so situated that the bladder\\nend of one ureter has to be removed, the resected end should be\\nimplanted into a slit of the bladder, as advised by Van Hook, before\\nthe opening in the bladder is closed by suturing.\\nFig. 253. Papillary carcinoma of the anterior wall of the hladder in the female (after Winckel) a, papillary\\ncarcinoma b, orifices of ureters c, urethra.\\nIn all these operations the bladder should be drained either by\\nthe use of a retaining catheter or through a separate opening. Scraping\\nout of a carcinoma through either a suprapubic or a vaginal incision\\nshould not be considered even in the light of a palliative operation.\\nAll that can be done in a case of inoperable carcinoma of the bladder\\nis to establish a permanent fistula to relieve the vesical tenesmus and to\\nprevent retention of urine by closure of the urethral opening by the\\ntumor or by blood-clots.\\nKidney. The kidney is more frequently the seat of sarcoma than\\nof carcinoma. Carcinoma of the kidney is of the tubular variety.\\nIn a delicate, very vascular stroma the columnar epithelial cells are", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0404.jp2"}, "397": {"fulltext": "CARCINOMA. 375\\narranged in the form of tubules. According to the degree of develop-\\n\u00e2\u0096\u00a0*r*\\nFig. 254. Displaced tissue from the suprarenal capsule in the kidneys X 500 (after Karg and Schmorl).\\nThe lower part of the picture is occupied by normal kidney-tissue (a), in which a glomerulus and transversely\\ncut uriniferous tubules can be seen the upper part is occupied by typical tissue from the suprarenal capsule\\n(b), which is imbedded in the kidney- tissue.\\nment of the stroma the tumor is either hard or soft, of slow or of rapid\\ngrowth. In exceptional cases the tumor, instead of springing from a\\nmatrix of embryonic cells representing kidney-tissue, originates from a\\ndisplaced matrix of epithelial cells derived from the suprarenal capsule.\\nSuch displaced groups of epithelial cells (Fig. 254) are found in the\\nvicinity of the kidney, in the capsule, or in the parenchyma of the\\nkidney itself (Klebs). Grawitz has shown that tumors originating from\\nsuch a matrix represent to perfection, histologically as well as clinically,\\nsimilar tumors of the suprarenal capsule. The tumor gradually dis-\\nplaces the parenchyma of the kidney, and when the pelvis and the\\nureter are reached it produces obstruction to the flow of urine secreted\\nby the intact part of the kidney. Eventually the tumor may perforate\\nthe capsule of the kidney and extend to the adjacent organs. Lymphatic\\ninfection takes place at a comparatively late stage. If the tumor is\\nlarge, it may produce intestinal obstruction by extending to the colon\\nor by pressure. Hematuria is a frequent symptom after the tumor has\\ninvaded the pelvis of the kidney.\\nDuring life it would be, of course, impossible to distinguish a carci-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0405.jp2"}, "398": {"fulltext": "376\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nnoma from a sarcoma. Advanced age and a nodular tumor would lead\\nus to suspect carcinoma. James Israel discovered by palpation a car-\\ncinoma of the kidney not larger than a cherry, removed the kidney,\\nand the specimen confirmed the diagnosis. The average surgeon would\\nFig. 255. Topography of the renal region (after Esmarch) Mc, trapezius muscle Mid, latissimus\\ndorsi SJ sacro-lumbalis Ql, quadratus lumborum Oe, external oblique Oi, internal oblique Tr, trans-\\nversalis Fid, lumbo-dorsal fascia R, kidney; C, descending colon.\\nhave difficulty in detecting a tumor the size of a walnut, and conse-\\nquently it is not very probable that another such early diagnosis will\\nsoon be recorded. If a diagnosis of the probable existence of a malig-\\nnant tumor of the kidney can be made, it is the duty of the surgeon to\\nmake careful search concerning the condition of the opposite organ,\\nand if this is satisfactory a radical operation is indicated if the disease\\nhas not extended beyond the capsule of the kidney. Partial removal\\nof the kidney for malignant disease is not permissible.\\nNephrectomy for Carcinoma of the Kidney. The location of the\\nkidney and its relations to the parts concerned in lumbar nephrectomy\\nare shown in Figure 255. An accurate knowledge of the topographical\\nanatomy of the renal region is an essential prerequisite in the perform-\\nance of lumbar nephrectomy. A carcinomatous tumor of the kidney\\ntoo large for the lumbar operation has in all probability reached the\\ninoperable stage. The lumbar operation is therefore the one that will\\nusually be selected to remove a carcinomatous kidney. The operation\\nof nephrectomy was devised and performed in 1871 by Simon. The\\nincision named after him was in reality planned by his pupil, Dr. Hotz,\\nnow of Chicago. One of two incisions is usually selected for the removal\\nof the kidney through the lumbar region. Simon s incision, which gives\\nthe best access to the hilus of the kidney, is commenced over the eleventh", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0406.jp2"}, "399": {"fulltext": "CARCINOMA. 377\\nrib, at the outer margin of the sacro-lumbalis muscle, and is extended\\nin a downward direction to a point halfway between the last rib and\\nthe crest of the ilium. If more room is needed, the incision can be\\nextended farther down. Konig s incision, which affords the most room,\\nextends from the twelfth rib, at the margin of the sacro-lumbalis muscle,\\ndirectly down to near the crest of the ilium it is then carried in a\\ncurve in the direction of the umbilicus to the outer margin of the rectus\\nmuscle. To enlarge the space between the last rib and the crest of the\\nFig. 256. Position of patient and location of incision for lumbar nephrectomy according to Simon s\\nmethod.\\nilium a firm round cushion should be placed between the chest and\\nthe pelvis on the opposite side, and the patient is placed on that side\\n(Fig. 256). The different muscular layers are divided separately, and all\\nhemorrhage is carefully arrested before the fatty capsule of the kidney\\nis opened. When the kidney has been reached the upper half is first\\nseparated with the index finger then the kidney is seized with three\\nfingers, drawn forward, and carefully isolated all around when the\\nhilus is reached the ureter and vessels are exposed by blunt dissection\\nall these structures are ligated en masse, and the kidney is separated by\\na cut at a safe distance from the ligature, after which ureter and vessels\\nare ligated separately. Iodoform-gauze drainage and suturing of the\\nbalance of the wound complete the operation.\\nWe have every reason to believe that if a diagnosis of renal carci-\\nnoma could be made at a time before the tumor has extended beyond\\nthe capsule and before it has given rise to regional infection, a nephrec-\\ntomy would yield better results than most of the operations for carci-\\nnoma in other localities. Under such circumstances the removal of all\\ncarcinomatous tissue by a nephrectomy would be assured.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0407.jp2"}, "400": {"fulltext": "XVII. FIBROMA.\\nFibroma is a representative mesoblastic tumor. Connective tissue,\\nwhich is found in all parts and organs of the body, is its prototype.\\nWe shall include in this class of tumors also the benign endothelial\\ntumors, which have been described as endothelioma because the con-\\nnective tissue and endothelial cells have a common embryonic origin.\\nHistological investigations have shown that in the connective tissue\\nmay be formed, independently of pre-existing blood-vessels, vascular\\nspaces lined with endothelial cells derived from connective tissue and\\nit is well known that during the cicatrization of blood-vessels after\\nligature and during plastic inflammation of serous surfaces endothelial\\ncells are converted into permanent connective tissue. Fibroma imitates\\nthe normal connective tissue in the arrangement of its fibres. If the\\ntumor is soft, the elastic fibres and connective-tissue corpuscles are\\narranged loosely and the cells are separated from one another by an\\nabundance of intercellular substance (Fig.\\n257). In hard fibromata the areolar struc- fill\\nture is lost, and the tumor presents to the\\nFig. 257. Subcutaneous areolar tissue (after Piersol) c, c,\\nsome of the connective-tissue corpuscles w, migratory cells\\nv, plasma-cells e, elastic fibres.\\nFig. 258. White fibrous tissue; one\\nend of the bundle has been teased to\\ndisplay the component fibrillae (after\\nPiersol).\\neye and to touch the appearance of firm white fibrous tissue in which\\nthe fibrillae form bundles that run parallel, but more frequently inter-\\nlace, forming coarser or finer meshworks (Fig. 258).\\nFibromata occur in every part of the body supplied with connective\\ntissue and blood-vessels.\\n378", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0408.jp2"}, "401": {"fulltext": "FIBROMA. 379\\nDefinition. A fibroma is a tumor composed of mature fibrous\\ntissue derived from a matrix of fibroblasts. This definition excludes\\nfrom this class of tumors all swellings of infective origin and all benign\\ntumors in which the predominating histological elements are not con-\\nnective-tissue fibres, but epithelial cells. Virchow included elephantiasis\\nand molluscum fibrosum among the fibrous tumors. We exclude these\\naffections because their infective origin has been demonstrated satisfac-\\ntorily. A great deal of confusion has been caused by some pathologists\\nwho continue to describe a papilloma as a fibroma. In papilloma the\\nepithelial cells compose the essential part of the tumor, the tumor develops\\nfrom a matrix of epithelial cells, and the fibrous central part is fur-\\nnished by pre-existing connective tissue which, under the stimulus fur-\\nnished by the proliferating epithelial cells, undergoes hypertrophic changes.\\nWe shall exclude from fibroma those tumors of the skin and the\\nmucous membranes that have an epithelial origin and in which the epi-\\nthelial cells take an active part in the growth of the tumor. These\\ntumors have been described in a previous section of this work as\\npapillomata. The connective tissue is the tissue chiefly predisposed to\\ninflammation, and the frequency with which infections of all kinds occur\\nin the connective tissue makes it often exceedingly difficult to distin-\\nguish practically between an infective swelling and a fibroma. It is for\\nthis reason that the adjective mature has been used in this definition.\\nConnective-tissue corpuscles in inflammatory products do not reach\\nthe same degree of maturity as in fibroma, even if the inflammatory\\nprocess is ever so chronic. Fibro-sarcomata, which by Paget and others\\nhave been described as fibroid tumors with a tendency to recurrence,\\nare composed of connective tissue which has nearly, but not quite,\\nreached maturity.\\nFibroid, desmoid, corps fibreux, are synonyms which even\\nat the present time are occasionally used in place of fibroma.\\nHistogenesis and Histology. The matrix of a fibroma is a group\\nof congenital fibroblasts which in the embryo were set aside, failed to\\nreach maturity, and remained in the connective tissue in a latent condition\\nuntil, under the influence of local or general causes, they were placed in\\na condition to assert their intrinsic capacity to proliferate. If we imagine\\na number of embryonic connective-tissue cells arrested in their develop-\\nment and unutilized in the embryo, remaining in their primitive condition\\nawaiting favorable conditions for their growth and reproduction, we can\\nreadily understand how in later life they would result in the production\\nof tissue of a character differing from, although similar in structure to,\\nthe surrounding tissues (see Fig. 2, p. 28). Arrest of differentiation\\nwould affect the intercellular substance as well as the cells. From", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0409.jp2"}, "402": {"fulltext": "3 8o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nan embryological standpoint a fibroma is never a heterologous or a\\nheterotopic tumor, as connective tissue is found in all parts and\\norgans of the body. A matrix of fibroblasts undoubtedly forms\\nfrequently in scars following wounds and injuries of all kinds and in\\nthe healing process after the subsidence of inflammatory affections.\\nKeloid and other fibroid tumors of scars must have such an origin.\\nA fibroma is always encapsulated, and can readily be enucleated.\\nIf it is located underneath a mucous membrane, the tumor-tissue fre-\\nquently becomes oedematous. On section the surface shows a number\\nof bands and bundles of connective tissue interlacing in all directions\\nwithout any definite arrangement. The cut\\nsurface often shows concentric arrangement\\nof the connective tissue in different parts of\\nthe tumor, as though the tumor had been\\ngrowing from different centres. Billroth has\\nshown that the centre of these concentric\\nmasses corresponds with the location of a\\nblood-vessel. The firmness of the tumor\\ndepends on the amount of intercellular sub-\\nstance and the degree of compactness of the\\ntumor-tissue. In the hard variety the tumor is almost as firm to the\\nFig. 259. Hard fibroma from fascia\\nof rib (after Liicke).\\nFig. 260.\u00e2\u0080\u0094 Fibrous tumor from the antrum of Highmore; X 450 (after D. J. Hamilton) a, fusiform nucleus;\\nb, younger nucleus of an oval shape c, isolated fibroblast.\\ntouch as cartilage, the intercellular substance is very scanty, and the\\nfibrillae are compactly arranged in wavy bundles or the fibres have a", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0410.jp2"}, "403": {"fulltext": "FIBROMA. 381\\nconcentric arrangement as shown in Figure 259. Sections under the\\nmicroscope show that the wavy bundles of white fibrous tissue interlace\\nand surround blood-vessels. On each bundle lies an oval or fusiform\\nconnective-tissue nucleus, as on any other fibrous tissue (Fig. 260).\\nThe younger parts of the tumor show young connective-tissue cells\\nof round or oval shape.\\nThe firmness and the histological structure of the tumor are not\\naffected by the amount or the character of the connective tissue in\\nwhich the tumor is developed, A fibroma in firm fascia may be soft,\\nwhile a tumor in a soft vascular organ may be very dense. Fibroma\\nin the soft parenchyma of the kidney may be very firm and be scantily\\nFig. 261. Fibroma of the kidney; X 38 (after Karg and Schmorl). The renal tissue (a), which contains\\nintact uriniferous tubules and glomeruli, is sharply separated from the tumor (b), which is composed exclu-\\nsively of vascular fibrillated tissue. The bundles of fibrous tissue interlace in all possible directions, and\\ninclude moderately numerous nuclei, which, according to the direction of the section, appear round or spindle-\\nshaped.\\nsupplied with blood-vessels, although surrounded on all sides by an\\nexceedingly vascular tissue (Fig. 261). In typical fibroma the vessels\\nare small and scanty. In a special form of fibroma vascular spaces,\\ncontaining venous blood, that appear anatomically as a transition form\\nbetween angioma and fibroma the atypical vascularization of the\\ntumor reaches the highest degree. Rindfleisch classifies this rare form\\nof cavernous fibroma with the fibromata. Nothing- is known regarding\\nthe existence of lymphatics in fibroma, but it is probable that they are\\npresent in the soft variety. Nerves are probably not present in fibroma,", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0411.jp2"}, "404": {"fulltext": "382\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nbut if present, they are pre-existing nerves from the sheath of which\\nthe tumor has developed. In fibroma of the uterus muscle-fibres are\\nso constantly found that Virchow classified fibrous tumors of the uterus\\nwith the myomata.\\nRetrograde Metamorphoses. One of the frequent retrograde\\nchanges found in fibroma is myxomatous degeneration, due, in part at\\nFlG. 262. Myxomatous fibrous tumor of the deep fascia of the neck; X 45\u00c2\u00b0 (after D. J. Hamilton).\\nleast, to oedema of the intercellular spaces (Fig. 262). The tumor\\nundergoing this change becomes softer, and in the course of time there\\nmay form cysts with mucous or serous con-\\ntents. This form of degeneration is observed\\nvery frequently in submucous fibroma. In\\ncystic myofibroma of the uterus there form\\ncysts, often of enormous size, which it is im-\\npossible sometimes to distinguish from ovarian\\ncysts.\\nCalcareous degeneration occurs in one of\\ntwo ways the tumor is either coated with\\na thin, rough, nodulated layer of a chalky\\nsubstance, or a similar substance is deposited\\nmore abundantly throughout the tumor (Fig.\\n263). Calcification is preceded by coagulation-\\nnecrosis, and the place occupied by the tumor-\\ntissue is taken by the earthy salts. Further\\ngrowth of the tumor in parts which have\\nundergone calcification is arrested.\\nFig. 263. Calcareous deposit\\nin a fibrous uterine tumor (after\\nDusseau).\\nColloid degeneration does not occur in\\nfibroma, as Mr. Symmonds has shown that it\\nnever takes place in the absence of epithelial cells. Fatty degeneration", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0414.jp2"}, "405": {"fulltext": "FIBROMA.\\n383\\nis not as constantly found in fibroma as in epithelial tumors, but occa-\\nsionally it not only takes place, but it may destroy large portions of\\nthe tumor.\\nThe tumor when exposed to external irritation is subject to ulcer-\\nation. Infection and suppuration may occur without exposure of the\\ntissue of the tumor to direct\\ninfection by ulceration or in-\\njury. Gangrene may occur if\\nin a pedunculated tumor the\\npedicle is twisted or the prin-\\ncipal artery becomes blocked\\nby a thrombus. Transforma-\\ntion of the tumor-tissue into a\\nhigher type is occasionally ob-\\nserved in fibroma. Ossification\\nhas been seen most frequently\\nin fibrous tumors attached to\\nbone (Fig. 264). It is difficult\\nto decide in such cases whether\\nthe new bone is produced by\\ntransformation of fibrous tissue,\\nor whether what seems more\\nprobable it is produced by\\ndisplaced osteoblasts.\\nEtiology. Fibroma alone or in combination with other tumors\\nlipoma, angioma, adenoma appears sometimes as a congenital tumor.\\nOld age predisposes to epithelial tumors, while the aptitude for fibroma\\nis lessened after the age of from thirty-five to forty years. The production\\nof fibroma of the lobe of the ear by the wearing of ear-rings, of keloids\\nin scars, and of desmoids in the abdominal wall of childbearing women,\\nwould indicate that trauma and irritation are potent factors in the etiology\\nof fibroma. Virchow describes and recognizes an hereditary fibromatous\\ndisposition, and he alludes to an instance of the occurrence of multiple\\nsubcutaneous fibromata in members of the same family in three con-\\nsecutive generations.\\nSymptoms and Diagnosis. The growth of a fibroma is always\\nslow. A simple, uncomplicated fibroma attains a certain limited size\\nand then remains stationary. The large cystic fibroids described in\\nsome of the older text-books were sarcomata, as it is often stated that\\nthe tumor reached the size of a child s head in a year or less. Fibroma\\nnever pursues such a rapid course. Uterine myofibromata grow more\\nrapidly than simple fibroids, are more vascular, and the muscular fibres\\nFig. 264.\\nOssification in a periosteal fibroma of the\\nlower jaw (after Lucke).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0415.jp2"}, "406": {"fulltext": "384 PATHOLOGY AND TREATMENT OF TUMORS.\\nconstitute the most important part of the tumor-tissue. The tumor is\\nsmooth and is always well encapsulated, hence movable unless restrained\\nby adj oining firm resisting tissues. A fibroma of the breast can be moved\\namong the tissues between two fingers without moving the gland an\\nimportant point in the differential diagnosis between fibroma and carci-\\nnoma. The tumor displaces, but does not infiltrate, the adjoining tissues.\\nThe pressure of a periosteal fibroma frequently results in great displace-\\nment of the bone by bending and by pressure-atrophy. If the tumor\\noccupies a cavity, it may interfere with important functions. A fibroma\\nof the nasal cavity interferes with respiration, and, when it reaches the\\npharynx, with speech and deglutition. A fibroma of the uterus, if\\nsubmucous, causes hemorrhage if subserous, it may by its size affect\\nimportant functions. Pain and tenderness are absent unless the tumor\\nis intimately connected with a sensitive nerve or unless it has become\\ncomplicated by infection and inflammation. In fibroma ulceration is\\nless likely to take place than in papilloma, because the tumor is covered\\nat least by skin or by mucous membrane. If the skin or the mucous\\nmembrane becomes atrophied from pressure, ulceration is likely to\\nensue, commencing in that part of the surface in which nutrition has\\nbecome most impaired.\\nIn differentiating a fibroma from a papilloma it is important to trace\\nthe tumor by the aid of its clinical history and by a careful examina-\\ntion as to its origin in the mesoblastic tissues. A papilloma of the\\nskin commences on the surface as an increase in the thickness of the\\nepithelial layer of the skin the papillary projections develop in conse-\\nquence of an accompanying hyperplasia of the underlying pre-existing\\nconnective tissue. In fibroma of the skin the tumor starts in the con-\\nnective tissue underneath the layer of epithelial cells, and pushes this\\nlayer before it. A fibroma of the skin is therefore less liable to become\\npedunculated than is a papilloma. A fibroma only becomes peduncu-\\nlated if the skin over it is yielding, and after the tumor has attained at\\nleast the size of a pea or a cherry. In pedunculated fibroma the skin\\nwhich covers the tumor becomes atrophic, smooth, and glassy, while in\\npapilloma the epithelial structures increase with the size of the tumor.\\nIn deep-seated fibroma the diagnosis between it and sarcoma is deter-\\nmined by the clinical history and, if need be, by the removal of a frag-\\nment of tissue with a harpoon for microscopical examination. In cystic\\nfibroma the use of the exploratory needle will often determine the cha-\\nracter of the tumor.\\nPrognosis. Fibroma may at any time undergo transition into a\\nsarcoma. As Virchow says, A fibroma only needs an increase in the\\nsize of its cells and a diminution of the cement-substance to change it", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0416.jp2"}, "407": {"fulltext": "FIBROMA. 385\\ninto a sarcoma. The hard variety is less apt to undergo this change\\nthan the soft, and particularly the pigmented, form. That irritation and\\nincomplete removal should hasten, if not determine, the transforma-\\ntion of a fibroma into a sarcoma no one would dispute. The young\\nconnective-tissue cells in the periphery of the tumor require only the\\naddition of conditions which enable them to leave the parent-tumor\\nand to migrate into the surrounding connective tissue to become\\nsarcoma-cells. A pure fibroma does not attain large size hence the\\nprognosis, aside from the possibility of the tumor undergoing transfor-\\nmation into sarcoma, must rest on the importance of the location it\\noccupies. If it involve passages essential for important functions, the\\nobstruction it produces may prove a source of danger. Fibroma of\\nthe respiratory and urinary passages affords an illustration in point. A\\nsubmucous fibroma of the uterus may become the cause of debilitating\\nand even fatal hemorrhages. A large interstitial fibroma of the uterus\\nmay destroy life by the size of the tumor interfering with important\\nfunctions of the abdominal organs.\\nTreatment. Operative treatment is indicated in fibroma in all cases\\nin which the tumor is accessible, as by the removal of the tumor the\\npatient is protected against a frequent cause of sarcoma. In uterine\\nfibroma an exception must be made to this rule, as the danger attending\\nthe operation outweighs the risk of a possible transition of the tumor\\ninto a sarcoma. In fibroma of the uterus other indications must\\ndecide the necessity of operation. Fibromata should be removed by\\nenucleation. Excision is necessary if the tumor has ulcerated on the\\nsurface or if the interior of the tumor has become infected and the\\nresulting inflammation has produced adhesions between its capsule\\nand the adjacent tissues.\\nTopography.\\nSkin. Fibroma of the skin occurs most frequently about the face,\\nneck, shoulders, chest, and abdomen. It is of very slow growth, and\\nseldom exceeds in size a pecan-nut. It appears first as a swelling in\\nthe connective tissue of the skin, which swelling projects toward the\\nsurface, becoming more and more prominent until the skin at its base\\nbecomes contracted and by the weight of the tumor elongated, resulting\\nin the formation of a pedicle. In the course of time this pedicle\\nbecomes elongated and very slender. It contains in its centre the\\nprincipal artery of the tumor, which artery sometimes, in consequence\\nof an injury or of textural changes, becomes thrombosed an accident\\nwhich results in gangrene of the tumor and a spontaneous cure. The\\nskin over the tumor atrophies, is thin and shining, and is usually thrown\\n25", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0417.jp2"}, "408": {"fulltext": "386 PATHOLOGY AND TREATMENT OF TUMORS.\\ninto longitudinal folds. The tumor is soft, and under the microscope\\nshows interlacing fibres with an abundance of intercellular cement-\\nsubstance.\\nThe diagnosis can be made without difficulty, as in papilloma, which\\nis most frequently confounded with fibroma, the epiblastic part of the\\ntumor predominates, and instead of a smooth surface presents a warty\\nappearance. If the tumor has become pedunculated, it is connected\\nwith the body only by a cylinder of skin, which can be clipped with\\nscissors on a level with the skin, and the resulting wound can be sealed\\nwith a cotton-collodion crust. If the tumor is sessile, the skin over it\\nor at its base is incised sufficiently to permit the removal of the tumor\\nby enucleation.\\nMole. A mole is a flat congenital fibroma of the skin. It is caused\\nby fibroblasts in excess in the connective-tissue portion of the skin.\\nMoles are usually pigmented, and giant growth is manifested by exces-\\nsive growth of the appendages of the affected part of the skin, the\\nhair, and the glands. Moles vary in size from that of a pin s head\\nto that of the palm of the hand or even larger. The increase in size\\nafter birth reaches its maximum during childhood and up to the age\\nof puberty, when the tumor generally becomes stationary. A mole\\nis exceedingly prone to undergo transition into a carcinoma or a sar-\\ncoma, and for this reason should be removed if the area involved is not\\ntoo extensive. A carcinoma or a sarcoma starting in a mole is usually\\npigmented the resulting malignant tumor is either a melano-carcinoma\\nor a melano-sarcoma both of them exceedingly malignant growths, and\\nvery prone to early diffuse regional infection and general dissemination.\\nSpontaneous Keloid. Under the term keloid Alibert described in\\n1 8 14 an affection of the skin characterized by hyperplasia of the sub-\\nepidermal connective tissue, with a strong inherent tendency to return\\nafter extirpation. He classified keloid into germinal and scar keloid.\\nThis affection was later described by Schwimmer, Kaposi, Deneriaz,\\nand Warren. For some time doubt existed as to the occurrence of\\nspontaneous keloid, owing probably to the rarity of the affection. A\\nsufficient number of cases have, however, been recorded by reliable\\nobservers in which the clinical history revealed no antecedent scar.\\nWarren divided keloid into (1) true keloid, (2) scar keloid, (3) hyper-\\ntrophic scar. Warren claimed that the new connective tissue is pro-\\nduced by proliferation of the tissues of the adventitia of blood-vessels,\\nas he found numerous round cells around blood-vessels, which he\\nclaimed were later transformed into connective tissue. From an ana-\\ntomical standpoint he distinguished a scar keloid from a true keloid by\\nthe absence of papillae in the former. According to Kaposi, the true", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0418.jp2"}, "409": {"fulltext": "FIBROMA.\\n387\\nkeloid occurs about once in every 2000 cases of skin affections of all\\nkinds. It is found most frequently upon the sternum and upon the\\ntrunk, although occasionally the limbs, and especially the fingers and\\ntoes, are the seat of the disease. Nasse and Volkmann saw each a\\ni\\nFig. 265. Spontaneous keloid (after Thorn).\\ncase of multiple keloid of the fingers and toes. In Nasse s case\\nrepeated excisions of the tumors of the toes finally made removal of\\ntwo toes by exarticulation necessary. The compact connective-tissue\\nbundles of which a keloid is composed are found in the deeper\\nlayers of the corium. The* fibers are arranged, as a rule, parallel to\\nFig. 266. Blood-vessels and tumor-tissue as seen in spontaneous keloid (after Thorn).\\nthe surface, and contain spindle-shaped nuclei some of the fibers\\ntake an opposite course this is especially the case near the sur-\\nface of the tumor underneath the epidermis (Fig. 265). Thorn never\\nsaw in any of his specimens any indications that the fibers are derived", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0419.jp2"}, "410": {"fulltext": "388 PATHOLOGY AND TREATMENT OF TUMORS.\\nfrom the vessel walls. The round cells which are found interspersed\\nbetween the keloid tissue Thorn is inclined to believe are the product\\nof an inflammatory process near the surface of the tumor. The new\\ntissue is unquestionably derived from the pre-existing connective tissue\\nof the corium under the influence of an as yet unknown cause. The\\nappearance of blood-vessels and the arrangement of fibers around\\nthem are well shown in Fig. 266. While keloid is an obstinate affection\\nto all kinds of local treatment, it differs from sarcoma in that it remains\\nlimited to the tissues primarily affected and never gives rise to metas-\\ntasis. After having attained a certain size it often remains stationary\\nfor an indefinite time. That such a tumor should occasionally undergo\\ntransformation into a sarcoma is not surprising considering the imper-\\nfect development of the tissues of which it is composed.\\nScar Keloid. Another variety of fibroma in the skin is the fibrous\\ntumor which starts in scar-tissue following a wound, the healing of a\\nFig. 267.\u00e2\u0080\u0094 Large keloid of the neck.\\nburn, or other surface lesions, particularly tubercular ulcers. Alibert in\\n18 14 was the first to describe this fibrous tumor, and from its resemblance\\nto carcinoma he called it keloid. Keloid resembles clinically some of\\nthe granulomata, and under the microscope it is a compromise between\\na fibroma and a sarcoma. Its frequent occurrence in tubercular scars and", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0420.jp2"}, "411": {"fulltext": "FIBROMA.\\n389\\nin minute scars resulting from small punctured wounds has led the\\nwriter to suspect that it might represent a particular form of tuber-\\ncular inflammation. We are, however, not in a position to prove its\\ntubercular origin and nature, and its clinical behavior would certainly\\ntend to negative the idea that it is a form of sarcoma. For the present\\nwe must include it among the fibromata, although strongly inclined to\\nbelieve that before long it will have to be classified with the infective\\nswellings. The colored race is peculiarly predisposed to keloid. The\\nsting of an insect, the prick of a needle, or a small abrasion frequently\\nacts as the exciting cause. The wearing of ear-rings is also a frequent\\ncause.\\nThe patient whose photograph is shown in Fig. 267 was the sub-\\nject at the same time of numerous keloids of the skin of the chest and\\nof the back.\\nKeloid sometimes affects different parts of the body at the same\\ntime, but always develops in a scar, which may be so small as to elude\\ndetection (Fig. 268). The tumor slowly\\nincreases in size up to a certain point, and\\nafter having remained stationary for from\\nten to twenty years may slowly disappear\\none of the strongest proofs that it is not\\na true tumor. The keloid tissue is charac-\\nterized by its great vascularity as compared\\nwith other fibromatous tumors and by the\\nexistence of numerous connective-tissue\\nspaces lined with endothelial cells. The\\ninflammatory part of a keloid is shown by\\nthe numerous leucocytes in the perivascular\\nspaces. From the structure of a keloid it\\nwould be reasonable to assume that occa-\\nsionally it is transformed into a sarcoma.\\nThe benign clinical aspects of a keloid\\nrender it easy to distinguish between it and\\na malignant tumor of the scar-tissue.\\nThe treatment of keloid is extremely unsatisfactory. External appli-\\ncations and compression are useless. Recurrence even after thorough\\nextirpation is common. The only treatment is by thorough excision.\\nThe incisions should include a zone of apparently healthy tissue at least\\na few lines in width. The scar following the operation should be pro-\\ntected carefully for a long time.\\nMucous Surfaces. Fibroma of the mucous surfaces resembles\\nthat of the skin in every respect except that the surface of the tumor\\nFig. 268. Multiple keloid in a colored\\nwoman (after Taylor).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0421.jp2"}, "412": {"fulltext": "39\u00c2\u00b0 PATHOLOGY AND TREATMENT OF TUMORS.\\nis covered by mucous membrane instead of by skin, and that the tumor\\nin this locality is more prone to oedema. Many of the polypoid growths\\nin mucous channels are cedematous fibromata. If pendulous, they\\nshould be removed with the wire ecraseur; if sessile, by excision or\\nby enucleation.\\nSubcutaneous Connective Tissue. Two kinds of fibroma, clinically\\ndistinct, are met with in the subcutaneous connective tissue the pain-\\nful tubercle and the soft multiple fibroma of Recklinghausen.\\nPainftil Subcutaneous Tubercle. This is a little hard tumor, not\\nlarger than a pea, noted for its painfulness, in the subcutaneous tissue.\\nThis tumor was first described by A. Petit, Cheselden, and Camper.\\nThe best description was given in 1812 by Mr. Wm. Wood. These\\ntubercles are most frequent in the extremities, especially the lower.\\nThey are more frequent in women than in men, they rarely occur\\nbefore adult life, and they are seldom multiple. Examined under the\\nmicroscope, they are seen to be composed of dense fibrous tissue, with\\nfilaments laid inseparably close together in the fasciculi and compactly\\ninterwoven. The young cells in the periphery of the tumor contain\\nlarge nuclei. The pain and tenderness appear either contemporane-\\nously with the tumor or after the tumor has reached a certain size.\\nThe pain, which is usually paroxysmal, but which can always be pro-\\nvoked by pressure, is sometimes attended by muscular spasms. Vel-\\npeau regarded these tumors as neuromata. Dupuytren, who made\\nseveral very careful dissections, was never able to trace their connection\\nwith nerve-fibres. Other surgeons have succeeded in finding the nerve-\\nfilaments with which these tumors are connected. In one case the\\nwriter could trace the nerve from the capsule of the tumor on both\\nsides. The nerve was no larger than a fine silk ligature. There can\\nbe no doubt that these tumors are connected with sensitive nerve-fila-\\nments. Their removal by excision is often followed by recurrence.\\nSuccessful removals of recurrent painful tubercles are reported by Sir\\nJames Paget and by Mr. Lawson Tait.\\nMultiple Subcutaneous Fibroma. The true pathology of multiple\\nfibrous tumors of the subcutaneous tissue was pointed out in 1882 by\\nRecklinghausen. He ascertained that these tumors are invariably\\nconnected with the sheaths of terminal nerves. They are sometimes\\ncongenital, but they usually develop after puberty. In number they\\nvary from a few to more than a thousand. In the case of Michael\\nLawler, described in Smith s monograph, they were estimated at least\\nat two thousand. This affection was formerly known as molluscum\\nfibrosum (PL 8, Fig. 2). In size these tumors vary from that of a\\nhemp-seed to that of a filbert. In the course of time some of the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0422.jp2"}, "413": {"fulltext": "FIBROMA\\nPlate 9.\\n1. Keloid of external ear (after Klebs) dense fibrous cutis tissue with wide juice-canals endothelial\\nlining, and hyaline ground substance 6, fibrillated connective tissue with abundance of cells w 1 laS el\\nperivascular proliferation, and at different^places wide juice-canals c, attenuated epiderm\\nin part disappeared. (Obj. 5, oc. 3.) 2. Multiple subcutaneous fibromat?\\npap\\nmg", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0423.jp2"}, "414": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0424.jp2"}, "415": {"fulltext": "FIBROMA.\\nPlate io.\\nMultiple neuro-fibroma, early stage (after Klebs) a, outer, inner nerve-sheath with endothelial hollow\\nspaces c, nerve-substance. (Zeiss, E. 2.)", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0425.jp2"}, "416": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0426.jp2"}, "417": {"fulltext": "FIBROMA. 391\\ntumors become pendulous. Histologically, these tumors are composed\\nlargely of fibrous tissue around and between bundles of nerve-fibres.\\nOn Plate 10 a number of nerve-bundles can be seen cut transversely.\\nThe connective tissue between the nerve-bundles has been changed\\nbut little perhaps the connective-tissue spaces are somewhat dilated.\\nSmall round groups of nuclei stained blue with hematoxylin show\\nthe transverse cuts of blood-vessels. The connective tissue is greatly\\nincreased in the nerve-sheaths. The nuclei of the cells are oblong,\\noval, crowded closely together in the larger bundle (3), while the sheath\\nof the smaller bundle contains fewer nuclei. The nerve-sheath can in\\nmany places be distinguished into an outer and an inner (a and b), as\\nthere can be seen between the fibres of the sheaths, arranged trans-\\nversely, spaces which do not occupy in a continuous manner the entire\\nperiphery there can also be seen, on the inner surfaces of the sheath,\\nspaces which at some points are quite wide, and which (at 3) show oval\\nnuclei in their walls. These spaces are in contact with the nerve-fibres\\nand are traversed by delicate connective-tissue threads. In the longi-\\ntudinal section (at 2) they can be seen in the same form. During the\\ngrowth of the tumor the interstitial connective tissue proliferates and\\nthe nerve-bundles are separated more widely. Clinically these tumors\\nform a contrast with the painful subcutaneous tubercle by the absence\\nof pain and tenderness and by their multiplicity. Owing to the multi-\\nplicity of the tumors operative treatment is contraindicated. Should\\nany of the tumors manifest malignant qualities, early and thorough\\nexcision is urgently indicated.\\nAbdominal Wall. A peculiar form of deep-seated fibroma of the\\nabdominal wall was first described by Nelaton. In his cases the tumors\\neither occupied the iliac fossa or were located near the crest of the\\nilium. These places are the favorite localities, but the sheath of the\\nrectus muscle is also not infrequently the starting-point of fibroma\\nof the abdominal wall. The primary starting-point is most frequently\\nnear the peritoneum, so that the tumor projects at the same time\\ninto the peritoneal cavity, pushing the peritoneum before it while it\\nbecomes prominent on the surface. More than sixteen years ago\\nGratzer advanced the theory that these tumors originate at a point\\nwhere the mesoblast divides into the peritoneum and the fibro-mus-\\ncular layer. It is most frequently met with in women after delivery.\\nW. Kramer reports a case in which the tumor was congenital. The\\npatient was a girl four and a half years of age. Examination of the\\ntumor after its removal showed that the congenital dermoid had\\nrecently been transformed into a sarcoma. Among 42 cases col-\\nlected by Guerrien there were 39 women and only 3 men. Of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0427.jp2"}, "418": {"fulltext": "392 PATHOLOGY AND TREATMENT OF TUMORS.\\n4 cases which have come under the writer s observation, all were\\nwomen, and in each of them the tumor appeared soon after child-\\nbed. As compared with other tumors of the abdominal wall, fibroma\\noccurs most frequently. Of 70 cases collected by Sanger, 60 were\\nfibromata. More recently Dannhauer has collected 183 cases. The\\nmost important determining cause appears to be trauma. The great-\\nest confusion has existed in regard to the proper classification of these\\n2**As*t\\nw li r*^ --a*j yi\\n00.\\nFig. 269. Desmoid fibroma of the abdominal wall; X 330, reduced one-third (Surgical Clinic, Rush\\nMedical College, Chicago) a, tumor-tissue b, striated muscle-fibres in cross-section the striae have disap-\\npeared, and the muscle is degenerating and is infiltrated with young connective-tissue cells.\\ntumors. Some authors are inclined to regard them as a variety of\\nfascial sarcoma. Their clinical course and histological structure do not\\njustify their classification with the sarcomata. They seldom recur after\\nthorough extirpation, and their histological structure bears a closer\\nFig. 270. Vessel in a desmoid fibroma of the abdominal wall; X 330 (Surgical Clinic, Rush Medical\\nCollege, Chicago) a, vessel-wall.\\nresemblance to fibroma and keloid than to sarcoma. To distinguish\\nthem from ordinary fibroma it is well to retain the name desmoid,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0428.jp2"}, "419": {"fulltext": "FIBROMA. 393\\na term applied by Miiller to benign connective-tissue tumors (Fig.\\n269). The tumor-tissue is composed of young connective-tissue cells\\nwith a scanty intercellular substance. The cells infiltrate the adjacent\\ntissues besides displacing them, in this respect differing materially from\\nordinary fibroma. The walls of the new blood-vessels in the tumor\\ndisplay an intimate relation with the tumor-tissue (Fig. 270). The\\nendothelial cells lining the new blood-vessels are large, and the tumor-\\ntissue forms the greater part of the vessel-wall.\\n3*\\nL\\nFig. 271. Relations between vessel-wall and tumor-tissue in a desmoid fibroma of the abdominal wall;\\nX 330, reduced one-third (Surgical Clinic, Rush Medical College, Chicago) a, junction of vessel-wall and\\ntumor-tissue.\\nFrom the histological description of a desmoid tumor as given\\nabove it is evident that the encapsulation of the tumor is imperfect\\nan important point to be remembered in the operative treatment of such\\ntumors. Desmoid tumors increase quite rapidly in size, sometimes\\nreaching from the umbilicus to the pubes and from the anterior superior\\nspinous process of the ilium to the median line. In three of the writer s\\ncases the peritoneum was firmly attached and had to be excised with\\nthe tumor.\\nEnucleation of the tumor is liable to be followed by recurrence. In\\ntwo of the writer s cases the tumor started in the iliac region, and in\\ntwo in the sheath of the rectus muscle. All these cases recovered.\\nIn one of them a recurrence made necessary a second operation, after\\nwhich complete recovery ensued.\\nThe diagnosis is not always easy. If the tumor projects as much\\nin the direction of the abdominal cavity as externally, it might easily\\nbe mistaken for an intra-abdominal tumor. The tumor moves with the\\nabdominal wall, but this is also the case if an abdominal tumor has\\nbecome attached to the parietal peritoneum anteriorly. The tumor is", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0429.jp2"}, "420": {"fulltext": "394 PATHOLOGY AND TREATMENT OF TUMORS.\\nfirm and can generally be outlined accurately. In the excision of a\\ndesmoid tumor of the abdominal wall the surgeon must be prepared\\nto resect the peritoneum, and must therefore make all the preparations\\nrequired for abdominal section. The removal of such a tumor results\\nin great defect of the abdominal wall, which defect must be corrected\\nby suturing the peritoneum and the muscular layer separately with\\nburied catgut sutures, including at the same time all the tissues in the\\ndeep sutures in order to approximate the surfaces of the wound accu-\\nrately, so as to prevent the subsequent formation of a ventral hernia.\\nAs an additional safeguard it is necessary to instruct the patient to wear\\na well-fitting abdominal bandage for from six months to a year after the\\noperation.\\nNose. Robert has shown that many of the naso-pharyngeal fibrous\\ntumors start from the anterior lacerated foramen, the basilar process of\\nthe occipital bone, and even from the upper cervical vertebrae. The\\nfibrous polypus of the nose grows slowly, and after it has reached a\\ncertain size protrudes in the direction of the nasal outlet or projects\\ninto the pharynx. From pressure the nose often becomes flattened and\\nthe mouth prominent, or the roof of the mouth is displaced downward.\\nDigital exploration of the naso-pharynx is important to determine the\\nexact location, size, and attachment of the tumor. If the tumor is not\\npedunculated sufficiently to enable its removal by torsion, its operative\\nremoval requires a bloody and often a dangerous preliminary operation\\nto reach its base. If the tumor is attached in front of the naso-pharynx,\\nthe nostril is incised from within outward on the side of the septum as\\nfar as the nasal process, as advised by Dieffenbach and Konig if this\\nincision does not afford sufficient room, the nasal process is temporarily\\nresected and if still more room is required, the upper lip is divided in\\nthe median line and is dissected backward. If the base of the tumor\\ncan be reached in this manner, the tumor is drawn forward with vulsel-\\nlum forceps and its attachment is severed with a narrow periosteal\\nelevator or with blunt-pointed scissors. All operations for the removal\\nof naso-pharyngeal growths requiring a preliminary bone operation\\nshould be performed under partial anesthesia, or, as the writer has been\\nin the habit of calling it, a talking narcosis.\\nFibrous tumors of the nose and the naso-pharynx are exceedingly\\nvascular, and their removal is attended by profuse and even fatal hem-\\norrhage, notwithstanding the employment of prompt and efficient\\nhemostatic precautions. In a case operated upon before the class in\\nRush Medical College, Chicago, in 1893, the writer took the precaution\\nto make a preliminary tracheotomy. Two weeks later the operation\\nwas commenced by ligating the common carotid. Kocher s temporary", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0430.jp2"}, "421": {"fulltext": "FIBROMA.\\n395\\nresection of the upper maxilla was then performed. The hemorrhage,\\nnotwithstanding compression and the use of hemostatic forceps, was\\nalarming, and the patient nearly died upon the table from loss of blood.\\nFig. 272. Resection of nasal process of the superior maxilla (after Langenbeck) a, external incision b,\\nline of section through nasal process.\\nInstead of slitting open the nostril, Langenbeck makes a curved\\nlateral incision through which he\\nresects the nasal process of the\\nsuperior maxilla (Fig. 272). If the\\ntumor obstructs both nasal passages,\\ntemporary detachment of the nose\\naccording to Rouge (Fig. 273) or\\nOilier (Fig. 274) will afford better\\naccess to the base of the tumor\\nthan will the unilateral incision.\\nFig.\\n273-\\n-Temporary detachment of the nose ac-\\ncording to Rouge.\\nFig. 274. Temporary resection of the nose accord-\\ning to Oilier.\\nThe bone-sections in making temporary resection of the nose\\nshould be made with a sharp chisel instead of with a saw. After the\\nremoval of the tumor the nose is replaced and the wounds are sutured\\naccurately with fine silk or with silkworm gut. Bruns makes tempo-\\nrary resection of the nose by displacing it laterally. The removal of\\nnaso-pharyngeal tumors through the hard or the soft palate has\\nbeen practised by Manne (171 1), Dieffenbach, Hueter, and Nelaton.\\nDemarquay and Trelat resected through an external incision the nasal\\nprocess of the superior maxilla and the anterior wall of the antrum of", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0431.jp2"}, "422": {"fulltext": "39^\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nHighmore. The great deformity which followed this operation led\\nLangenbeck in 1861 to devise temporary resection of the upper maxilla.\\nKocher has recently modified Langenbeck s operation. Temporary\\nresection of the upper maxilla after Langenbeck and Kocher is a diffi-\\ncult and an exceedingly bloody operation, and should never be lightly\\nundertaken. Konig lost a patient on the table from hemorrhage in\\nperforming Langenbeck s operation, and the patient mentioned on page\\n394 barely escaped the same fate, and later succumbed to the effects\\nof the excessive loss of blood, although the common carotid artery\\nhad been tied as a prophylactic hemostatic precaution.\\nIn naso-pharyngeal fibrous growths every attempt should be made\\nto remove the tumor by less heroic measures than extirpation through\\nthe hard palate or after temporary resection of the upper maxilla, by\\nthe use of the wire ecraseur or the galvano-caustic sling, the formal\\noperation being reserved for the most desperate cases.\\nTumors of the base of the skull which are behind the maxilla and\\ngrow into the temporal fossa can be removed only after a temporary\\nresection of the maxilla.\\nMammary Gland. Most of the tumors that have been described\\nas fibroma have been cases of adenoma. If the tumor contains any\\nadenomatous tissue, it is an adenoma and not a fibroma, no matter\\nhow much fibrous tissue it may contain. Pure fibromata of the mam-\\nFig. 275. Fibroma of the mammary gland X 250 (after Perls). The fibrous tissue is swollen the spaces\\nwith the nuclei appear as connective-tissue corpuscles a, a, remnants of gland-ducts.\\nmary gland are exceedingly rare. They start in the interacinous or\\nintertubular connective tissue, grow very slowly, and never attain large\\nsize. Pain and tenderness are either entire-ly absent or, when present,\\nare not well marked. The fibrous tissue may surround and include\\npre-existing gland-ducts, in which event the cells become destroyed by\\npressure-atrophy, and the ducts in the course of time may become com-\\npletely obliterated (Fig. 275).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0432.jp2"}, "423": {"fulltext": "FIBROMA.\\n397\\nDifferential diagnosis between fibroma of the breast and adenoma\\nis impossible without the use of the microscope. Fibroma is distin-\\nguished from sarcoma and carcinoma by its slow growth and by the\\nmobility of the tumor in the tissues of the gland. Fibroma of the\\nbreast should be removed by enucleation. The recurrent fibroid tumor\\nof the breast described by Paget is a spindle-celled sarcoma.\\nUterus. Fibroma of the uterus as a purely fibroid growth is ex-\\nceedingly rare. With few exceptions the tumor contains muscle-cells,\\nand has been described in the section on Myoma.\\nFig. 276. Fibroma of both ovaries the right is as large as a kidney, the left larger than a child s\\nhead (after Winckel) a, surface of tumor on left side, with numerous nodules b, fundus of uterus c, sur-\\nface of tumor on right side d, section of right ovary e, os uteri f, surface of left ovary g, cut surface\\nof tumor on left side.\\nOvary. Fibromata of the ovary are so rare that Sutton regards\\nthem as pathological curiosities. The writer has met with two such\\ncases. In one of them the tumor was recognized ten years before the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0433.jp2"}, "424": {"fulltext": "398\\nPATHOLOGY AND TREATMENT OF TUMORS.\\noperation. The operation was postponed until the patient was driven\\nto it by a very extensive ascites. The pedicle of the tumor was slender\\nand there were no adhesions. The tumor weighed twenty pounds, was\\nvery firm, and was nodulated on the surface. Sections under the micro-\\nscope showed nothing but wavy bundles of fibrous tissue interlaced\\nin all directions. The blood-vessels were few and small. In the sec-\\nond case the tumor was about half as large and presented a similar\\nstructure. The enlargement of the abdomen due to ascites in this\\ninstance also induced the patient to submit to an operation. Both\\npatients recovered from the operation and remain well up to the present\\ntime, the first twenty and the second two years after operation. In\\nboth cases the peritoneum was exceedingly vascular a condition\\ncaused by its being thrashed, as it were, by the tumor, for a number,\\nof years. The writer has come to regard ascites as an important\\ndiagnostic evidence of movable solid tumors of the ovary. Neither of\\nthe tumors showed on section evidences of cystic degeneration. Occa-\\nsionally both ovaries are affected at the same time (Fig. 276).\\nAscites is usually the first thing noticed by the patient, and it is\\nfor this condition, and not for its cause, that the patient seeks relief.\\nAscites in the absence of malignant disease of the pelvic or abdominal\\nviscera should remind us of fibroma of the ovary as the possible cause.\\nFibroma of the ovary occurs most frequently in women between twenty\\nand forty years of age. Leopold\\nmentions 1 3 cases at from five to\\nthirty years of age, and only 4\\nat thirty to forty years. Ferrier\\nremoved a fibroma of the ovary\\nfrom a woman seventy-six years\\nold.\\nThe differential diagnosis be-\\ntween a fibroma of the ovary and\\na desmoid cyst is difficult, and be-\\ntween a fibroma and a peduncu-\\nlated myofibroma of the uterus is\\nimpossible, without an explora-\\ntory laparotomy. Removal by\\nlaparotomy is a safe operation,\\nand if the tumor is completely\\nremoved recurrence never takes\\nplace.\\nVulva. Tumors are rare as compared with chronic infective swell-\\nings of the vulva. Fibroma occurs less frequently than papilloma,\\nmm\\nFig. 277. Papilloma of the vulva; X 25 (Surgical\\nClinic, St Joseph s Hospital, Chicago): a, stroma of\\nloose connective tissue b, blood-vessels c, epithelium\\nd, horny layer.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0434.jp2"}, "425": {"fulltext": "FIBROMA. 399\\nis found more often upon the labium majus than upon the nymphae, and\\nappears first as a soft swelling with a broad base. It is of slow growth,\\ndoes not attain large size, and may become pendulous by elongation of\\nthe skin covering it. Fibroma, which can be distinguished from papil-\\nloma by the smoothness and thinness of the overlying skin, is not as\\noften multiple as is papilloma. Sections of a papilloma show that the\\ngreater part of the tumor is composed of epithelial cells attached to a\\nvascular stroma (Figs. 277, 278). A vertical section of a fibroma would\\nshow the skin covering the tumor to be atrophied and the tumor-tissue\\nto be composed exclusively of interlacing fibres or bundles of fibres\\nof connective tissue.\\nFibromata of the vulva may be enucleated, or their pedicles may be\\ncut, without danger of hemorrhage, as the blood-supply is scanty.\\nfcj\\nFig. 278 Periphery of tumor shown in Figure 276 (X J 4o) a, stroma; b, blood-vessels; c, very thick\\nstratum of epithelial cells d, horny layer; e, loss of substance probably caused by degeneration.\\nGums. Formerly all tumors of the gums were included under the\\nname of epulis. Microscopical examination of different tumors has\\nshown the necessity of differentiating between sarcoma, carcinoma, and\\nfibroma of the gums. Fibroma of the gums appears as a bone-swelling\\ncovered by the mucous membrane the tumor grows slowly and does\\nnot return after thorough removal. The term epulis should be\\nrestricted to designate a fibroma originating from the gums or from the\\nperiodontal membrane. Local irritation caused by a decayed tooth or\\nby incrustation upon the teeth is the most frequent exciting cause of\\nfibroma of the gums. The tumor is seldom larger than a walnut, and\\nits base is often constricted into a short pedicle. Mr. Hawkins made\\nthe assertion that fibroma of the gums, the fibrous epulis, grows, like", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0435.jp2"}, "426": {"fulltext": "4-00\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nmost of the other fibrous tumors, from the bone and periosteum and\\ncontinuous with them.\\nThe radical removal of a fibroma of the gums can be effected only\\nby excision of the alveolar border of the jaw. This excision can be\\ndone, after the extraction of one or more teeth, with the chisel or with\\na narrow metacarpal saw. In benign fibrous tumors of the alveolar\\nborder and the gums it is unnecessary to resect the jaw in its entirety,\\nas recommended by Gross and others.\\nPeriosteum and Bone. The maxillary bones are the most frequent\\nseat of fibroma. The fibrous tumor of these bones is very hard, has a\\nFig. 279.\u00e2\u0080\u0094 Distortion of dental arch caused by the tumor represented on Plate 10.\\nsmooth surface, and is covered by skin and mucous membrane. Cystic\\ndegeneration occasionally takes place. It is difficult to determine\\nwhether these tumors start from the periosteum or from the connective\\ntissue of the bone. They do not infiltrate the bone to which they are\\nattached, but cause pressure-atrophy and distortion of the bone.\\nThe tumor represented on Plate 1 1 (Fig. i) occurred in a man twenty", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0436.jp2"}, "427": {"fulltext": "FIBROMA.\\nPlate ii.\\ni. Enormous fibroma of the upper maxilla. 2. Showing condition of parts immediately after excision\\nof the tumor.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0437.jp2"}, "428": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0438.jp2"}, "429": {"fulltext": "FIBROMA. 401\\nyears of age, and was first discovered when he was ten years old. In\\n1890 it was only partially removed through a small incision. Two\\nyears before the operation the patient consulted a prominent surgeon,\\nwho pronounced it a sarcoma and refused to operate. When the patient\\ncame under the writer s observation the tumor had become very promi-\\nnent in the cavity of the mouth so much so that deglutition and speech\\nwere greatly affected. The tumor was removed, through the incision\\nshown on Plate 11 (Fig. 2); by enucleation, without any special diffi-\\nculty. The wound healed promptly, leaving a deep depression in the\\nright cheek, where the tumor had been most prominent. No recurrence\\nhad taken place two years after the operation. Sections of the tumor\\nexamined under the microscope showed the typical structure of a dense\\nfibroma.\\nSmall fibromata of the jaw can be removed through the mouth,\\nbut large tumors must be enucleated through an external incision.\\nSerous Surfaces. Papillomatous and fibrous tumors of the serous\\nsurfaces are rare, and their structure is very similar to that of the same\\nkind of tumors of the skin, except that in place of epithelial cells the\\ntumors are covered by endothelial cells in the former variety by\\nnumerous strata, in the latter usually by a single layer. Benign fibrous\\nand endothelial tumors are found most frequently upon the peritoneum\\nand upon the synovial membrane of joints. When such a tumor\\nbecomes pedunculated it is often detached and remains in the cavity\\nas a foreign body.\\nCholesteatoma.- Closely allied to psammoma is cholesteatoma, first\\ndescribed by J. Miiller. It was later described by Cruveilhier as tumeur\\nperlee, or pearl tumor. The tumors do not exceed in size a cherry.\\nThey present a pearl-like metallic lustre, and they are found most fre-\\nquently at the base of the brain, imbedded in the tissues of the pia\\nmater. In this locality these tumors are often found so closely aggre-\\ngated as to form nodulated masses an inch or more in diameter.\\nWithin a very delicate membrane there is found a fatty substance in\\nconcentric leaf-like layers. Microscopical examination of the layers\\nshows that they are composed of large cells between which globules of\\nfat and cholesterin-plates are seen. The pearl-like appearance of the\\ntumor is due not to the cholesterin, but to the compact layers of the\\ncells. The cells are derived from endothelium, and not from epithelium,\\nas was formerly supposed. Recently some doubt has been raised as to\\nthe endothelial origin of cholesteatoma. J. Bland Sutton and Ribbert\\nsupport their epithelial origin. Ribbert has examined a case in which\\nthere was nothing to indicate that the three-layered epithelial coat of\\nthe inner surface of the tumor had any connection with the endothe-\\n26", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0439.jp2"}, "430": {"fulltext": "402\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nHum of the pia. The very sharp line of demarcation between the epi-\\nthelium and the normal pia mater made the idea of the origin of the\\ntumor from separated epithelial cells seem very probable. This idea\\nhas a strong support in the case described by Bonorden, in which the\\ntumor contained glands and hair-follicles, structures belonging only to\\nthe external skin. Beneke has shown that the meningeal steatomata\\nare produced by proliferation of the endothelial cells of the pia. He\\nbases his opinion upon the fact that silver staining yields the outlines\\nof endothelial cells, which would not be the case with epithelial cells.\\nFig. 280. Fibroma of upper jaw.\\nCholesteatoma is found, besides, in the meninges and the ventricles\\nof the brain, in bones, especially the petrous portion of the temporal\\nbone, and in the mastoid process, in the testicle, and in the ovary.\\nIn the meninges of the brain cholesteatoma probably starts in the\\nperivascular lymph-spaces. Rindfleisch very strongly maintains that\\nthese tumors in the meninges of the brain are of endothelial origin.\\nWendt believes that in the petrous portion of the temporal bone chole-\\nsteatoma is produced by inflammation of the middle ear resulting in\\ndesquamation and accumulation of epithelial cells, but he has described\\nalso genuine cholesteatoma of endothelial origin in the drum of the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0440.jp2"}, "431": {"fulltext": "FIBROMA. 4\u00c2\u00b03\\near. In tumors of the pia mater belonging to this category this mem-\\nbrane surrounds the tumor mass, but the space is not lined by endo-\\nthelial cells. Ziegler found hair in some of these tumors, in which\\ncase we must assume for some of them an epithelial origin from a\\ndisplaced tumor-matrix but these cases must be exceedingly rare.\\nEberth found that in cholesteatoma of the pia mater the first change\\nthat is seen in the formation of the tumor is the appearance of proto-\\nplasmic masses which surround the vessels like a sheath. In. the\\nsheath irregular nuclei are seen, besides giant-cells. Virchow and\\nEberth claimed that these cells were epithelial cells produced by hetero-\\nplastic proliferation of the connective tissue. This view is, of course,\\nno longer tenable, as we have shown repeatedly that epithelial cells\\nare never produced from connective tissue. Cholesteatoma never gives\\nrise to metastasis, and it manifests no tendency to invade surrounding\\ntissues to any extent, resembling in these respects psammoma, with\\nwhich it is histologically and clinically so closely allied.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0441.jp2"}, "432": {"fulltext": "XVIII. LIPOMA.\\nDefinition. A lipoma is a circumscribed or diffuse tumor composed\\nof fatty tissue produced from a matrix of lipoblasts. The subcutaneous\\nfatty tissue is the favorite seat of lipoma. Toldt ascertained that in\\nthe embryo the panniculus adiposus is formed by cell-islets, the so-\\ncalled fat-organs, each of which has a separate and independent\\nblood-supply. These islets are separated from one another by connec-\\ntive tissue. Young fat-cells are called lipoblasts. Their number and\\nactivity, as well as the assimilation of fat from the blood or the food,\\ndetermine the amount of fat. Each fat-lobule has its own artery and\\ncapillary circulation, terminating in a common vein. The lobule there-\\nfore represents an organized unity, like an acinus in the liver. Accord-\\ning to Virchow, the lipoblasts develop from fetal myxomatous tissue\\ninto which the mature fat-cells can revert. If the cells of any of\\nthese fat-forming centres should become arrested in their develop-\\nment and remain in a quiescent state, it is easy to see how at any time,\\nby their resuming active tissue-proliferation, they could give rise to a\\nfatty tumor. Having become emancipated, as it were, from the organ-\\nFig. 281.\u00e2\u0080\u0094 Fat-cells imbedded in subcutaneous areolar tissue (after Schiefferdecker) fat-cells; n t\\nnucleus; c, connective-tissue corpuscles; w, migratory cells; e, elastic fibres; b, capillary blood-vessels.\\nism, their growth, development, and reproduction would no longer be\\ncontrolled by the laws which regulate normal nutrition. It would be\\ndifficult to explain localized hyperproduction of fatty tissue in any\\nother way.\\nHistology. The fat-cells in a lipoma, as in normal adipose tissue,\\nrepresent connective-tissue cells with oily contents. The cells are\\n404", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0442.jp2"}, "433": {"fulltext": "LIPOMA. 4\u00c2\u00b05\\nround or oval sacs the transparent contents are limited by a delicate\\nenvelope composed of cell-membrane and of an extremely thin layer\\nof protoplasm. The nucleus is located on one side of the sac (Fig.\\n281).\\nThere is nothing to distinguish a fat-cell in a lipoma from a fat-cell\\nin normal adipose tissue. The cells occur in groups supported and\\nheld together by areolar tissue through which ramifies a rich vas-\\ncular network. The amount of stroma varies in the soft lipomata it\\nis very scanty, so that under the microscope it is difficult to recognize\\nit, it being almost completely overshadowed by the fat-cells. In the\\nhard lipoma the fibrous structure of the tumor is well developed and\\nthe fat-cells are crowded into the large areolae of the stroma. Some\\nlipomata are exceedingly vascular, and we then speak of a lipoma\\ntelangiectodes. In other instances the stroma contains venous channels\\nof large size, when the tumor is called lipoma cavernosum. The writer\\nhas met with such vascular lipomata most frequently in congenital\\nlipoma.\\nRegressive Metamorphoses. The stroma of a lipoma is more\\nprone to undergo retrogressive metamorphosis than is the parenchyma\\nof the tumor. The most frequent degenerative change observed is\\nmyxomatous degeneration of the stroma. The connective-tissue fibres\\nare separated by the myxomatous material, and the stroma presents\\nthe appearance of juvenile connective tissue. The tumor or part of a\\ntumor undergoing this process becomes softer. Calcification of the\\nstroma arrests the growth of the tumor affected by this change, the\\nparenchyma-cells degenerate, and the tumor becomes eventually com-\\npletely petrified. Burow found cholesterin in a large lipoma of the\\naxilla. The lime-salts found in a calcified lipoma are carbonate and\\nphosphate of lime. Furstenberg found in the fat-cells lime-salts in\\ncombination with fatty acids. Ossification of parts of the stroma occurs\\nin rare cases. Oil-cysts have been found in the interior of fatty tumors,\\nand are supposed to have been formed by atrophy of the cell-envelopes\\nand accumulation of their contents in the stroma.\\nAnatomical Varieties. All lipomata are encapsulated. The cap-\\nsule is perfect in the circumscribed variety in the diffuse form the\\ntumor sends out into the surrounding loose connective tissue pro-\\nlongations which sometimes are not discovered in the removal of the\\ntumor, and lead to a recurrence of the growth. The diffuse form fre-\\nquently occupies a large territory, as, for instance, the anterior surface\\nof the neck. The lipoma arborescens or raccmositm described by\\nJ. Muller is a branching fatty tumor (Fig. 282). It is found most\\nfrequently in the knee-joint, where it starts beneath the synovial mem-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0443.jp2"}, "434": {"fulltext": "406\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nbrane, and, pushing this before it, sends branching lobes into the joint.\\nLipoma arborescens is also found quite frequently as a diffuse tumor\\nunder the peritoneum and the pleura.\\nSymptoms and Diagnosis. Lipoma frequently occurs as a con-\\ngenital tumor. Sometimes it is found as a symmetrical affection for\\ninstance, the simultaneous occurrence of a lipoma in each axillary\\nspace. The writer has observed such a case in a woman fifty years of\\nFig. 282. Lipoma arborescens (after Liicke).\\nage. Billroth, in a paper published shortly before his death, called\\nattention to the occurrence of symmetrical lipoma. As a post-natal\\ntumor it commences most frequently after puberty. Its growth is\\nalways slow. Sometimes it remains stationary for a certain length of\\ntime, when, without any apparent provocation, it resumes its growth.\\nIt attains occasionally an immense size. Rhodius recorded a case in\\nwhich the tumor weighed sixty pounds. Tumors weighing more than\\nten pounds, however, are very rare. If the tumor is subcutaneous, the\\nskin over it, from tension, atrophies, and ulceration from impaired nutri-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0444.jp2"}, "435": {"fulltext": "LIPOMA. 407\\ntion may take place. In other instances ulceration is caused by a\\ntrauma or in consequence of irritating applications. Infection of a fatty\\ntumor through a break in the surface is frequently followed by intense\\nphlegmonous inflammation of the stroma of the tumor, extensive gan-\\ngrene, and profuse suppuration.\\nExamination of a tumor complicated by acute inflammation might\\nlead the surgeon to suspect a malignant growth. Under such circum-\\nstances a careful consideration of the clinical history will prevent a\\nmistake in diagnosis. A soft lipoma imparts to the palpating finger\\na sense of fluctuation. Pseudo-fluctuation of soft tumors has led to\\nmany mistakes in diagnosis. Chelius compares the sensation felt on\\npalpating a lipoma to that felt on compressing a bag filled with cotton.\\nIf the tumor is hard, the resistance to pressure is of a firm, elastic\\nkind. A subcutaneous lipoma is a lobulated, movable tumor. Its slow\\ngrowth differentiates it from sarcoma. A lipoma, however, may attain\\nconsiderable size before being discovered by the patient, and surgeons\\nhave often been misled by dating the origin of the growth to its acci-\\ndental discovery by the patient. In doubtful cases the negative result\\nof an exploratory puncture will prove of great value in differentiating\\nbetween a lipoma and an infective or cystic swelling. The recognition\\nof a cavernous or telangiectatic lipoma is often impossible. This com-\\nbination tumor should be suspected if under pressure the tumor is\\ndiminished in size, but the effect of pressure is less marked than in\\ncases of deep-seated angioma.\\nPrognosis. The prognosis in lipoma is favorable. Transition into\\nsarcoma is less frequently observed than in any other kind of benign\\nmesoblastic tumors. Myxomatous degeneration of the stroma often\\ninitiates the transition of a lipoma into a sarcoma. This transition occurs\\nmost frequently in intermuscular lipomata. The first case of this kind\\nwas described by Forster. Virchow examined three fatty tumors which\\nhad undergone this degeneration, and made the statement that their\\nmalignancy depended upon the extent of the degeneration. The fat-\\ncells are not affected by this change. Waldeyer showed that myxo-\\nlipoma can give rise to metastasis. In a mesenteric tumor of this kind\\nhe found metastatic deposits in the liver and lungs. The pressure-\\neffects are also less marked, owing to the location of the tumor being\\nusually in places where the surrounding tissues are yielding. Even the\\nlarge subserous lipomata seldom give rise to any serious functional\\ndisturbances. Patients with fatty tumors seek surgical advice more\\nfrequently for cosmetic reasons or for inconveniences attending the\\npresence of the tumor than for the relief of suffering or the functional\\ndisturbances.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0445.jp2"}, "436": {"fulltext": "4-08 PATHOLOGY AND TREATMENT OF TUMORS.\\nTreatment. The only proper surgical treatment of lipoma is\\nremoval by excision. Lipoma of the abdominal cavity is rarely or\\never recognized before the abdomen is opened. The removal of a sub-\\ncutaneous lipoma must be done under strictest aseptic precautions, because\\nthe bed of the tumor presents the most favorable conditions for progres-\\nsive infection. The numerous large connective-tissue spaces which are\\nexposed by the removal of the tumor and the abundance of connective\\ntissue forming its bed are admirably adapted for a diffuse infection.\\nBefore antiseptic surgery came in use numerous instances of progres-\\nsive phlegmonous inflammation, sepsis, and pyemia occurred after the\\nremoval of small lipomata. The surgeon must not be lulled into a\\nsense of ease and security offered by an easily-removable lipoma in\\nundertaking its removal by enucleation. He must make as careful\\npreparations to procure asepsis as though he were to operate upon the\\nabdominal cavity. Owing to the attenuated skin overlying tumors\\nimmediately under the surface, the incision, as a rule, should be made,\\nnot over the centre of the tumor, but at its base. A semilunar incision\\nin this location will secure more room than a straight one. After reflec-\\ntion of the flap the capsule of the tumor must be found, and in the\\nenucleation which follows it is taken as a guide. Bands of connective\\ntissue which convey the blood-vessels to the tumor should not be torn,\\nbut should be cut with scissors or with a knife. Tearing must be\\navoided. After the enucleation all bleeding points are tied. As few\\nblood-vessels are cut in the operation, the wound can be sutured\\nthroughout. Drainage is unnecessary. The dressing must be applied\\nwith care in order to bring and to hold the wound-surfaces in uninter-\\nrupted apposition. If the wound is sealed with cotton and iodoform\\ncollodion, an elastic dressing is applied over it to aid the sutures in\\nsecuring and maintaining accurate coaptation of the wound-surfaces.\\nIn the majority of cases general anesthesia is superfluous in the removal\\nof a lipoma.\\nTopography.\\nSubcutaneous Adipose Tissue. By far the greatest number of\\nfatty tumors originate in the panniculus adiposus and present them-\\nselves as lobulated movable subcutaneous tumors. In this locality the\\ntumor is occasionally multiple, from two to ten or more appearing\\nsimultaneously or in succession. Lipoma is found most frequently\\nupon the neck (Fig. 283), shoulders, chest, abdomen, arms, and thighs.\\nGrosch collected 716 cases of solitary lipoma, and found their regional\\ndistribution, in the order of frequency, as follows Neck, back, thigh,\\nforearm, volar side of hand and foot; the scalp only in exceptional cases.\\nIt appears, then, that lipoma occurs most frequently in localities where", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0446.jp2"}, "437": {"fulltext": "LIPOMA.\\n409\\nthe skin is scantily supplied with glands. Symmetrical lipomata Grosch\\nregards as of neuropathic origin. Lipoma of the scalp is very rare. In\\nthis locality the tumor is flattened and never becomes pendulous.\\nLipomata in localities where the skin is loose often become peduncu-\\nlated.\\nA neuropathic cause of symmetrical lipomata has been assumed\\nby some. Madelung observed the growth of fatty tumors at the\\ninsertion of the deltoid muscle following neuralgia and tremors which\\noccurred in consequence of contusions. In one of the two cases which\\nFig. 283.\u00e2\u0080\u0094 Diffuse lipoma of the neck (after Baker)\\nhe reported the neuralgia disappeared after extirpation of the tumor.\\nMathieu in 1890 described a case in which sciatic neuralgia attended\\ntwo pairs of lipomata, one on the trochanter major, of the size of the\\nhead of a new-born child, and two smaller ones, of the size of a fist,\\non the inner side of the knee. Other tropho-neurotic affections com-\\nplicated the case. Targlowa recorded a case where symmetrical\\nlipomata, seven pairs, had developed in a man affected with general\\nparalysis. The tumors occupied the neck, the zygomatic and mastoid\\nprocesses, the subclavicular, the deltoid, and the sacral region of both\\nsides. Cases of the same nature are reported by Oldham, MacCormac,\\nHutchinson, C. Beck, and others. In Beck s case the tumors occupied\\nthe neck, the parotid, and the mastoid regions on both sides. The", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0447.jp2"}, "438": {"fulltext": "4io\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwriter has seen only one case of diffuse lipoma of the neck, and in this\\ninstance the swelling extended diffusely around the whole neck and\\ncame up well in front of both ears. Diffuse lipoma is not encapsulated.\\nFig. 284. Symmetrical lipoma of the axillae.\\nThe fat bears a coarsely granular appearance, due to being bound up\\nin small lobules, which causes it to resemble omentum in its structure.\\nOperative treatment in diffuse lipoma is not indicated, as a rule, as\\nthe tumor usually becomes stationary.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0448.jp2"}, "439": {"fulltext": "LIPOMA. 411\\nThe palm of the hand is occasionally the seat of a lipoma. The\\ntumor in this locality might be mistaken for tuberculosis of the tendon-\\nsheaths or for a plexiform neuroma. The very slow growth and the\\nabsence of pain are important factors in differentiating lipoma from\\nneuroma and inflammatory swellings.\\nEyelids. The fibroma lipomatodes of Virchow, the xanthoma\\nwhich is usually found upon the eyelids, appears as yellowish or brown\\nspots, and consists of large fat-cells with a reticulated protoplasm.\\nThe tumor is sometimes quite diffuse and large. Some authors have\\ndescribed xanthoma as a variety of endothelioma, but the cells of\\nendotheliomata contain no fat except as a product of degeneration.\\nThe coloring-material is lipoxanthin, belonging to the class of blood-\\npigments. Klebs proposes for these tumors the name of lipoxan-\\ntJwma. Xanthoma may occur as a primary lesion in other parts\\nof the body, more especially where the skin is exposed to repeated\\ninjuries.\\nSubserous Lipoma. The peritoneum, like the skin, rests upon\\na bed of fat, the thickness of which varies considerably. This layer\\nof fat is sometimes the seat of very large fatty tumors. In Carlsberg s\\ncase the tumor weighed thirty-five pounds and was in part petrified.\\nTerillon removed a subperitoneal lipoma weighing fifty-seven pounds.\\nHomans of Boston removed two large retroperitoneal fatty tumors.\\nJosephson and Vestberg have collected 30 cases of multiple, retroperi-\\ntoneal lipomata, of which 3 have been seen personally. The point of\\norigin of these tumors is always retroperitoneal, and never mesenteric,\\nalthough they may encroach upon the mesentery secondarily. In the\\ndiagnosis it is stated that an abdominal tumor which presents none of\\nthe evidences of malignancy, but which increases rapidly in size,\\nwhich displaces the large intestine to one side, which presents pseudo\\nfluctuation, and which is hard in some places, is surely a retroperitoneal\\nlipoma. If the tumor is perceptible beneath the abdominal wall, in\\nthe lumbar region, and if it tends to return to its former position by a\\nkind of spring, due to its elasticity, when one tries to pull it away from\\nthe abdominal wall, its retroperitoneal location can be assumed with a\\ngreat deal of certainty. The authors advise surgical intervention, call-\\ning attention to the fact that in certain cases resection of a portion\\nof the large intestine will be made necessary for the removal of a\\ntumor which has involved the entire thickness of the mesentery, if one\\nwishes to avoid gangrene of the intestine. The removal of large lipo-\\nmata by laparotomy is a very dangerous operation of 10 cases, only\\n3 recovered. Smaller lipomata cause no serious symptoms, and when\\nincidentally discovered can be safely removed by enucleation. They", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0449.jp2"}, "440": {"fulltext": "412 PATHOLOGY AND TREATMENT OF TUMORS.\\nare frequently found in connection with femoral and inguinal herniae.\\nRoser believed that lipoma in subperitoneal spaces usually occupied\\nby herniae is a frequent cause of hernia. A subperitoneal tumor of\\nthe anterior abdominal wall sometimes, by displacing the abdominal\\nmuscles, becomes subcutaneous, especially near the umbilicus. If the\\ntumor is situated between the folds of the broad ligament, it simulates\\nvery closely an ovarian tumor. The removal of omental lipoma has\\nproved more successful than the removal of tumors from behind the\\nperitoneum of the posterior ab-\\ndominal wall. Meredith removed\\ns W^k successfully an omental lipoma\\nweighing fifteen and a half pounds.\\nj uJ/t Forster saw one that weighed fifty-\\n-M three pounds. Waldeyer described\\nIJW^X^^^M a lipo-myxoma of the mesentery\\nthat weighed sixty-three pounds.\\nSubserous lipoma of the colon\\nis met with occasionally. The\\nappendices epiploicae are often the\\nseat of polypoid lipomata. Lipoma\\nof the abdominal organs and of the\\nsubperitoneal layer of fat are not\\nrecognized before the abdomen is\\nopened. If abdominal section re-\\nveals the existence of a lipoma in\\nthe retroperitoneal space, its removal\\nshould not be attempted if, as is so\\noften the case, it dips down deeply\\non the side of the vertebral column,\\nunless the tumor interferes with an\\nimportant function or is the cause\\nFig. 285.\u00e2\u0080\u0094 Meningeal lipoma simulating a spina Q f p a i n If the tumor is more\\nbifida in a child eight months old (after Temoin). 111 11\\nfavorably located, the peritoneum\\ncovering it should be incised over the most prominent part of the\\ntumor, and the tumor should be removed by enucleation. After the\\ntumor is removed the peritoneal incision should be sutured.\\nSubmucous Lipoma. Submucous lipoma of the gastro-intestinal\\ncanal is rare. Virchow examined a submucous lipoma of the stomach\\nas large as a walnut. Turner has seen a fatty tumor, the size of a large\\nwalnut, growing in the submucous tissue of the large intestine and pro-\\njecting into the lumen of the bowel near the ileo-cecal valve. Sub-\\nmucous intestinal lipomata may cause intussusception, and thus become", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0450.jp2"}, "441": {"fulltext": "LIPOMA. 413\\na source of danger to life. A few instances of submucous lipoma of\\nthe larynx have also been reported.\\nMeninges of the Brain and Spinal Cord. Lipoma of the menin-\\nges of the brain and spinal cord is a heterotopic tumor which develops\\nfrom a displaced matrix of lipoblasts. Tauber records a case where\\nthe tumor was located in the tubercula quadrigemina on the right side,\\nand had given rise to destruction of brain-tissue from pressure. Roki-\\ntansky has seen cases of lipoma upon the internal surface of the dura\\nmater and in the lateral ventricle. Polypoid masses of fat are occa-\\nsionally associated with protrusions of the spinal or cerebral meninges,\\nand fatty tumors may be found as a pathological curiosity in the central\\nnervous system. Chiari found two lipomata the size of a pea under the\\narachnoid, and Weichselbaum found one in the posterior lobe of the\\nhypophysis in a soldier twenty-two years old. Lipomata are frequently\\nobserved at the seat of a spina bifida occulta, which may even penetrate\\ninside the theca (Fig. 285).\\nIn the cases of meningeal tumors examined by Recklinghausen\\nand Obre the tumors contained striped muscular fibres, showing\\nthat the matrices were composed of displaced fetal tissue. A lipoma\\ncomplicating a spina bifida greatly complicates the diagnosis. The\\npresence of a solid tumor over the spine in children should induce the\\nsurgeon to look for, and to be prepared to treat, a spina bifida at its\\nbase.\\nIntermuscular Lipoma. Fatty tumors in rare instances have been\\nfound between nearly all the great muscles, and have given rise to\\ngreat difficulty in diagnosis. Myxo-lipoma, according to Liicke,\\noccurs most frequently below the gluteal fold, between the muscles\\nof the thigh, and frequently penetrates the ischiatic foramen.\\nIntermuscular lipoma being more liable than superficial tumors to\\nundergo transition into sarcoma, their operative removal is rendered so\\nmuch more imperative.\\nPeriosteum. As a heterotopic tumor lipoma of the periosteum\\nmust be mentioned. Sutton collected nine such cases representing so\\nmany different bones. The heterotopic nature of periosteal lipomata\\nhas been established by microscopical examination, which in each\\nspecimen showed traces of striated muscle-fibre. Without an explora-\\ntory incision or an examination of tissue removed it would be next to\\nimpossible to make a positive diagnosis.\\nJoints. Subserous lipoma of joints, from the location of the tumor,\\nappears as a diffuse growth. The lobes of the branching tumor present\\na racemose or arborescent appearance hence these tumors are known\\nand described as lipoma arborescens. So far, 16 cases of lipoma of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0451.jp2"}, "442": {"fulltext": "414 PATHOLOGY AND TREATMENT OF TUMORS.\\nknee-joint have been recorded. In this joint Schmolk describes two\\nvarieties (i) the diffuse and (2) the circumscribed. The diffuse variety\\nis not a tumor, but an inflammatory swelling of a tubercular nature\\nwith fatty degeneration of the synovial villi. The circumscribed form\\nhas, according to Konig, its starting-point in the retrosynovial fat-tissue\\nin the same manner as the retroperitoneal lipoma. The tumor projects\\ninto the joint through a rent in the synovial membrane caused by an\\ninjury or otherwise. Subsynovial lipoma is found most frequently in\\nthe knee-joint, but has also been seen in the shoulder-joint. The\\nfringes of the tumor are covered by the synovial membrane. If the\\ntumor disturbs the function of the knee-joint, its removal by arthrec-\\ntomy is indicated. Thorough removal under strict aseptic precautions\\nis not followed by recurrence and yields a satisfactory functional result.\\nTendon-sheaths. Lipoma outside the tendon-sheaths has been\\ndescribed by Ranke and Trelat. It is found most frequently along\\nthe tendon-sheaths of the flexor tendons of the hand. Lipoma inside\\nthe tendon-sheaths springs from the adipose tissue of the mesotendon.\\nIt develops usually as a multiple tumor which presents an arborescent\\nappearance, and it is easily mistaken for tuberculosis of the tendon-\\nsheaths and for plexiform neuroma. According to Hammann, Sprengel,\\nand Haeckel, it can be treated successfully by excision.\\nEye. Subconjunctival lipoma is a rare affection of the eye. It\\noccurs most frequently near the point where the conjunctiva is reflected\\nfrom the lower lid to the eyeball, and it is almost confined to children.\\nAs a rare retrobulbar benign tumor a lipoma is found in the cushion\\nof fat behind the eyeball, producing, according to its size, more or less\\ndisplacement of the eyeball.\\nBroad Ligament. Lipoma of the broad ligament as a subserous\\ntumor is very rare. Pozzi saw a case of this kind in which the tumor\\nwas mistaken for an ovarian tumor because of the misleading sense of\\nfluctuation. The patient suddenly died of embolism three days after\\nan exploratory incision.\\nVulva. Lipoma of the vulva arises in the fatty tissue of the mons\\nveneris, and often reaches large dimensions. Stiegele operated on one\\nwhich weighed ten pounds. In one of Bruntzel s cases the tumor\\nincreased greatly in size during pregnancy.\\nScrotum. Lipoma of the scrotum occurs rarely as a subcutaneous\\ntumor. Fatty tumors of the cord often reach considerable size. Park\\nsuccessfully removed a large lipoma of the cord, and he refers to a\\nnumber of similar cases. Sarazin has collected from different sources\\n26 cases of lipoma of the spermatic cord.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0452.jp2"}, "443": {"fulltext": "XIX. MYXOMA.\\nThe frequent occurrence of myxomatous degeneration of the stroma\\nof benign and malignant tumors and the rarity with which pure myx-\\nomatous tumors are found have induced some authors to abandon\\nmyxoma as a separate class of tumors and to include it among the\\nfibromata. Myxoma is a tumor which presents so many characteristic\\npeculiarities that it is well to give it a separate place in the classification\\nof tumors, and not to regard it as a variety of cedematous degeneration\\nof other connective-tissue type of tumors.\\nDefinition. A myxoma is a tumor composed of mucous tissue resem-\\nbling Wharton s jelly in the umbilical cord. Virchow selected Wharton s\\njelly of the umbilical cord as a prototype\\nof the tissue of which a myxoma is com-\\nposed (Fig. 286)-\\nIn the embryo the connective tissue is\\nidentical in structure with Wharton s jelly.\\nThe meshes of the cellular network are\\noccupied by a semi-gelatinous, indifferent,\\nand but slightly differentiated intercellular\\nsubstance containing few fibres and occa-\\nsional wandering cells. During the devel-\\nopment of myxomatous into connective\\ntissue the fibrous tissue in the meshes\\nbecomes more abundant, while the intercellular substance is diminished\\nin quantity. If a group of cells should become arrested in their devel-\\nopment at an early stage and be set aside, it is to be expected that\\ntissue-proliferation from them would result in a connective-tissue tumor\\nof lowly-organized tissue a myxoma. On the contrary, arrest of\\ndevelopment at a later stage would result in a tumor-matrix which would\\nproduce a connective-tissue tumor of a higher type a fibroma. The\\nstage at which development of the mucous cells in the embryo is arrested\\ndetermines whether the tumor from such a matrix is to be a myxoma or\\na fibroma. The intrinsic capacity of mature connective tissue to revert to\\nits original embryonic state accounts for the frequency with which the\\nstroma of all tumors undergoes myxomatous degeneration. A post-natal\\n415\\nFig. 286. Connective-tissue cells from\\nyoung umbilical cord processes of cells\\nunite to form protoplasmic network\\nfibrous elements slightly developed (after\\nPiersol).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0453.jp2"}, "444": {"fulltext": "416\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nmatrix of myxoma is created if the pre-existing connective-tissue cells\\nrevert to their original embryonic state and remain unspecialized.\\nHistology. The histological structure of a myxoma is subject to\\nmany variations. The variable structure depends on the amount and\\ncharacter of the intercellular gelatinous substance and the abundance\\nand vascularity of its stroma. Mucin is a substance which in the living\\nbody is rapidly destroyed and eliminated. In a myxoma the retention\\nof this substance gives rise to hydropic conditions, and this reten-\\ntion occurs in myxomatous tumors if the production and absorption of\\nmucin are arrested.\\nMyxoma may occur as a clear, colorless, gelatinous mass which\\ndiffers from fluid only in its greater consistence. The delicate stroma\\nof such a jelly-like mass contains small blood-vessels which nourish\\nthe lowly-organized tumor-tissue. Such tumors are found in the\\nantrum of Highmore. In the firmer variety the translucency is lessened\\nby a more copious stroma and by larger blood-vessels. The prognosis\\nin the latter form is less favorable than in the former, on account of\\nthe more active cell-proliferation. The capsule of a myxoma is com-\\nposed of connective tissue which has become condensed by pressure\\non the part of the tumor-tissue.\\nThe typical myxoma is composed of a network of branching cells,\\nthe intercellular substance in its meshes being composed of a gelatinous\\nhomogeneous substance which contains mucin. The nuclei of the cells\\nare large. If the cells of the tumor are few and the stroma is in an\\nextremely hydropic condition, the\\ntumor is called a hyaline myxoma\\n(Fig. 287, a). If the cells are more\\nabundant and less stellate, it is\\ncalled a medullary myxoma (Fig.\\n287, b). If the tumor is very\\nvascular, we speak of a myxo-\\nangioma. Klebs found that\\nmyxomatous degeneration takes\\nplace in cells which are in close\\nproximity to blood-vessels, and\\nthat it appears first as a vacuole\\nin the protoplasm of the cell.\\nAs a component part of other\\ntumors, benign as well as malignant, myxomatous tissue is very com-\\nmon, in which case the nomenclature of the tumor is modified by\\nsubstituting a compound word for the single word and retaining the\\nname of the primary tumor, as adeno-myxoma, chondro-myxoma,\\nFig. 287. Myxoma transition of (a) hyaline form into\\n(b) medullary form; X 2 5\u00c2\u00b0 (after Perls).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0454.jp2"}, "445": {"fulltext": "MYXOMA. 417\\nmyxo-carcinoma, myxo-sarcoma, etc. The most frequent combination\\nis myxoma with lipoma, lipoma myxomatodes.\\nEtiology. Congenital myxomata have been reported by C. O.\\nWeber, Schuh, and others. No age is exempt, but they are met with\\nmost frequently in young adults. The most potent exciting causes\\nare chronic irritation and inflammation. The formation of nasal\\nmyxomata is frequently preceded by chronic catarrhal inflammation.\\nMyxomatous polypi of the external auditory meatus are most always\\nassociated with chronic inflammation of the external ear.\\nSymptoms and Diagnosis. A myxoma is a soft, gelatinous, trans-\\nlucent, interstitial, sessile or pedunculated growth. It is of slow growth,\\nand as a surface tumor it does not attain large size. Its growth is\\nunlimited if it receives its blood-supply from the entire periphery, as is\\nthe case in interstitial myxoma. The diagnosis is not attended by any\\ndifficulties if the tumor is accessible to sight and touch. Its color and\\nconsistence distinguish it from fibroma, adenoma, and the malignant\\ntumors. Fluctuation is a constant sign, owing to the softness of the\\ntumor-tissue. The transition of a myxoma into a sarcoma should be\\nsuspected when the tumor without any obvious cause begins to grow\\nrapidly. In such cases an examination of the tumor-tissue under the\\nmicroscope should be made before an operation is undertaken, as a\\ncorrect diagnosis is of paramount importance in planning and executing\\nan operation of sufficient thoroughness to remove all the infected tissues\\nin case the tumor has become malignant. If the microscope is to be\\nrelied upon in ascertaining whether or not malignant transition has taken\\nplace, tissue from the new part of the tumor must be obtained for exam-\\nination. Serious blunders in practice have arisen from the examination\\nof old portions of the tumor, in which portions no traces of malignant\\ntransition could be seen. Wherever possible, tissue from the base of\\nthe tumor should be taken for microscopic examination, as it is here\\nthat malignant transition is most frequently initiated.\\nPrognosis. A pure myxoma is a benign, local, encapsulated tumor.\\nMyxoma has received an unenviable reputation from a prognostic\\nstandpoint from the fact that it has been so often confounded with\\nmalignant tumors that had undergone myxomatous degeneration, and\\nfrom the frequency with which it undergoes transformation into sar-\\ncoma. A pure myxoma does not give rise to local, regional, or general\\ninfection. The implication of adjacent tissues, regional infection, and\\ngeneral dissemination are positive proofs either that the primary tumor\\nwas malignant and had undergone myxomatous degeneration or that\\nthe tumor is no longer a myxoma, but is a sarcoma produced in con-\\nsequence of transformation of a benign into a malignant tumor. In\\n27", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0455.jp2"}, "446": {"fulltext": "418 PATHOLOGY AND TREATMENT OF TUMORS.\\nrendering a prognosis in cases of myxoma the aptitude of such a tumor\\nto undergo malignant transition must be remembered. The greater\\nliability of myxoma than of fibroma to become transformed into a\\nsarcoma is due to the more lowly organized cells of which its matrix\\nis composed.\\nTreatment. Remembering the liability of myxoma to transition\\nfrom a benign tumor into a sarcoma, it is necessary to emphasize the\\nimportance of early and thorough removal. Imperfect removal by\\noperation or incomplete destruction by caustics has frequently been\\nfollowed by a sarcomatous recurrence. The irritation incident to such\\nimperfect treatment has proved sufficient to bring about a transition of\\nthe remnant of the tumor into sarcoma. The writer has more than once\\nseen such a transformation follow incomplete removal of nasal polypi\\nwith the snare. It is especially necessary to remove the base of the\\ntumor complete removal is seldom accomplished with the snare or by\\ntorsion. A hyaline myxoma of a mucous surface is so friable that its\\ncomplete removal cannot be effected by avulsion. If the tumor is so\\nlocated that its base cannot be reached for its removal by the snare or\\nby avulsion, these procedures should be followed by cauterization with\\nthe Pacquelin cautery, in order to destroy every remaining vestige of\\nthe tumor. The removal of an intermuscular myxoma must be done\\nwith the utmost care, as the tumor usually has prolongations into the\\nloose connective tissue surrounding it these prolongations might be\\noverlooked, and if not removed would become the source of a certain\\nand early recurrence.\\nTopography.\\nSkin. Myxoma of the skin occurs as a sessile or pedunculated\\ntumor, but is rare as compared with fibroma or with papilloma. Myx-\\nomatous tumors of the skin are most frequent in the neighborhood\\nof the perineum and the labia in women. In young persons these\\ntumors possess a regular, usually oval, outline. Later in life they\\nshrink, and the surface of the tumor assumes a lobulated appearance.\\nThese tumors ordinarily occur in the labium majus, although they\\nmay be found in the nymphae or in the perineum.\\nSessile myxomata are very prone to recur after removal, unless espe-\\ncial care is taken to carry the incisions beyond the limits of the capsule.\\nEnucleation is often attended by rupture of the capsule consequently\\nthis method of operating cannot be relied upon for complete removal\\nof the tumor unless its capsule is unusually firm.\\nIntermuscular Spaces. Myxoma, like lipoma, is sometimes found\\nto occupy the intermuscular spaces, and in this locality frequently", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0456.jp2"}, "447": {"fulltext": "MYXOMA. 419\\nexists in combination with lipoma. The favorite locality, as has been\\npointed out by Lucke, is the space between the external and internal\\nhamstring muscles, below the gluteal fold. These tumors are of slow\\ngrowth and may reach great size. The writer has seen a myxoma the\\nsize of an adult s head between the adductor muscles of the thigh. In\\nthe excision of deep-seated myxoma it is often necessary to excise\\nsome of the connective tissue around it in order to remove all the\\nmyxomatous tissue.\\nNose. Unmixed myxoma occurs more frequently in the sub-\\nmucous tissue of the nasal cavities than in any other locality. It starts\\nusually in the mucous membrane overlying the turbinated bones, and\\nonly in exceptional cases in the frontal sinus or in the antrum of\\nHighmore. The tumor is usually multiple, often from three to six\\nbeing found in one nasal cavity. Frequently both nasal cavities are\\nsimultaneously affected. The growths may project anteriorly or in the\\ndirection of the pharynx. During moist weather the tumors absorb\\nmoisture, swell, and produce more obstruction than during dry weather.\\nIf numerous and large, they distend the nose; and when located in the\\nfrontal sinus bulging at the inner angle of the orbit takes place, like\\nthat produced by hydrops or by empyema of this cavity.\\nFig. 288.\u00e2\u0080\u0094 Myxoma of nose (Surgical Clinic, Rush Medical College, Chicago) a, delicate connective-tissue\\nstroma; b, granular amorphous myxomatous material, non-staining; c, nuclei d, blood-vessels.\\nA nasal myxoma appears as a jelly-like, translucent mass which\\nmoulds itself to the cavity of the nose. It is covered by mucous\\nmembrane paved with columnar or stratified epithelium. Under the\\nmicroscope the tumor-tissue appears like very cedematous connective\\ntissue. The great mass of the tumor is composed of myxomatous\\ntissue in the meshes of the reticulum of connective tissue and paren-\\nchyma-cells (Fig. 288). The blood-vessels traversing the connective-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0457.jp2"}, "448": {"fulltext": "420 PATHOLOGY AND TREATMENT OF TUMORS.\\ntissue stroma are usually quite large with very thin vessel-walls. Nasal\\nmyxoma occurs most frequently in persons from the age of puberty to\\nthat of fifty years.\\nThe removal of nasal myxomata is by no means an easy operation.\\nAvulsion with the different kinds of forceps devised for this purpose is\\nusually followed by recurrence owing to incomplete removal of the\\ntumor; the use of the snare gives better results, but recurrence is by\\nno means infrequent. In cases in which a permanent cure followed\\nthese procedures, usually a part of the turbinated bone to which the\\ntumor was attached was removed with the tumor. Konig s operation\\nshould be resorted to if snaring and avulsion have not resulted satis-\\nfactorily. This operation consists in cutting through the ala of the\\nnose on the side of the septum from within outward as far as the bony\\nframework, thus rendering the base of the tumor more accessible.\\nAfter locating the attachment of the tumor the index finger should be\\ninserted into the nasal passage from the pharynx, and with it the tumor\\nis pushed forward, when it may be removed with the snare or, what is\\nperhaps better, the sharp spoon. If the tumor is attached far back, a\\ntemporary resection of the nose may become necessary to effect\\ncomplete removal. This preliminary operation becomes absolutely\\nnecessary in the removal of polypoid tumors of the nose that have\\nundergone malignant transformation.\\nMiddle Ear. Myxomatous tumors in the external meatus are fre-\\nquently preceded by chronic or acute inflammation of the middle ear\\nand by perforation of the drum. These tumors usually spring from\\nthe mucous lining of the tympanum, filling this cavity and projecting\\ninto the external meatus through a perforation in the drum, causing\\ndeafness. Jacobson suggests that myxoma of the middle ear may in\\nsome instances arise from vestiges of connective tissue in this locality\\nan opinion which will be sustained by all who adhere to Cohnheim s\\ntheory regarding the origin of tumors.\\nThe operative treatment of aural myxomata should be consigned to\\nskilled aural surgeons, as the reckless use of instruments and of caustics\\nin the middle ear is calculated not only to destroy hearing, but may\\neven be followed by fatal cerebral complications.\\nNerve-sheaths. Myxomatous tumors are not infrequently found\\nin the central nervous system, the brain and the spinal cord. Myxoma\\nof the sheaths of peripheral nerves is called neuroma myxomatosum. The\\ntumors often occur multiple, and they have been found in connection\\nwith diffused nerves (Fig. 289). They often produce serious functional\\ndisturbances in the form of neuralgia or paralysis. The most frequent\\nseat of myxomatous tumors of the nerve-sheaths is the optic nerve.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0458.jp2"}, "449": {"fulltext": "MYXOMA.\\n421\\nGlands. In the mammary and salivary glands, the ovary, and the\\ntesticle myxomatous tumors occur frequently, but usually in combi-\\nFig. 289. Myxoma of the sheath of the ulnar nerve (after Huter).\\nnation with other benign tumors or as the result of regressive meta-\\nmorphosis of benign or malignant tumors.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0459.jp2"}, "450": {"fulltext": "XX. CHONDROMA.\\nChondroma is a tumor which, according to its structure, is a close\\nimitation of hyaline, reticulated, or fibrous cartilage. It occurs in parts\\nof the body in which cartilage exists in the fetus, as in the epiphyseal\\nextremities of the long bones, or it springs from an island of displaced\\ncartilage-cells, as in the connective tissue, the parotid gland, the testicle,\\nand the ovary.\\nDefinition. A chondroma is a tumor composed of cartilage which is\\nthe product of tissue-proliferation from a matrix of chondroblasts. This\\ndefinition refers all cartilaginous tumors to a matrix composed of\\nembryonal cartilage-cells.\\nOrigin. It has been customary to attribute to the connective tissue\\nunder certain conditions a chondrogenetic function. It is not more\\nlikely that connective tissue can produce cartilage than that it can pro-\\nduce epithelial cells. In the study of the origin of tumors we must\\nadhere closely to the teachings of Remak and Thiersch, that tissue\\nbegets tissue of its own kind. We have traced adenomata to localities\\nwhere, in a normal condition, neither glands nor epithelial tissue exists,\\nand we have to account for the presence of the tumor-matrix by the\\ndisplacement of islets of adenoid tissue during the development of the\\nembryo. We have to assign to heterotopic chondroma a similar origin\\nby assuming as its starting-point the presence of a matrix composed\\nof embryonic cartilage-cells or chondroblasts. Chondroma is some-\\ntimes produced by a simple outgrowth from pre-existing cartilage, that,\\nas a rule, attains no great size. Virchow names these growths ecchon-\\ndroses, and cites as their best examples outgrowths from the cartilages\\nof the ribs, the cartilages of the amphiarthrodial joints, the cartilages\\nof the trachea and the bronchial tubes, and from the cartilage between\\nthe basi-sphenoid and occipital bones in the young cranium. In such\\n422", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0460.jp2"}, "451": {"fulltext": "CHONDROMA. 4^3\\ncases we must assume the existence of a superabundance of chondro-\\nblasts which produce the localized hyperplasia, but which do not\\nresult in the formation of large tumors, owing to the inhibitory\\ninfluence exerted upon the growth by the surrounding normal\\ncartilage.\\nIn the majority of cases cartilaginous tumors are found connected\\nwith the bones and the joints. Virchow, in his classical article on\\nChondroma, places great stress on the frequency with which such\\ntumors spring from the epiphyseal cartilage. He found frequently in\\nthis locality, in adults, remnants of unossified cartilage a centimeter\\nand more in diameter. Such islands of cartilage-tissue are frequently\\nseen in the epiphyseal extremities of the long bones in rickety sub-\\njects.\\nIt is well known that rickety persons are exceedingly prone to car-\\ntilaginous tumors. Virchow believes that a deficient blood-supply is\\noften the cause of arrested ossification in such cases. The influences\\nthat excite proliferation in such embryonal remnants of cartilage are\\nrickets and an hereditary predisposition. In glands and in other parts\\nof the body in which normally no cartilage is found the tumor springs\\nfrom a displaced matrix of chondroblasts. Forster describes two car-\\ntilaginous tumors of the lung, as large as a bean, that had undergone\\npartial ossification. In these cases the matrix was derived from the\\ncartilage-rings of the bronchial tubes.\\nHeterotopic chondroma occurs most frequently in the parotid gland\\nand about the external ear, from tumor-cells which are derived from\\nthe cartilage of the external ear. In the vicinity of the external ear and\\nthe neGk they occur as remnants of the first branchial cleft. Wartmann\\nmade a careful study of eight cases of chondroma in which the tumor\\ndeveloped independently of bone or cartilage. He is of the opinion that\\nthe tumor-elements start from ordinary fibrillary connective tissue,\\nsome of the fibres of which undergo hyaline degeneration the con-\\nnective-tissue fibres proliferate actively, and form groups of cells which\\nbecome surrounded by a capsule and are transformed into cartilage-\\ncells. Other cells assume a stellate form the projections form free\\nanastomoses with similar structures which constitute a network, the\\nintercellular hyaline substance becoming softer, forming myxomatous\\nspaces. Both forms of cells, prior to encapsulation, present glycogen\\nreaction, which with the perfection of the capsule disappears.\\nIt is of course difficult to trace a tumor to its primary histogenetic\\norigin, but it is no more difficult to explain the occurrence of chon-\\ndroma in connective tissue from a displaced matrix of chondroblasts", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0461.jp2"}, "452": {"fulltext": "424\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nthan to explain its presence in other tissues normally devoid of carti-\\nlage-tissue, for which such an origin is generally conceded.\\nHistology. The structure of a chondroma depends on the kind\\nof cartilage it represents.\\nHyaline chondroma is composed of a uniform, dense, cartilaginous\\nmass in which islands of cartilage can be seen surrounded by ground\\nsubstance. The islands of cartilage-cells are not larger than a line or\\na line and a half in diameter (Fig. 290). The stroma of the tumor is\\nm\\n\u00e2\u0096\u00a0\u00e2\u0096\u00a0\u00e2\u0096\u00a0.\u00e2\u0096\u00a0p.v w\\nS\u00c2\u00a35*T *I\\niF^gha**\\ni\\ni-\\n\u00c2\u00bb/i\\nj^L\\nFiG. 290. Hyaline chondroma of ilium; X !30 (Surgical Clinic, Rush Medical College, Chicago): a, amor-\\nphous and granular stroma; b, cartilage-cells and capsule; c, cells in course of segmentation.\\nsupplied with blood-vessels, but the cartilage-masses are devoid of ves-\\nsels of any kind. The spaces in which the cartilage-cells are enclosed\\nare called lacunae. The interior of these spaces is lined by a mem-\\nbranous structure from which the cells, after death, separate by shrink-\\nage. The spaces are sometimes branched, and they have been described\\nas branched cells.\\nFibro-chondroma. These tumors occur most frequently in the cap-\\nsule of joints and in the fibrous structures adjacent to the parotid\\ngland. In the latter location the tumor often reaches the size of a\\nhen s egg. The tumor resembling fibro-cartilage is not so sharply cir-\\ncumscribed as is the hyaline variety. The tumor-tissue consists of a\\nuniform mass composed of fibrous tissue in the meshes of which car-\\ntilage-cells are uniformly distributed throughout (Fig. 291). The cells\\nfrequently contain oil-globules.\\nReticidated Chondroma. In this variety of chondroma the fibrous", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0462.jp2"}, "453": {"fulltext": "CHONDROMA.\\n425\\ntissue is arranged in a reticulate manner and the spaces are occupied\\nby groups of cartilage-cells (Fig. 292). The vascular system of chon-\\ndroma is imperfect. Lymphatics and nerves have not been found.\\nFig. 291. Fibro-chondroma from a cartilaginous Fig. 292. Reticulated chondroma from index finger\\ntumor of the parotid gland (after Liicke). (after Liicke).\\nRetrogressive Metamorphoses. Calcification is the most common\\nregressive metamorphosis it begins at circumscribed points of the\\nFig. 293.\u00e2\u0080\u0094 Chondroma of index finger, showing central ossification and lobulated structure of the tumor\\n(after Liicke).\\ntumor, and often terminates in the formation of large plates which are\\nexceedingly hard and which have often been mistaken for bone. The", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0463.jp2"}, "454": {"fulltext": "426 PATHOLOGY AND TREATMENT OF TUMORS.\\ngranules of chalk form first in the capsules and later in the cells, and\\ndeposition in the intercellular substance, takes place later.\\nCystic degeneration is often found in the interior of chondroma.\\nSometimes the tumor presents a honeycombed appearance from the\\npresence of numerous small cysts. Coalescence of many cysts results\\nin the formation of large irregular cavities. The softening which results\\nin the formation of cysts is preceded by fatty degeneration of the carti-\\nlage-cells. Fat-granules appear at different points in the protoplasm\\nof the cells, and the fatty degeneration finally terminates in the dis-\\nsolution of the cells. At the same time the intercellular substance\\nundergoes mucoid liquefaction. Hemorrhage into the cysts results\\nin discoloration and pigmentation of the cyst-contents. If a cyst by\\nulceration on the surface is opened, there forms a fistulous tract which\\nresists all treatment short of extirpation of the tumor.\\nDevelopment of cartilage-cells into bone is observed in chondromata\\nof bone and periosteum as well as in those of soft parts. Complete\\nossification of the tumor has never been observed. The new bone\\nappears in the form of spiculae representing cancellated bone (Fig. 293).\\nThe spiculae of bone form septa between the cartilage-masses. Very\\nfrequently small islets of bone are found disseminated throughout the\\ntumor.\\nMyxomatous degeneration is frequently observed in glandular\\nchondroma.\\nCartilaginous tumors have always been looked upon with suspicion,\\nas they are liable to undergo transformation into sarcoma. Wartmann\\nasserts that embolism may occur in the centre as well as in the periphery\\nof a chondroma, and that from the emboli secondary tumors develop\\nwith the assistance of the endothelial cells of the blood-vessels, the\\nseat of the embolic process. It is more than probable that in all cases\\nin which a chondroma invaded adjacent tissues, and in all instances in\\nwhich metastasis occurred, the tumor had undergone transition into\\nsarcoma.\\nEtiology. We have reason to assert that a chondroma cannot occur\\nindependently of the existence of a congenital matrix of chondroblasts\\nor a post-natal matrix of embryonal cartilage-cells derived from the\\nperiosteum or the bone. O. Weber describes a case of multiple chon-\\ndroma of fifteen years duration in a man twenty-five years of age.\\nRegarding the heredity, it has been ascertained that the grandfather,\\nthe father, the brother, and one sister were also affected with the same\\ndisease. He alludes to similar cases proving the heredity of chon-\\ndroma.\\nChondroma of bone occurs usually before or at the age of puberty,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0464.jp2"}, "455": {"fulltext": "CHONDROMA. \\\\2J\\nwhile in other tissues it frequently appears later in life. Trauma\\nappears to exert a powerful influence in stimulating a latent matrix of\\nembryonal cartilage-cells to active tissue-proliferation. O. Weber\\nproved by statistics that in one-half of all cases of chondroma the\\norigin of the tumor could be traced to a trauma.\\nRachitis is a frequent exciting cause of chondroma of bones. We\\ncan readily understand that the serious changes which occur in this\\ndisease in the bone surrounding a matrix of chondroblasts would excite\\ntumor-growth by diminishing the physiological resistance of the adja-\\ncent tissues.\\nSymptoms and Diagnosis. A chondroma, from the unequal\\ngrowth of its different parts, always appears as a lobulated tumor.\\nLobulation increases with the size of the tumor. In central chondroma\\nof the long bones the tumor is surrounded by a shell of bone that\\nbecomes thinner as the tumor increases in size this shell eventually\\ndisappears entirely by absorption. Periosteal and glandular chondro-\\nmata are never surrounded by a complete shell of bone. Occasionally\\nan attempt at the formation of such a shell can be seen, but it is always\\nimperfect.\\nA chondroma displaces, but does not infiltrate, the adjacent tissues,\\nSo long as it remains as a benign tumor it is surrounded by a capsule\\nwhich completely separates it from the adjacent tissues. The tumor is\\nhard except at points where cysts may have reached the surface of the\\ntumor, which upon palpation would impart a sense of fluctuation. A\\nchondroma may attain the size of an adult s head, but it may become\\nstationary at any time, especially at the age of puberty. Ossification\\narrests tumor-growth in that part of the tumor which is the seat of\\nsuch a transition. Tumor-growth is also arrested by calcification.\\nEpiphyseal chondroma often appears in many of the long bones at the\\nsame time, and is commonest in rickety subjects. Chondroma always\\ngrows slowly. Its growth is not attended by pain or by tenderness.\\nA tumor in the vicinity of a joint may by its presence interfere with\\nfull motion. The slow growth and the frequency with which it occurs\\nas a multiple affection distinguish chondroma from osteo-sarcoma.\\nThe differential diagnosis between chondroma and osteoma can often\\nonly be made by resorting to akidopeirasty. If the tumor is an\\nosteoma, the advance of the steel needle will be arrested when the\\nsurface of the tumor is reached if the tumor is a chondroma, the\\nneedle can be forced into the substance of the tumor.\\nPrognosis. Aside from the aptitude of a chondroma to undergo\\ntransformation into a sarcoma, the prognosis is favorable. Epiphyseal\\nchondromata may impair the range of motion of adjacent joints, but", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0465.jp2"}, "456": {"fulltext": "428 PA THOLOG Y AND TREA TMENT OF TUMORS.\\notherwise functional disturbances do not occur. Glandular chondro-\\nmata usually become stationary after they have reached a certain, and\\nusually a very moderate, size. A chondroma upon the inner surface\\nof the pelvis in females may complicate labor and necessitate Cesarean\\nsection. A chondroma of the shaft of the long bones may cause such\\na degree of atrophy of the bone by pressure that fracture will occur\\nupon application of slight force. Chondromata of the bones usually\\nbecome stationary after the completion of ossification of the skeleton.\\nTreatment. The removal of a chondroma is indicated only in\\nexceptional cases. The removal of an epiphyseal chondroma should\\nnot be attempted unless the tumor interferes materially with the func-\\ntion of an important joint or unless by pressure upon a nerve it causes\\npain. The removal of such a tumor should not be undertaken lightly,\\nas during the operation recesses of the joint may be opened or bursae\\noverlying the chondroma may communicate with the joint. If the\\nchondroma completely surrounds a long bone, its extirpation is out of\\nthe question, and amputation is only justifiable if the tumor is very\\nlarge or its interior has become infected through a suppurating super-\\nficial cyst. Chondroma of the fingers, if pedunculated, can readily be\\nextirpated. The same treatment will suffice in similar tumors of the\\nshafts of the larger bones. Large encircling tumors of the phalanges\\nmay require amputation.\\nIn the removal of a chondroma of the long bones it must be\\nremembered that the tumor usually has a central origin, and that\\nremoval on a level with the bone is generally followed by recurrence.\\nThe central part of the tumor must be removed with gouge and\\nhammer to guard against a recurrence. The removal of chondromata\\nof the soft tissues should be done by enucleation. If a chondroma\\nmanifests malignant properties, no time should be lost in making a\\ncorrect diagnosis by the microscopical examination of sections of the\\ntumor taken from the parts which are most suspicious in case the\\nmicroscope reveals evidences of a malignant transition, the most\\nradical measures must be resorted to, in removing not only the\\ntumor, but also the adjacent infected tissues.\\nTopography.\\nChondroma occurs most frequently in connection with bone and in\\norgans situated in a locality where displacement of chondroblasts is\\nmost likely to occur. A post-natal matrix can occur only in bone-\\nproducing tissues, in bone, and in periosteum.\\nCartilage. The overgrowth of cartilage Virchow calls ecchondro-\\nsis. Localized ecchondroses occur in four favorite localities namely,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0466.jp2"}, "457": {"fulltext": "CHONDROMA.\\n429\\nalong the edges of articular cartilages, of the laryngeal cartilages, of\\nthe cartilages of the ribs, and of the triangular cartilage of the nose.\\nThe tumors never attain large size, and they resemble in many respects\\nthe osteomata. Ecchondrosis of the articular cartilage is found most\\nfrequently in persons past middle life, in connection with the condition\\nknown as rheumatoid arthritis. Bruns collected 14 cases of laryngeal\\nFig. 294.\u00e2\u0080\u0094 Lad twenty years of age with multiple chondromata (after Steudel).\\n4 with\\nSmall\\nThey\\nchondromata; of these, 8 were connected with the cricoid,\\nthe thyroid, 1 with the arytenoid, and 1 with the epiglottis,\\nchondromata of the triangular nasal cartilage are quite common,\\nare sessile, and they hardly ever exceed in size a pea.\\nBone and Periosteum. The existence of islands of cartilage\\nthe interior of the long bones near the epiphyseal cartilages has been\\ndemonstrated by Virchow and others. A chondroma of bone always\\nin", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0467.jp2"}, "458": {"fulltext": "43Q\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nsprings from such a matrix or from a matrix of post-natal origin pro-\\nduced by the bone-forming cells of the marrow or the periosteum.\\nPeriosteal chondroma is rare, and springs from a matrix of displaced\\nchondroblasts or from a post-natal matrix produced by the cambium.\\nThe greater frequency of chondromata in rickety subjects is due, as\\nVirchow pointed out, to the existence of islands of cartilage that have\\nfailed to undergo ossification, and which serve the purpose of a tumor-\\nmatrix.\\nEpiphyseal chondromata often appear simultaneously in different\\nparts of the skeleton, notably in the epiphyseal extremities of the long\\nbones. The phalanges of the fingers and toes are favorite localities\\n(Fig. 294). The tumors are always lobulated, and in the central variety,\\nwhen the tumor is covered by a thin\\nshell of bone, a crackling sensation\\nis produced on pressure. In the super-\\nficial form enucleation can be effected\\nwithout difficulty, while in the central\\nvariety it may become necessary to\\nremove the remnants of the tumor\\nwith chisel and hammer. Unless the\\ntumor interferes seriously with the\\nfunction of a joint or causes pain by\\npressure upon a nerve (Fig. 295), ope-\\nrative treatment is not indicated, as\\nm the majority of cases limitation of\\nthe growth takes place at the age of\\npuberty. If the tumor causes great\\ninconvenience from its weight or\\nbecomes the seat of ulceration, ampu-\\ntation may become necessary. A\\nresort to a mutilating operation may\\nbecome necessary if a fracture occurs\\nat the place where the bone has become\\npartially destroyed by the tumor.\\nJoints. Floating or loose cartilages are found most frequently in\\nthe knee- and elbow-joints. They are in the majority of cases sub-\\nsynovial chondromata which are formed at the margin of the articular\\ncartilage, project into the joint, become pedunculated, and finally are\\ndetached, changing their position in the joint with the movements of\\nthe joint. A less frequent source of such loose fragments of cartilage\\nin joints is the detachment of fragments of the articular cartilage by\\na trauma. The ecchondroses of the articular cartilage exhibit under the\\nFig. 295. Chondroma of humerus, show-\\ning relations of tumor to vessels and nerves\\n(after Liston).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0468.jp2"}, "459": {"fulltext": "CHONDROMA. 431\\nmicroscope a cartilaginous structure which has undergone partial cal-\\ncification. They vary in size from a pea to double the size of the\\npatella. In many instances the articular ecchondroses are multiple.\\nBentlif removed 1532 loose cartilages from the shoulder-joint of a girl.\\nThe presence of the foreign movable body usually produces hydrops\\nof the joint. Impaction of the cartilage between the articular surfaces\\nis attended by sudden pain and fixation of the joint symptoms which\\ncontinue until the cartilage becomes displaced to a part of the joint\\nwhere its presence is less harmful.\\nThe most characteristic symptoms of a loose cartilage in a joint are\\nattacks of sudden pain and arrest of function of the joint when the\\ncartilage gets between the opposed surfaces of the joint, followed, as a\\nrule, by more or less serous effusion into the joint.\\nThe removal of such cartilages from joints calls for special anti-\\nseptic precautions. Before the incision is made the cartilage should be\\nimmobilized in a sacculus of the joint by transfixing it with a stout\\naseptic needle. After the removal of the cartilage the capsule of the\\njoint should be sutured separately with one or two catgut sutures\\nbefore closing the external wound. The joint should be immobilized\\nfor at least a week or two.\\nSalivary Glands. Chondroma is found much more frequently in\\nconnection with the parotid than with the submaxillary gland. Of 12\\ncases of chondroma in the soft tissues observed by Bryant, 9 occurred\\nin the parotid, 2 in the submaxillary, and 1 in the leg. Chondroma is\\nfound in connection with the salivary glands more frequently than any\\nother benign tumor. Lucke and Konig have shown that the tumor\\nsprings from the capsule of the glands or from the surrounding con-\\nnective tissue, and as it enlarges it grows into the glands and becomes\\nbound up with the gland-substance. The growth of such tumors is\\nalways very slow. They seldom exceed in size a walnut. They are\\nmovable and lobulated, and displace the surrounding tissues.\\nThe proper treatment is enucleation. This operation requires special\\ncare in the removal of benign tumors of the parotid gland, in order\\nto prevent injury to the facial nerve and to Stensen s duct. The ex-\\nternal incision must be made with special reference to these structures,\\nand the deep dissection must be made between two dissecting-forceps,\\ndividing the tissues only after they have been identified. Incomplete\\nremoval of cartilaginous tumors is very often followed by transforma-\\ntion of the remnant of the tumor into a sarcoma. A case of this kind\\nhas recently come under the writer s observation. A chondroma in\\nthe parotid gland in a woman thirty-five years of age had existed for\\ntwenty years. It was removed partially by a timid surgeon. Two", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0469.jp2"}, "460": {"fulltext": "432\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nyears later, when the case came under the care of the writer, there was\\nfound in the scar and involving the entire gland a sarcoma larger than\\na hen s egg. This case and many similar cases must impress the sur-\\ngeon with the importance of a careful and complete removal of all\\ncartilaginous tumors when a radical operation is deemed advisable.\\nTesticle. In rare cases the testicle is the seat of pure and of mixed\\nchondromata. Kocher recorded eight cases of pure chondroma.\\nO. Weber saw a case of congenital chondroma of the testicle. The\\ncartilage is usually hyaline, seldom fibrous. The great liability of chon-\\ndroma of the testicle to undergo malignant transformation is shown by\\nthe fact that in half the cases regional and general infection were\\nnoted. Paget reports a number of such cases in detail. The tumors\\nare very hard and lobulated, with softer portions between the nodules.\\nUnless the tumor is very small enucleation should give way to castra-\\ntion.\\nOvary. Chondroma of the ovary occurs very rarely as an isolated\\nseparate tumor. Kiwisch reported two cases of cartilaginous tumors\\nof the ovary, but only in one case was the diagnosis corroborated under\\nthe microscope. Klob has shown\\nthat the cartilage in such tumors\\nappears in the form of large fen-\\nestrated plates in the periphery\\nof the tumor, or forms granular\\nprominences, or, finally, is dis-\\nseminated through the fibrous\\nstroma in groups of cartilage-\\ncells the size of a pea.\\nConnective Tissue. In ex-\\nceptional cases chondromata\\noccur in the subcutaneous and\\ndeep connective tissue in different\\nparts of the body. Their origin\\nin such unusual localities must\\nbe sought in displaced matrices\\nof chondroblasts. The tumors\\nare met with most frequently in situations where such displacements are\\nmost liable to occur that is, in localities in close proximity to parts\\ncontaining cartilage in the embryo.\\nChondroma Branchiogenes. Chondromata in line with the first\\nbranchial tract spring from displaced islands of cartilage derived from\\nthe external ear. Some of the cartilaginous tumors in the vicinity of\\nthe hyoid bone may derive their matrix from the hyoid bone and larynx,\\nFig. 296.\u00e2\u0080\u0094 Accessory auricles of neck (after C. Beck).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0470.jp2"}, "461": {"fulltext": "CHONDROMA.\\n433\\nas suggested by Callender. A number of writers have described acces-\\nsory auricles in lines of the branchial tracts. Beck of Chicago recently\\ndescribed such a case. Some of these isolated islands of cartilage have\\nbecome the matrix of cartilaginous tumors the size of a hen s egg and\\nlarger. Heusing describes the case of a large cystic chondroma of\\nthe neck. In Schaffer s case the tumor was of the size of an egg,\\nbeneath the skin on the side of the neck. Beck described a case of\\naccessory auricles of the neck in a man forty-eight years old (Fig. 296).\\nVfL\u00c2\u00ae\\nFig. 297. Cartilage from accessory auricles of neck (after C. Beck) a, perichondrium b, new cartilage-cells\\nunder perichondrium c, reticulum d, islands of cartilage-cells surrounded by stroma of fibrous tissue.\\nHe removed a particle of one of the cartilaginous masses and subjected\\nsections of it to microscopical examination. The sections showed the\\ntypical structure of cartilage (Fig. 297).\\nIn the majority of cases of branchiogenous chondroma the matrix\\nremains latent until after the age of puberty, as in most of the fourteen\\ncases so far reported the tumors did not develop until some time after\\npuberty.\\n28", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0471.jp2"}, "462": {"fulltext": "XXI. OSTEOMA.\\nDefinition. An osteoma is a tumor which possesses a structure\\nresembling that of cancellous or compact bone, produced from a con-\\ngenital or post-natal matrix of osteoblasts. Osteomata occur usually in\\nconnection with some part of the skeleton, but they are also found in\\nparts and organs that have no genetic relations with the skeleton, as in\\nthe pia mater and the brain. It is doubtful if the tumors which are not\\nin connection with bone present the structure of bone so perfectly as do\\nosseous tumors of the skeleton. Fleischer described an osteoma of the\\ntendon of the ilio-psoas muscle in which he found the Haversian canals\\nand the medullary tissue arranged in the same typical manner as in\\nnormal bone. In another heterotopic osteoma described by the same\\nauthor the tumor was situated upon the inner surface of the dura mater.\\nIn both instances bone-production was traced to the connective tissue\\nand independently of the presence of osteoblasts. According to\\nFleischer s interpretation, the connective tissue at the seat of tumor-\\nformation became more vascular and presented active tissue-prolifera-\\ntion, and was transformed into hyaline masses in the interior of which\\nthe bone-cells appeared. The hyaline lumps become coalescent and\\nundergo calcification. Osteoblasts were active in the further develop-\\nment of bone. The capacity of connective tissue to produce bone\\nhas been recognized for a long time, and this view of the bone-pro-\\nducing power of connective tissue is accepted by most of the modern\\npathologists.\\nA distinction must be made between calcification and ossification of\\nconnective tissue. The production of bone is carried on in the embryo\\nby a distinct and specific part of the mesoblast, resulting in the forma-\\ntion of the skeleton and the growth of bone, and the production of\\nnew bone can take place only from a matrix of cells derived from the\\nosseous system. The displacement of osteogenetic matrices into the sur-\\nrounding tissues is as liable to occur as the displacement of matrices of\\nepiblastic and hypoblastic tissue. Heterotopic osteomata are usually\\nfound in close proximity to a bone. Heterotopic matrices of osteoblasts\\nusually result in imperfect development of the tissue of the ttimor.\\nVirchow found in the apex of the lung an osteoma in which Haversian\\n434", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0472.jp2"}, "463": {"fulltext": "OSTEOMA. 435\\ncanals and medullary spaces were absent. Steudener found a number\\nof small osteomata near the trachea, but entirely distinct from its rings.\\nLesser found in the lung an osteoma which presented under the micro-\\nscope all the histological elements and the typical structure of bone.\\nThe metaplastic theory concerning the origin of bone is no longer\\ntenable. A careful etiological distinction must also be made between\\na true osteoma and an exostosis. The origin of the former must be\\nrestricted within the limits of the definition to a growth of bone from\\na matrix of osteoblasts either in the bone or by displacement from a\\nbone, while the latter is the result of a localized or diffuse hypertrophy\\nusually following a reparative process.\\nHistogenesis. The osteomata representing compact bone are usu-\\nally found upon the surface of bone, and they appear to be produced\\nfrom the periosteal osteoblasts, as in the case of bony tumors of the\\nflat bones of the skull and of the shafts of long bones or they\\nbegin as chondromata, and proceed most commonly from the epiphys-\\neal lines and from the places of origin of ecchondroses. The latter\\ngroup of tumors, which have therefore a mode of origin distinct from\\nthe preceding, are usually pedunculated, are covered with cartilage,\\nand possess a cancellous structure continuous with that of the bone\\nfrom which they arise. Osteomata from a displaced matrix of osteo-\\nblasts are found most frequently at the insertion of tendons. Ossifica-\\ntion of the deltoid from the shouldering of arms in the soldier, ossi-\\nfication of the adductors of the thighs in cavalrymen, and the more\\ndiffuse bone-formation in myositis ossificans do not belong to osteoma t\\nbut occur as one form of muscular degeneration.\\nHistology. In spongy osteoma (Figs. 298, 299) the cancellated\\nstructure of the bone is well shown in decalcified stained sections. If\\nthe tumor starts in the bone, it is surrounded by a zone of connective\\ntissue which separates it from the surrounding tissues. In the ivory-\\nlike tumors upon the surface of the cranial bones and the shaft of the\\nlong bones the lamellae are so compact that the medullary spaces and\\nthe blood-vessels cannot be identified. The section of such a tumor\\nresembles ivory in compactness. In periosteal osteoma the tumor is\\nat first not connected with the underlying bone, and at this stage can\\nreadily be detached. Later the surface of the tumor becomes attached\\nto the bone and receives from it a part of its vascular supply. After\\nthe union has become complete a section through the tumor does not\\nshow the line where the union was effected.\\nIn the development of an osteoid chondroma into an osteoma the\\ndifferent phases of transition of cartilage into bone-tissue can be\\nobserved. Osteoma is almost immune to the different regressive meta-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0473.jp2"}, "464": {"fulltext": "43^\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nFig. 298. Spongy osteoma of cranium X 250 (after Perls) a, old bone-tissue with thick cancelli parallel\\nwith the surface b, young spongy bone-tissue with irregularly-arranged cancelli.\\n\u00e2\u0080\u00946\\nw\\nFig. 299. Osteoma of finger X 3\u00c2\u00b0 (after Karg and Schmorlj. The tumor (a), separated by a narrow-\\nzone of connective tissue (b) from the epithelium of the surface (c), consists of cancellous tissue. The nar-\\nrow cancelli with delicate contour include the bone-cells, which appear as minute black dots and are covered\\non the surface with cells arranged like epithelium. Between the cancelli is a substance like myeloid tissue,\\nwhich toward the periphery of the growth shows many nuclei.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0474.jp2"}, "465": {"fulltext": "OSTEOMA. 437\\nmorphoses which have been described in connection with the other\\nbenign mesoblastic tumors.\\nTransformation of an osteoma into a sarcoma has never, to the\\nwriter s knowledge, been observed.\\nAnatomical Varieties. Osteoma durum or eburneum resembles\\nivory by its hardness it is found most frequently upon the outside\\nof the skull. Osteoma spongiosum resembles the cancellated structure\\nof bone, and usually takes its origin from the epiphyses of the long\\nbones. As the tumor is usually covered with a thin crust of cartilage,\\nVirchow used the term exostosis cartilaginea. Enostosis is a term\\napplied to a bony tumor which originates in the interior of a bone.\\nExostosis apophytica is a term introduced by Virchow to denote the\\norigin of a bony tumor in a tendon independently of the bone to which\\nit is attached. A tuberous osteoma is an osseous tumor with a con-\\ntracted, pedunculated base, as is the case in osteomata of the frontal\\nsinus, the antrum of Highmore, and the orbit. Callus luxurians is a\\nterm used to designate an osteoma produced at the seat of a fracture\\n(Van Heekeven).\\nSymptoms and Diagnosis. An osteoma always grows very\\nslowly, and becomes stationary after it has reached a certain limited\\nsize. It is not attended by pain or by tenderness. The slow growth\\nand the absence of pain and tenderness distinguish it from inflamma-\\ntory swellings of bone. Sarcoma of bone is usually a painless affection,\\nbut it increases in size more rapidly than osteoma, and its growth is\\nprogressive. Osteoma is frequently a multiple affection like chondroma,\\nwhile sarcoma as a primary disease of bone seldom if ever appears\\nexcept as an isolated tumor. The differential diagnosis between an\\nosteoma and a chondroma can often be made only by resorting to\\nakidopeirasty.\\nPrognosis. The prognosis in osteoma is always favorable. Trans-\\nformation into sarcoma does not take place, and regressive metamor-\\nphosis of any kind is almost unknown. In the female, pelvic osteomata\\nmay become a source of danger to life by interfering with the passage\\nof the child through the pelvis. As the osteoma rarely attains great\\nsize, ulceration of the skin is seldom observed. Osteomata in mucous\\ncavities occasionally necrose and give rise to a continuance of sup-\\npuration until they are removed by operation. Osteoma of the orbit\\nby displacing the eyeball may cause impairment of vision and expose\\nthe eye to destructive inflammation from exposure.\\nTreatment. The indications for surgical interference in the treat-\\nment of osteoma are the same as in chondroma. This statement\\nshould be modified in so far that operative removal is less urgently", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0475.jp2"}, "466": {"fulltext": "438\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ndemanded in osteoma than in chondroma, because in chondroma there\\nis some liability of the tumor undergoing malignant transformation,\\nwhich is not the case in osteoma. The removal of an osteoma of bone\\nshould be done either with a fine saw or with a sharp, thin chisel.\\nTopography.\\nCranial Bones. The cranial bones are the most frequent seat of\\nosteoma durum, or ivory exostosis. The tumors, which are occasion-\\nally multiple, are found most frequently upon the frontal bone,\\nespecially at or near the superciliary arch. The tumors are smooth\\nwith a wide base, and the overlying skin is usually intact. In con-\\nsequence of a trauma or of the application of irritating salves or\\nlotions ulceration of the skin will occasionally ensue.\\nOsteomata of the cranial bones must be distinguished from syphilitic\\nexostosis by a careful inquiry into the history of the case and by the\\nexclusion of all signs and symp-\\ntoms suggestive of an inflam-\\nmatory origin. The removal\\nof such tumors, in the absence\\nof complications such as shown\\nin Figure 300, is usually done\\nonly for cosmetic considerations.\\nIf an operation is decided upon,\\nit should be performed under\\nstrictest antiseptic precautions,\\nwith a view of obtaining primary\\nhealing of the wound and of\\npreventing necrosis, and pos-\\nsibly also pyemic complications,\\nwhich might result from sup-\\npurative infection. The tumor\\nshould be well exposed by a\\nsemilunar incision following its\\nFig. 300.\u00e2\u0080\u0094 Osteoma durum of the frontal bone with baSC After reflecting all the\\nsuperficial ulceration (after Textor). Tumor removed by cQff tissues with the skin-flaD\\nTextor.\\nthe tumor should with a very\\nfine saw be sawed off even with the surrounding bone. For this pur-\\npose the writer prefers a scroll saw to the metacarpal or butcher s saw.\\nBy using the scroll saw the cut surface can be made to correspond\\nwith the outlines of the surface occupied by the tumor. After all\\nhemorrhage has been arrested the soft parts are replaced carefully and\\nare sutured with fine catgut or with horse-hair. The wound should be", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0476.jp2"}, "467": {"fulltext": "OSTEOMA.\\n439\\nFig. 301. Osteoma of the skull, transverse section (Bruns).\\nsealed with cotton and iodoform collodion, over which an elastic com-\\npress is to be applied for the purpose of keeping the flap in uninter-\\nrupted contact with the sawn surface of the bone. In Guy s Hospital\\nReports for 1864 four cases of ivory exostosis of the skull are described.\\nIn all of them the tumors were removed with a fine saw, as they were\\ntoo hard to chisel.\\nThe internal surface of the skull is occasionally the seat of an\\nosteoma. The small conical exostoses which Virchow describes as occa-\\nsionally growing from the upper surface of the basilar process into the\\nFig. 302. Osteoma of the frontal sinus (after Paget).\\ncranial cavity are ossifications of outgrowths of cartilage connected with\\nthe basicranial synchondrosis, and a thin layer of cartilage often remains\\non the surface of the tumor. Osteomata have been found upon the\\ninner surface of nearly all the cranial bones, but more especially upon\\nthe frontal. Endocranial osseous tumors, when they reach consider-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0477.jp2"}, "468": {"fulltext": "44\u00c2\u00b0 PATHOLOGY AND TREATMENT OF TUMORS.\\nable size, disturb the function of the brain by causing irritation and\\npressure-atrophy, which are frequently manifested by well-defined focal\\nsymptoms.\\nFrontal Sinus. Osteomata of the frontal sinus belong to the\\ntuberous variety. Their origin from islands of persistent cartilage has\\nbeen described fully by J. Arnold. A very interesting specimen rep-\\nresenting an osteoma in this locality has been preserved in the\\nmuseum of the Royal College of Surgeons, London. Many of these\\ntumors extend into the orbit, and others sometimes enter the cranial\\ncavity through the orbital roof. The tumor in this locality sometimes\\nattains a very large size, growing externally and in the direction of\\nthe cranial cavity. One of the largest specimens of this kind is in\\nthe Museum of the University of Cambridge, England. Clark, who\\nexamined this tumor, found in the hardest parts neither Haversian\\ncanals nor lacunae in the less hard parts the canals were very large\\nand the lacunae were not arranged in circles around them and every-\\nwhere the lacunae were of irregular or distorted forms. In a case\\nexamined by Turner the bony growth from the inner table and orbital\\nplate of the left frontal bone, which had a knotted, irregular, cerebral\\nsurface, caused a considerable indentation in the anterior part of the\\nleft frontal lobe of the cerebrum. In the absence of suppurative in-\\nflammation of the frontal sinus the presence of the tumor is indicated\\nby an expansion of the anterior wall of the sinus and by displacement\\nof the eye if the tumor has extended in the direction of the orbit.\\nHeadache and focal symptoms would point to the extension of the\\ntumor toward the cranial cavity.\\nSuppurative inflammation often results in detachment of the pedicle\\nof the tumor, when the osteoma becomes a sequestrum in the suppu-\\nrating cavity. Cases of this kind have been described by Dolbeau,\\nVolkmann, Badal, Fenger, Socin, and Konig.\\nAn osteoma large enough to expand the frontal sinus should be\\nremoved by operation. The operation is not a difficult one if the\\nosteoma has necrosed. In such cases the anterior wall of the sinus is\\nresected with the chisel and the loose sequestrum is extracted, after\\nwhich the cavity is carefully disinfected, drainage into the nasal cavity\\nis established, and the wound is sutured with the exception of the\\nlower angle, which is used as an additional point for drainage. If the\\nosteoma remains attached, its removal is attended by more difficulty\\nand requires a larger opening. In such cases it would be advisable to\\nmake a temporary resection of the anterior wall of the frontal sinus,\\nin order to prevent the unsightly deformity which follows the loss of\\nso much bone. The pedicle of the tumor should be traced carefully", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0478.jp2"}, "469": {"fulltext": "OSTEOMA.\\n441\\nto its point of attachment to the bony wall of the sinus, when it is\\nsevered with a chisel.\\nExternal Meatus. Osteomata of the external meatus, which are\\nnot uncommon, are of importance, as they are apt to obstruct the\\nmeatus and cause deafness. The tumors always spring from an island\\nof cartilage-tissue these islands are present in great numbers during\\nthe development of the external ear. Seligmann has given a very\\naccurate description of osteoma of\\nthe external meatus. If the tumor\\nencroaches sufficiently upon the\\nmeatus to threaten deafness, it\\nshould be removed with a small\\nchisel and a hammer after detach-\\ning from it freely the surrounding\\nsoft tissues.\\nJaws. Osteoma of the jaws is\\nof very rare occurrence, and some\\nof the tumors described as such\\nhave been cases of odontoma. The\\ntumor may appear as an enostosis\\nor an exostosis, and usually belongs\\nto the hard variety. Removal is\\nnecessary only if the tumor inter-\\nferes with speech or with mastica-\\ntion or if it causes an unsightly deformity. In the case of symmetrical\\nosteomata of the upper maxillae described by Hutchinson the tumors\\nhad taken their starting-point from the nasal processes (Fig. 303).\\nPaget describes a specimen of an osseous tumor of the lower jaw. The\\ntumor appeared as a nodulated mass nearly three inches in diameter,\\ninvested the right angle of the jaw, and was in its whole substance as\\nhard and as heavy as ivory. He refers to another specimen in which\\nivory-like osseous tumors were formed in connection with the outer\\nand inner surfaces, especially the latter, close to the alveolar border.\\nOsseous tumors of the jaws are more frequent in the lower animals\\nthan in man. The antrum of Highmore and the nasal processes of the\\nsuperior maxillae are sometimes the seat of large and disfiguring osseous\\ntumors.\\nBrain. Heterotopic osteomata are occasionally found in the brain.\\nSome of these tumors are connected with the meninges others have\\ntheir origin in the brain independently of its envelopes. These tumors\\nspring from a displaced matrix of cartilage-tissue or of osteoblasts.\\nMaschede describes an osteoma which was attached to the pia and\\nFig.\\nSymmetrical osteomata of nasal processes\\nof maxillae (after Hutchinson).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0479.jp2"}, "470": {"fulltext": "442\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwhich produced epilepsy and idiocy. Bidder found an irregular\\ndenticulated osteoma four centimeters in diameter in the left corpus\\nstriatum. The patient was the subject of\\ncontracture of the left arm and leg since\\ninfancy, the left leg being shortened two\\ncentimeters. In the case reported by\\nEbstein the tumor was located in the\\ncerebellum and produced no symptoms.\\nIn operations upon the brain for epilepsy\\nor other focal or cerebral symptoms\\nosteoma as a possible cause should be\\nremembered.\\nEpiphyses of the Long- Bones. By\\nfar the greatest number of osteomata\\noccur in the epiphyses of the long bones.\\nTheir origin is similar to that of chon-\\ndromata in the same locality, only that in\\nthis instance the chondroblasts undergo a\\nhigher degree of development and the\\nchondroma is transformed into an osteo-\\nma. Syme met with cases of epiphyseal\\nosteoma in which the tumor was sur-\\nrounded by a sort of synovial capsule in\\nother cases the tumor projects into the joint.\\nEpiphyseal osteomata are often multiple like the chondromata, and\\nare nearly always covered by a thin crust of cartilage, resembling in\\nthis respect the articular extremities. The tumors, which are composed\\nof cancellous bone-tissue, are often supplied on their surface with a\\nbursa interposed between the tumor and the fascia, tendons, or muscles\\noverlying it. Occasionally an osteoma is pedunculated, and frequently\\nit has a broad base. The tumors are painless, but they often produce\\npain by pressing on adjacent nerves.\\nA favorite locality for osteoma is above the inner condyle of the\\nfemur (Fig. 304), close to the insertion of the adductor magnus. In this\\nlocality the tumor is peculiarly apt to acquire a narrow, pedunculated\\nbase. The pedicle of such a tumor may occasionally fracture, as hap-\\npened in the cases reported by Paget and Lawrence. Epiphyseal\\nosteomata, unless of great size, seldom interfere with the functions of\\nadjacent parts, and unless this is the case operative treatment is contra-\\nindicated.\\nMuscles and Tendons. Osteomata are occasionally found in soft\\nparts as distinct and discontinuous tumors invested with capsules of\\nFig. 304. Exostosis of the femur\\n(after Orlow) its surface was clad with\\ncartilage and surmounted by a bursa.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0480.jp2"}, "471": {"fulltext": "OSTEOMA. 443\\nconnective tissue. Paget refers to a tumor of soft cancellous tissue\\noccupying the dorsal surface of the trapezial and scaphoid bones, com-\\npletely isolated from them and from all the adjacent bones. In the\\nmuseum of St. George s Hospital, London, is a tumor formed of com-\\npact bony tissue that lay over the palmar aspect of the first metacarpal\\nbone, loosely imbedded in the connective tissue, and easily separated\\nfrom the flexor tendons of the fingers.\\nExostoses tendineae have frequently been observed. The bony\\ngrowth originated in the tendon, independently of the bone to which\\nthe tendon was attached. Folk removed an exostosis apophytica which\\nwas attached with a broad base to the sacrum and which terminated\\nin a conical projection several inches in length in the gluteus maximus.\\nSeat of Fracture. Under certain circumstances the callus in the\\nrepair of a fracture is so profuse that a large bone-tumor remains after\\nconsolidation has been completed. Van Heerkeven applied to this\\ncondition the term callus luxuriaiis. A good example of this condition\\nis furnished by the bony hyperplasia which often occurs around a frac-\\ntured rib in a lower animal. Such enormous permanent callus-forma-\\ntion has been observed by Konig and others as one of the remote\\nresults of fracture. In some cases it has been impossible to make\\na differential diagnosis between an osteoma at the seat of fracture and\\nan osteo-sarcoma. The tumor under such circumstances springs from\\na post-natal matrix of osteoblasts produced by the injury. The differ-\\nence between a superabundant callus and an osteoma at the seat of\\na fracture is that in the former case the provisional callus disappears\\nor is at least greatly diminished in size, while an osteoma remains per-\\nmanently as a bone-tumor. The operative removal of such an osteoma\\nmay become necessary if the tumor implicates important muscles, ves-\\nsels, or nerves. An operation should not be undertaken until by the\\nclinical course the true nature of the tumor has been revealed, by\\nwhich means only is it possible to make a differential diagnosis between\\na superabundant provisional callus, an osteo-sarcoma, and an osteoma.\\nOrbit. Osteoma of the orbit occurs either as a primary tumor,\\nwhen it is attached to the bony wall of the orbit, usually on the nasal\\nside, or the tumor reaches the orbit from the frontal sinus or from the\\nantrum of Highmore. In the latter case the appearance of the tumor in\\nthe orbit is usually preceded by signs and symptoms which point to its\\nprimary location in either of the adjoining cavities. In a case of orbital\\nosteoma that recently came under the observation of the writer, con-\\nsiderable exophthalmus was observed and the eye was displaced out-\\nward. Beneath the orbital arch a hard tumor could be felt under the\\nupper eyelid, at the inner angle. The tumor, which was exposed by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0481.jp2"}, "472": {"fulltext": "444 PATHOLOGY AND TREATMENT OF TUMORS.\\nan incision along the superciliary arch, was an inch and a half in length,\\nand was attached to the inner wall of the orbit by a contracted, almost\\npedunculated, base. The tumor was detached from the bony wall with\\na narrow chisel, and was removed without inflicting any injury upon\\nthe more important contents of the orbit. The eye after the operation\\ngradually resumed its normal position. If the tumor is located pri-\\nmarily in the frontal sinus or in the antrum of Highmore, its removal\\nmust be preceded by a temporary resection of the anterior wall of the\\ncavity in which it is located.\\nEye. Schiess-Gemuseus collected eight cases of osteoma of the\\neyeball. In each case the tumor occupied the elastic lamella and the\\nchoroid capillaries.\\nSubungual Osteoma. The last phalanx of the great toe is not\\ninfrequently the seat of a subungual osteoma. It always grows on the\\nmargin, and usually on the inner margin, of this bone. The tumor\\nprojects under the edge of the nail, lifting it up, and thinning the skin\\nthat covers it until an excoriated surface is presented at the side of\\nthe nail. The growth of the tumor is usually veiy slow, and when it\\nhas reached a diameter of from one-third to one-half an inch it becomes\\nstationary. The extirpation of subungual osteoma with cutting-forceps\\nmust be preceded by partial or complete removal of the nail.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0482.jp2"}, "473": {"fulltext": "from the tooth-follicle.\\nXXII. ODONTOMA.\\nDefinition. An odontoma is a tumor composed of dental tissue in\\nvarying proportions and in different degrees of development, arising from\\nteeth-germs or from teeth still in the process of growth. This definition\\nand the description of the different varieties are gleaned from Sutton s\\nexcellent work on Tumors, which contains the most accurate account\\nof tumors of dental origin.\\nSutton s Classification of Dental Tumors.\\n1 Epithelial odontome, from the enamel-organ.\\n2. Follicular odontome,\\n3. Fibrous odontome,\\n4. Cementome,\\n5. Compound follicular odontome, J\\n6. Radicular odontome, from the papilla.\\n7. Composite odontome, from the whole gum.\\n1. Epithelial Odontomes. These tumors occur, as a rule, in the\\nmandible; but they have been observed in the maxilla (Sutton). They\\nare encapsulated and contain numerous small cysts. In color they\\nresemble myeloid sarcoma, for which they have been mistaken. They\\nconsist of branching and anastomosing columns of epithelium, portions\\nof which form alveoli. Although they may occur at any age, they\\nare most frequent at the age of puberty.\\n2. Follicular Odontomes. The follicular odontomes are the den-\\ntigerous cysts. They occur commonly in connection with teeth of the\\npermanent set, and especially with the molars. The tumors often\\nattain large size. The wall of the cyst may be very thin, so that it\\ncrepitates under pressure. The cavity contains a viscid fluid and the\\nencysted tooth, which is often imperfectly developed.\\nDentigerous cysts rarely suppurate. Three cases of follicular odon-\\ntome have come under the writer s observation. In one case the cyst\\nwas as large as an orange, and contained an imperfectly developed\\nmolar tooth and a clear viscid fluid. In the second case a fistulous\\nopening led into the bone above the permanent molars, and necrosis of\\nthe maxilla was suspected. The patient had been treated for a long\\ntime for suppuration of the antrum. At the bottom of the cyst part\\nof a molar tooth was found.\\n445", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0483.jp2"}, "474": {"fulltext": "44 6 PATHOLOGY AND TREATMENT OF TUMORS.\\nA follicular odontome invariably occurs in connection with teeth the\\neruption of which is retarded or prevented owing to their being devel-\\noped in an abnormal position, whereby they become impacted by the\\nsurrounding bone. These tumors appear at a period of life succeeding\\nthat at which the alveolar portions of the maxillae are in a state of\\nactive development, in which they readily furnish an amount of bone\\nsufficient to perfectly envelop the tooth. The capsule of the tooth, the\\nremains of the enamel-organ, has been shown by Tomes to be, after\\nthe calcification of the enamel, quite free and detached from that struc-\\nture, and therefore, being attached only to its surroundings, will be\\ncarried away from the surface of the enamel with them there will\\nthus be left a space into which, as a matter of course, serous fluid must\\nunder atmospheric pressure be effused, and thus there is formed a\\ncyst, the walls of which will be the dental capsule, including the pro-\\njecting crown of the tooth (Coleman).\\n3. Fibrous Odontomes. The fibrous capsule of a tooth, composed\\nof an outer firm wall and an inner loose layer of tissue, may become\\nthickened, constituting with the contained tooth a fibrous odontome.\\nSuch a tumor is often mistaken for a fibroma, especially if the tooth be\\nsmall and ill-developed. Under the microscope fibrous odontomes pre-\\nsent a laminated appearance with strata of calcareous matter. Rickets\\nappears to play an important part in the production of fibrous odontomes.\\n4. Cementomes. A cementome is a fibrous odontome which has\\nundergone ossification. The tooth in such cases is encapsuled in a\\nmass of cementome. Cementomes occur most frequently in horses.\\nTomes describes a tumor of this kind which weighed ten ounces.\\nSutton refers to one which weighed seventy ounces.\\n5. Compound Follicular Odontomes. If the thickened capsule\\nossifies sporadically instead of en masse, a curious condition is brought\\nabout, for the tumor will then contain a number of small teeth or den-\\nticles consisting of cementum or of dentine, or even ill-shaped teeth\\ncomposed of three dental elements cementum, dentine, and enamel\\n(Sutton). As many as four hundred denticles have been found in a\\nsingle tumor. Tumors of this character have been seen in the human\\nsubject. Tellander met with a case in a woman aged twenty-seven.\\n6. Radicular Odontomes. This term is applied to odontomes\\nwhich arise after the crown or the root has been completed and while\\nthe roots are in the process of formation (Sutton). In the specimen\\nrepresented in Figure 305 the outer layer of the tumor is composed of\\ncementum within this is a layer of dentine, deficient in the lower part\\nof the tumor; and inside this dentine is a nucleus of calcified pulp. A\\nnumber of radicular odontomes have been observed in the human\\nsubject. Suppuration is a common complication of these tumors.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0484.jp2"}, "475": {"fulltext": "ODONTOMA.\\n447\\n7. Composite Odontomes. These are hard tooth-tumors which\\nbear little or no resemblance in shape to teeth, but which occur in the\\njaws. The tumors, which consist of a disordered conglomeration of\\nenamel, dentine, and cementum, arise from an abnormal growth of all\\nFig. 305. Radicular odontome from human subject (after Salter) a represents the natural size of the\\nspecimen.\\nthe elements of a tooth-germ (Fig. 306). In the majority of cases the\\ntumors are composed of two or more tooth-germs indiscriminately\\nfused (Sutton). It is supposed that odon-\\ntomes are more frequent in the lower than\\nin the upper jaw, but there is good ground\\nfor the belief that many such tumors have\\nbeen described as exostoses of the antrum.\\nThe diagnosis of dental tumors is very\\nobscure, and in consequence of faulty\\ndiagnosis uselessly severe operations have\\noften been performed for the removal of\\ntumors of this kind. It is important to\\nexamine solid and cystic tumors of the\\njaws, especially if they occupy the site of tooth-germs, with special\\nreference to their possible dental origin. A diagnosis once made, a\\nsuccessful operation can be performed with little mutilation. The bone\\nsurrounding the tumor is removed by subperiosteal resection, when the\\ntumor can be enucleated or removed with gouge and mallet. The\\ncavity is tamponed for a few days with iodoform gauze.\\nFig. 306. Composite odontome from\\na young lady aged eighteen natural size\\n(after Heath).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0485.jp2"}, "476": {"fulltext": "XXIII. ANGIOMA.\\nDefinition. -An angioma is a tumor composed of blood-vessels pro-\\nduced from a matrix of angioblasts. Angiomata were formerly\\ndescribed as teleangiectasia, angiotelectasia, angioma pleni-\\nforme, erectile tumors, and nsevi. Virchow included all vascular\\ntumors under the head of angioma. Tumors composed of lymphatic\\nvessels are called lymphangioma, to distinguish them from tumors\\ncomposed of blood-vessels, and this is what is generally understood\\nby the unqualified term angioma. The definition excludes from\\nthis class of tumors all swellings caused by dilatation of pre-existing\\nblood-vessels, aneurysm, and varicose veins. The angiomatous tumor\\nFig. 3\u00c2\u00b07-\u00e2\u0080\u0094 Angioma of tongue, showing newly-formed blood-spaces not yet in connection with pre-\\nexisting vessels; X 33\u00c2\u00b0 (Surgical Clinic, Rush Medical College, Chicago): a, angioblast b, newly-formed\\nspaces filled with delicate fibrous network and amorphous material.\\nis composed of new blood-vessels which are in communication with\\nthe adjacent vessels, interstitial tissue composed of the pre-existing\\ntissues in which the tumor develops, and the blood contained in the\\nvascular spaces. The size of the tumor is very variable at different\\n448", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0486.jp2"}, "477": {"fulltext": "ANGIOMA. 449\\ntimes and under different circumstances, according to the anatomical\\nstructure of the vessels and the amount of blood the vessels contain.\\nHistogenesis. Weil in a study of the growth of angioma came\\nto the conclusion that the origin of new blood-vessels is as variable as\\nis the formation of new embryonal vessels. He found projecting\\nfrom the wall of old and new capillary blood-vessels streaks of proto-\\nplasm which showed nucleated projections which in the course of time\\nbecame laminated and were traversed by blood from the pre-existing\\nvessels. In other places he found proliferation of the endothelial cells\\nwhich formed buds and projected into the surrounding tissues. These\\nmasses of endothelial cells form new vessels by the formation of hollow\\nspaces which communicate with the vessels from which they originated.\\nRokitansky has seen and described the formation in the connective\\ntissue of blood-spaces discontinuous with pre-existing blood-vessels,\\nand which only later entered into communication with them (Fig. 307).\\nIn a case of pulsating cavernous tumor of the spleen Langhans noticed\\nan extraordinary proliferation of the endothelium of the venous spaces,\\nand to this proliferation he ascribes the growth of the tumor, in oppo-\\nsition to the theory advanced by Rindfleisch, and the illustrations\\nwhich accompany his paper appear to justify his conclusions. If the\\nmatrix of angioblasts forms a part of the vessel-wall, the new blood-\\nvessels are formed by budding, and are in communication with the pre-\\nexisting vessel from the beginning. If the angioblasts have become\\ndisplaced into the connective tissue, the tumor-tissue becomes vascular\\nafter the new blood-spaces have formed a communication with the pre-\\nexisting vessels.\\nHistology. Angioma is closely related to endothelioma, as its\\ncellular elements possess the shape and arrangements of their mother-\\nsoil. The angioblasts are a modified form of fibroblasts. Their intrin-\\nsic function is to produce new blood-vessels.\\nIn the growth of normal blood-vessels the angioblasts furnish the\\nessential tissue-elements of blood-vessels the blood-vessels reach their\\nrequisite normal size, when the process becomes stationary. The angio-\\nblasts from which an angioma develops observe no such limitation of\\nfunction their function is a progressive one, and their product of tissue-\\nproliferation results in the formation of atypical blood-vessels which are\\nnot required by the part in which they are produced, and which con-\\nstitute the essential tumor-tissue. The vascular spaces, whether capil-\\nlary, venous, or arterial, are lined with endothelial cells the product of\\nthe angioblasts. In a growing angioma new blood-spaces continue to\\nform, and again enter into communication with the older vascular spaces\\n(Fig. 308). As the blood-spaces are formed by the production of an\\n29", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0487.jp2"}, "478": {"fulltext": "450 PATHOLOGY AND TREATMENT OF TUMORS.\\nintima from the angioblasts, active proliferation takes place in the\\nremaining tissues of the vessel-wall. Connective tissue and muscle-\\nlpi\\n^\u00e2\u0096\u00a0j\\n-:V^-\\ni^gt0\\nb\\nFig. 308. Angioma of the back X no (Surgical Clinic, Rush Medical College, Chicago) a, wall of blood-\\nspaces b, newly-formed blood-spaces.\\nfibres derived from the pre-existing blood-vessels are produced, form-\\ning the outer and middle coats of the new vessels (Fig. 309). The\\nFig. 309.\u00e2\u0080\u0094 Angioma of rib, showing new vessel-wall; X no (Surgical Clinic, Rush Medical College, Chi-\\ncago): a, intima; b, adventitia c, proliferating cell-areas in the media.\\nlimits of the tumor, as in all benign growths, are well defined, as will\\nbe seen in Figure 310.\\nAngioma as a component part of other tumors gives rise to the\\ndifferent combination tumors in which the angiomatous part so often", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0488.jp2"}, "479": {"fulltext": "ANGIOMA. 451\\nconstitutes what imparts to the tumor its most serious clinical aspects,\\nas in angio-lipoma, angio-fibroma, angio-adenoma, angio-sarcoma, and\\nangio-carcinoma. The communication of all angiomata with blood-\\nvessels is very free. Virchow and Maier have shown that an angioma\\nof the liver can be injected from the hepatic artery and vein and from\\nthe portal vein.\\nComplications. According to the number and activity of the\\nangioblasts, the tumor may grow rapidly, may remain stationary, or in\\nexceptional cases may disappear spontaneously. Inflammation occur-\\nn\\nb\\nFig. 310. Cavernous angioma of liver; X 3\u00c2\u00b0 (after Karg and Schmorl). The tumor (a), which shows\\na well-defined border at its junction with the liver-tissue {b), exhibits a structure similar to cavernous tissue.\\nThe tumor consists of irregular spaces lined with endothelial cells and separated by their connective-tissue\\nsepta. The hollow spaces contain blood c, a hepatic vein.\\nring spontaneously or produced by artificial means occasionally results\\nin a permanent cure. This complication may, however, become a\\nsource of danger to life from septic thrombo-phlebitis. In venous\\nangioma there sometimes forms a thrombus of a plastic character that\\nmay result in the formation of a phlebolith or vein-stone. Extensive\\nthrombosis is one of the ways in which finally all the blood-vessels\\nbecome obliterated. Transformation of an angioma into the most\\nmalignant form of sarcoma is by no means rare. Such a transition\\nis shown in Figure 311. The tumor from which the section repre-\\nsented in Figure 3 1 1 was taken was a superficial capillary angioma of", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0489.jp2"}, "480": {"fulltext": "45 2\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nthe face that had become stationary during childhood in a man\\ntwenty years of age. Without any obvious cause the tumor com-\\nmenced to grow very rapidly, and when removed it showed the typical\\nstructure of a round-celled sarcoma. The section represented in the\\nillustration was taken from the periphery of the tumor. Calcification\\nof the stroma of the tumor and of the vessel-walls arrests the further\\ngrowth of the tumor. The angiomata are occasionally the seat of a\\nstriking hyaline or colloid change, a cylindromatous appearance often\\nbeing given to the tumor.\\nFig. 311. Capillary angioma undergoing transformation into a sarcoma; X 55 (Surgical Clinic, Rush\\nMedical College, Chicago) a, connective tissue b, capillary vessel cut transversely c, capillary vessel cut\\nobliquely d, group of sarcoma-cells.\\nAnatomical Varieties. The division of angioma into anatomical\\nvarieties is based on the kind of vessels the tumor-tissue represents.\\nIn superficial angioma the color of the tumor indicates its structure and\\nthe kind of blood it contains. An arterial angioma presents the bright-\\nred hue of arterial blood the red color of a capillary angioma is of a\\nless bright hue and the venous or cavernous angioma presents the\\ndark-blue appearance of venous blood.\\nCapillary Angioma A capillary angioma, known as simple naevus\\nor mother s mark, is the incipient form of vascular tumor. Its", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0490.jp2"}, "481": {"fulltext": "ANGIOMA.\\n453\\nfavorite sites are the skin of the face and the orbit. The tumors\\nare flattened or slightly pendulous, and they are blue, pink, or purple\\nin color. The difference in color, varying from a pink to a livid tint,\\ndepends, according to Billroth, upon whether the vessels be situated\\nsuperficially or deeply. The most superficial form of capillary angioma\\nis known as a port-wine stain. If the terminal veins are involved,\\nthe tumor is more prominent and of a darker color. The tumor can\\nusually be emptied of its blood by pressure sometimes, however, this\\ncannot be done. The dilated capillaries and veins are separated by\\na variable quantity of connective tissue. If the connective tissue is\\nabundant, the tumor is firm if scanty, it offers little resistance to\\npressure. As a rule, the tumor-tissue does not extend beyond the\\nsubcutaneous cellular tissue. The vessels are arranged in small groups\\nfrom the size of a hemp-seed to that of a pea, consisting of dilated\\ncapillaries and venulae arranged around the appendages of the skin\\n(Fig. 312).\\nAll capillary angiomata are congenital. They may be so small that\\n*\u00c2\u00a3s\\nFig. 312. Capillary angioma of the skin (after Perls). In the upper layer of the skin can be seen capil-\\nlaries dilated into cavernous blood-spaces. In the fatty layer only a few capillaries (a), somewhat dilated and\\nwith thickened walls, can be seen b, a sweat-gland.\\nthey cannot be detected at the time of birth, but they soon begin to\\nincrease in size, whereas the cavernous angiomata are not always con-\\ngenital and may develop at any time after birth. Their growth is best\\nstudied in the subepithelial fat, where the tumor forms small cellular\\nmasses of angioblasts and connective-tissue corpuscles.\\nCavernous Angioma. The cavernous angiomata form tumors of", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0491.jp2"}, "482": {"fulltext": "454\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nlarger size than the capillary variety, and are composed of irregular\\nblood-spaces which communicate freely with one another. The new\\nblood-spaces are formed by angioblasts in the cellular connective tissue.\\nCavernous angiomata are found in the deep connective tissue, in the\\nbones, the liver, the spleen, and the kidney, and are composed of a\\ntissue almost identical with that of the corpus cavernosum penis that\\nis, of irregular blood-spaces communicating freely with one another and\\nseparated by fibrous septa of variable thickness (Fig. 313). The walls\\nFig. 313.\u00e2\u0080\u0094 Cavernous angioma of the liver; X 350 (after D. J. Hamilton) a, liver-cells at margin of the\\ntumor b, blood contained in the cavernous spaces c, walls of the cavernous spaces.\\nof the blood-spaces are lined by endothelium. The formation of new\\nblood-spaces takes place in the fibrous septa and in the periphery of\\nthe tumor. Cavernous angioma is a much more formidable tumor than\\na superficial naevus, as its tendency to progressive growth is much\\ngreater and from its deeper location it involves more important struc-\\ntures. A simple naevus may, however, later in life become converted\\ninto a cavernous angioma.\\nPlexiform Aiigioma. Plexiform angioma, which is a true angioma-\\ntous tumor, and not an aneurysm, has been known as aneurysm by\\nanastomosis or cirsoid aneurysm terms that should no longer be\\nemployed to designate an arterial angioma. Plexiform angioma con-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0492.jp2"}, "483": {"fulltext": "ANGIOMA.\\n455\\nsists of a number of tortuous blood-vessels of moderate size arranged\\nparallel with one another. These tumors, which are composed of\\narteries alone, of veins, or of arteries and veins in equal proportions,\\nare found most frequently about the forehead, the temporal regions, the\\nfingers, the anus, and the legs. The largest angioma that came under\\nthe writer s observation was in the axilla of a boy seventeen years old.\\nThe tumor had existed for many years and had undergone active\\ngrowth for two years. It had reached the size of a child s head.\\nFig. 314.\u00e2\u0080\u0094 Dissection of a plexiform angioma of the forehead (after H. Miiller).\\nSome of the veins were as large as the thumb, and the arteries, several\\nin number, were about the size of an ordinary lead-pencil. Pulsations\\nand bruit were well marked and extended along the subclavian vessels.\\nPreliminary to excision, on two different occasions two of the largest\\narteries that fed the tumor were ligated. The operation of excision,\\ndespite the preliminary deligation, was an exceedingly bloody one. At\\nleast fifty compression-forceps were required, and nearly as many points\\nwere ligated after the excision of the growth. The boy made a good\\nrecovery, notwithstanding the excessive loss of blood.\\nThe tumors are found most frequently in young adults, and they\\nalmost always, sooner or later, manifest progressive tendencies. Plex-\\niform angioma in many instances develops in pre-existing blood-vessels,", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0493.jp2"}, "484": {"fulltext": "456 PATHOLOGY AND TREATMENT OF TUMORS.\\nbeing then caused by an excessive quantity of angioblasts in the vessel-\\nwall. During the growth of the tumor there are produced new blood-\\nvessels which remain in communication with the lumen of the vessel\\nsimilarly affected. Bruit and pulsation are usually frequent, and the\\nsize of the tumor is greatly diminished by pressure. In cases of\\nepicranial plexiform angioma the bone beneath the tumor undergoes\\npressure-atrophy, so that deep depressions occur, and even perforation\\nof the skull may take place.\\nSymptoms and Diagnosis. The diagnosis of a surface angioma\\ncan be made from the color of the tumor alone. The color depends\\non the kind of blood the tumor contains, and is also modified, accord-\\ning to Billroth, by the amount of tissue over the tumor. In most\\ninstances the color of the tumor disappears under pressure, and returns\\nwith the entrance of blood into the tumor-tissue. In plexiform angioma\\npulsation and bruit are frequently present, and the tumor almost dis-\\nappears under pressure. Any and all of the causes which increase\\nintravascular pressure, as coughing, laughing, straining, and active\\nexercise of all kinds, increase the size of plexiform and cavernous\\nangiomata. In plexiform angioma, if the tumor is subcutaneous, the\\ntortuous vessels can be outlined distinctly.\\nThe differential diagnosis between intracranial angioma and angioma\\nof other internal organs and aneuiysm is impossible. A positive dif-\\nferential diagnosis between pulsating inflammatory swellings and\\nangioma can be made by resorting to an exploratory puncture.\\nPrognosis. Surface angioma in exceptional cases becomes con-\\nverted into a plexiform angioma, and not infrequently it serves as a\\nstarting-point for sarcoma. With the exception of these possible termi-\\nnations it is a benign affection. In some cases a spontaneous cure is\\neffected in other cases a cure follows inflammation occurring acci-\\ndentally or produced intentionally. In cavernous and plexiform\\nangiomata the prognosis is more grave. Inflammation of such tumors\\nmay result in septic thrombo-phlebitis, pyemia, and death. Wounds\\nof angiomata may give rise to serious and even fatal hemorrhage. The\\nprogressive growth of a plexiform angioma may interfere by pressure\\nwith the function of important adjacent organs. Ulceration may result\\nin serious hemorrhage or may give rise to dangerous inflammatory\\ncomplications.\\nTreatment. The probability of the occurrence of a spontaneous\\ncure in angioma is so small that operative treatment should be instituted\\nin appropriate cases as soon as the tumor is discovered. In the super-\\nficial variety, the so-called port-wine mark, operative treatment is\\ncontraindicated if the tumor is diffuse that is, if it occupies an area", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0494.jp2"}, "485": {"fulltext": "ANGIOMA. 457\\nlarger than a silver dollar. If the tumor is limited, excellent results\\nare obtained by electrolysis. Only a small part of the surface should\\nbe treated at each sitting, and the operation should be repeated every\\nfew days. Among the other surgical resources which have been em-\\nployed in the treatment of ordinary naevus may be mentioned ignipunc-\\nture, coagulating injections, ligature, and the application of caustics.\\nIgnipuncture with the needle-point of a Pacquelin cautery is an excel-\\nlent method of treating superficial angiomata in localities not easily\\naccessible to excision, as the soft palate and the mucous membrane of\\nthe mouth and the pharynx. The method can also be employed in\\nthe removal of surface angiomata in parts of the body not exposed, as\\nthe chest, abdomen, arms, and legs. The scarring following ignipunc-\\nture is much greater than after excision. The needle should be heated\\nto a dull-red heat, as puncturing with a needle heated to a white heat\\nis likely to give rise to hemorrhage. The punctures should be made\\na few lines apart and in a circle corresponding with the periphery of the\\ngrowth. The central portion may be treated in the same manner at\\nthe same time, or this part of the tumor may be treated later. If the\\ntumor is larger than a half-dollar, a number of sittings are necessary\\nto complete the treatment. Before puncturing the surface should be\\nmade aseptic, and after the puncturing it should be protected carefully\\nagainst infection.\\nCoagulating injections in the treatment of angiomata are mentioned\\nsimply for the purpose of condemning them. Their employment has\\nproduced instant death from embolism, and has frequently been fol-\\nlowed by suppuration and ulceration.\\nThe ligature causes pain and sloughing, and the resulting scar is\\nmore unsightly than that following excision. The ligature is now\\nseldom used in the treatment of angioma. The same may be said of\\npercutaneous threads saturated with coagulating solutions. Nitric acid\\nhas been recommended strongly by Billroth and others in the treat-\\nment of circumscribed superficial angiomata. All caustics are inferior\\nto the use of the knife.\\nThe fear of hemorrhage attending the excision of angiomata is\\nunfounded, provided the incisions are not made through, but outside\\nof, the tumor-tissue, or, as Sutton so happily says, if the naevus\\nis cut out, not cut into. The writer never encountered trouble-\\nsome hemorrhage when this advice was followed in the excision of\\nangiomata.\\nThe ideal treatment of angioma is excision. The incision should be\\nmade a few lines away from the visible boundary of the tumor, on the\\nsides as well as at its base. The bleeding vessels can be caught at once", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0495.jp2"}, "486": {"fulltext": "458 PATHOLOGY AND TREATMENT OF TUMORS.\\nwith hemostatic forceps, the surgeon being enabled to remove the\\ngrowth quickly before the bleeding points are tied. Circular pressure\\nsome distance from the periphery of the tumor is a material aid in\\ndiminishing the amount of bleeding. If the wound cannot be closed\\nby suturing, the surface should be covered at once by a Wolfe graft\\nor by Thiersch grafts.\\nThe surgical treatment of plexiform angioma has so far not yielded\\nvery encouraging results. Ligature of the principal artery of the part\\noccupied by the tumor has not proved satisfactory. Ligature of the\\narteries supplying the tumor has not yielded much better results. In\\ntumors of moderate size and readily accessible on all sides, excision\\noffers the best prospects. If the tumor is large, as in the case men-\\ntioned on page 455, it is well to tie several of the larger vessels prior\\nto the excision. If it is important to make the incision some distance\\naway from the growth in the excision of an ordinary naevus, this advice\\napplies with still greater force to the excision of a plexiform angioma.\\nThe principal vessels which nourish the tumor should be exposed and\\nbe secured with hemostatic forceps before they are cut. Pressure is\\nan important factor in removing provisional hemostasis in the excision\\nof a plexiform angioma. In such cases the skin over the tumor should\\nbe reflected and preserved if it is intact. If the angioma involves the\\nskin, this must be excised with the tumor, and the resulting wound-\\nsurface is paved at once with Thiersch grafts.\\nTopography.\\nSkin and Mucous Membranes. The skin and the mucous mem-\\nbranes are the seats of capillary angioma. The face and the mouth are\\nthe favorite localities. The most superficial form, the port-wine mark,\\nfrequently is very extensive, occupying the larger part of one side of\\nthe face, and in some instances even one half of the body. This\\nvariety of tumor is occasionally converted into a cavernous or a plex-\\niform angioma. Breschet relates the case of a girl who was born with\\na port-wine mark on the external ear. The tumor remained stationary\\nfor several years, when it became the seat of pulsation, ulcerated, and\\nbled freely from time to time. In her eighteenth year all the arteries\\nin the temporal region were consistently enlarged, as was also the\\noccipital, which, together with the tumor, made a pulsating swelling of\\nconsiderable size. At the necropsy it was ascertained that the arteries\\nhad such thin walls that they could hardly be distinguished from the\\naccompanying veins. Breschet believed that the arteries communicated\\ndirectly with the veins. In another case observed by Breschet an\\ninsignificant angioma behind the ear was followed by dilatation of the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0496.jp2"}, "487": {"fulltext": "ANGIOMA. 459\\ncarotid artery on the same side to three times its natural size the aorta\\nand the common iliac artery showed similar changes, while the arteries\\nof the extremities were normal in size and in structure. The disease\\nin this case was progressive, extending from the congenital angioma to\\nthe vessels mentioned by an uninterrupted process.\\nThe most typical structure of angioma of the skin is seen in the\\ngrowing tumors in young children. The appendages of the skin in\\nthe part affected undergo hypertrophy. In port-wine mark the skin is\\nbut little thicker than normal the epidermis is thinner than normal,\\nthe papillae are flattened, and the epithelial depressions between them\\nare more shallow. The arteries and veins can be distinguished with-\\nout difficulty, and the dilated capillaries can be identified readily. A\\ncloser study of the process under the microscope reveals the places\\nwhere the new vessels permeate the fatty tissue. Klebs has seen the\\nangioblasts form solid cylinders of cells which project into and displace\\nthe adipose tissue and which mark the beginning of a new blood-\\nvessel. These cell-masses are in immediate connection with open\\nvessels, and within the mass can be seen red corpuscles which push\\nbefore them the cellular wall. The new vessel is at first composed\\nsimply of a tube of endothelial cells. Weil has seen how the angio-\\nblasts in pre-existing vessels proliferate and form cell-masses outside\\nthe vessel-wall these masses become hollow cylinders and form new\\nvessels. The same process is observed in arteries which supply the\\nfat-tissue. According to Ziegler, this process is characterized by active\\nkaryokinetic changes. The new endothelial cells perforate the muscu-\\nlar coat, and outside form cell-masses which are transformed into new\\nblood-vessels. Klebs is inclined to believe that other angioblasts find\\ntheir way through the muscular coat by ameboid movements. Most\\nof the new vessels are formed from the capillaries in the form of solid\\nbuds of new endothelial cells. The process is accomplished exclusively\\nby the angioblasts.\\nAll the superficial angiomata are congenital. Port-wine marks\\nseldom increase much in size after birth. The deeper variety often\\nappears as small red dots not larger than a pin-head at the time of\\nbirth, but later they increase in size. These small tumors should be\\ndestroyed by ignipuncture as soon as they are discovered. If the\\ntumors are larger than a split pea and occupy exposed parts of the\\nbody, they should be excised. If the wound is too large to be closed\\nby suturing, it should be covered at once by skin-grafts.\\nDeep Connective Tissue. The deep connective tissue is the seat\\nof cavernous or plexiform angiomata. The tumors may have their\\nprimary origin in the skin, and reach the deep connective tissue by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0497.jp2"}, "488": {"fulltext": "460 PATHOLOGY AND TREATMENT OF TUMORS.\\nextension, or may originate primarily in the connective tissue. The\\nformation of blood-spaces is not always the result of dilatation by\\ngrowth of the vessel-wall, but is also produced by confluence. The\\nvessel-walls, at points where they come in contact, undergo absorption\\nby pressure-atrophy and impaired nutrition. In cavernous and plex-\\niform angioma the skin overlying the tumor is usually intact if the\\ntumor originated primarily in the deep connective tissue. In large\\npulsating tumors the skin is subjected to pressure, becomes atrophic,\\nand, in consequence of impaired nutrition or of injury, ulceration may\\nensue, giving rise to recurrent hemorrhages and to infection. Venous\\ncysts, which often result from passive dilatation of veins, are a form of\\ndeep varices, and do not belong to tumors. In other cases such cysts\\noccur as a congenital affection, and are discontinuous from pre-existing\\nvessels. These cysts are produced by a displaced matrix of angioblasts.\\nThe frontal and parietal regions are favorite localities for deep angio-\\nmata. The tumors are usually congenital, but from their deep location\\nthey are not discovered until they become larger. W. Koch reports a\\ncase where, immediately after birth, an angioma the size of a walnut was\\ndiscovered above the right clavicle the tumor could be seen through\\nthe normal intact skin. Uninterrupted slow growth took place until\\nthe child was eighteen months old, when it died. The tumor then\\nmeasured fifteen inches in a horizontal and seven inches in a vertical\\ndirection. After the fourth month pressure had no effect in diminish-\\ning the size of the tumor, but brought on asphyctic symptoms. Post-\\nmortem examination showed that the tumor was made up of three\\ncompartments which communicated with one another, of which only\\none compartment answered to the external swelling. Of the other\\ncompartments, one occupied the deep region of the neck, and the third\\noccupied the anterior mediastinum and the right pleural cavity, where\\nit had displaced the lung. The chambers contained spaces variable in\\nsize occupied by fluid and coagulated blood. The right subclavian vein\\nwas absent, and the tumor was undoubtedly composed of the tissues\\nwhich were intended for its structure.\\nIn a case of cavernous angioma of the arm Esmarch removed in\\na man twenty-eight years old fifty-four tumors, each of which com-\\nmunicated with veins. The first tumor appeared about the region of\\nthe wrist when the patient was six years, old. Esmarch believed that\\nthe tumors developed from pre-existing veins.\\nThe legs and arms, and more especially the fingers, are sometimes\\nthe seat of plexiform angioma. Vascular tumors of the fingers should\\nbe excised if their size renders this procedure impracticable, multiple\\nligation should be tried before resorting to amputation. Deep plexi-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0498.jp2"}, "489": {"fulltext": "ANGIOMA. 461\\nform angiomata of the leg and the arm are always grave affections.\\nIf the extent of the tumor contraindicates excision, multiple ligation\\nshould be tried in some cases this procedure may be followed by\\nexcision. In the gravest cases amputation may become necessary.\\nPlexiform angioma of the frontal, temporal, and occipital regions should\\nbe treated by excision with or without preliminary ligation of the prin-\\ncipal vessels supplying the tumor, according to the size of the tumor\\nand the accessibility of the vessels which feed it.\\nBones. Most difficult to explain is the origin of vascular tumors\\nof bone, called by Virchow myelogenous angiomata. There is good\\nreason to believe that pulsating sarcoma of bone has often been mis-\\ntaken for so-called aneurysm of bone. Only a very few well-authen-\\nticated cases of myelogenous angioma of bone have been recorded.\\nDupuytren ligated the femoral artery in a case of pulsating tumor of the\\ntibia, and the tumor disappeared, but returned (sarcoma) after seven\\nyears. Virchow in a case of cavernous angioma of the liver found\\nalso two similar growths in two separate vertebrae. Klebs saw a case\\nof genuine bone-aneurysm and cavernous angioma in the same patient.\\nThe case occurred in Kronlein s practice. The patient was a woman\\ntwenty-four years old. The tumor was of one year s standing, and\\noccupied the upper portion of the vertebral column and the lateral\\naspect of the neck. The tumor was covered by a thin shell of bone,\\nand presented neither bruit nor pulsation. On incising the tumor there\\nwas found a blood-cyst from which at one point there was free hemor-\\nrhage. It was ascertained that the hemorrhage was from the vertebral\\nartery. As the vessel could not be ligated, hemorrhage was arrested\\nby grasping the bleeding point with a hemostatic forceps which was\\nincorporated in the dressing. Death occurred from sinus-thrombosis.\\nThe necropsy showed that the vertebral artery was bent at an acute\\nangle and terminated in a network of vascular spaces, and that through\\na small opening these spaces communicated with a large blood-cyst.\\nThe third and fourth cervical vertebrae were involved by the tumor.\\nMicroscopical examination of sections of the tumor showed giant-celled\\nsarcoma.\\nAngioma of bone, as angioma in other localities, is always produced\\nby the formation of new blood-vessels from a matrix of angioblasts.\\nThe differential diagnosis between angioma of bone and myeloid sar-\\ncoma is impossible. In doubtful cases, in view of the fact that the\\nmore benign forms of sarcoma have been treated successfully by a local\\noperation, it is advisable to resort to removal of the diseased tissue with\\na sharp spoon. Should the subsequent clinical course and microscopical\\nexamination of the tissue removed reveal the sarcomatous nature of the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0499.jp2"}, "490": {"fulltext": "462 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor, amputation should be performed as soon as evidences of a\\nrecurrence show themselves. Angioma of bone is a?i exceedingly rare\\naffection, whereas myeloid sarcoma is common facts which should not\\nbe forgotten in the differential diagnosis between these two affections\\nof bone.\\nIntracranial Angiomata. Demme has described bjood-cysts of the\\nsuperior longitudinal sinus that perforate the skull and appear exter-\\nnally as pulsating vascular tumors. A positive diagnosis between such\\ncysts and an extracranial plexiform angioma must be made before an\\noperation is decided upon. Akidopeirasty with a fine needle will show\\nwhether or not the skull has been perforated. Intracranial angiomata\\nmay belong to blood-cysts of bone developed from the vasa nutritia of\\nthe parietal bone. As the walls of such cysts are lined by endothelial\\ncells, the cysts are undoubtedly produced by angioblasts, possibly\\naided by mechanical causes. Other cysts communicating with the\\nlongitudinal sinus are multilocular. Bruns cites such a case. The\\ncyst, which was discovered when the patient was fourteen years old,\\nwas situated in the parietal region and was composed of veins covered\\nby normal skin. The cystic spaces communicated freely with one\\nanother. In a case of large plexiform angioma of the frontal region, the\\nwriter, in excising the tumor, found at its base large veins which com-\\nmunicated with the longitudinal sinus. The hemorrhage from this\\nsource could be controlled only by compression. Death resulted from\\nsuppurative sinus-phlebitis.\\nAngioma in the central nervous system occurs where the vessels\\nare all new, all of them starting from the pia. Brunetti found such a\\ntumor the size of a pea in the fourth ventricle. Klebs found a similar\\ngrowth upon the surface of the middle lobe.\\nLiver. Cavernous angioma of the liver is of common occurrence.\\nIt appears in the form of round or wedge-shaped spaces filled with\\nblood in parts of the organ not occupied by parenchyma. The spaces\\nare nearly uniform in size. New spaces form in the fibrous septa\\nand in the periphery of the tumor. It has been asserted that the\\ncavernous spaces are formed by dilatation of pre-existing vessels accom-\\npanied by pressure-atrophy an opinion which receives the sanction\\nof Ziegler. Such a view is untenable, as the structure of the tumor\\ndoes not represent the conditions produced by vascular obstruction.\\nThe endothelial cells which line the spaces are attached to and sup-\\nported by a strong scaffolding of connective tissue. In the neighbor-\\nhood of such angiomata no evidences of inflammation can be found.\\nJohannes Muller found in the lining of such spaces large spindle-shaped\\ncells which are the endothelial cells. The number of these cells is not", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0500.jp2"}, "491": {"fulltext": "ANGIOMA. 463\\nthe same in all parts of the wall they are most numerous where the\\nprocess of cell-proliferation is most active, and less numerous where\\nthe growth of the tumor has become stationary. Similar tumors are\\nfound less frequently in the spleen and the kidney.\\nMammary Gland. In rare instances the mammary gland is the\\nseat of an angioma. Sutton relates the case of a boy, seventeen years\\nof age, who as a child had an ordinary nevus of small size in the skin\\nabove the left nipple. For many years this nevus gave no trouble\\nit then gradually increased in size until the whole breast was converted\\ninto a cavernous angioma three inches in diameter. At intervals the\\nsurface ulcerated, and profuse hemorrhages were the consequence.\\nAnother and larger angiomatous tumor of the breast came under the\\nobservation of Smage.\\nTongue. The tongue is not infrequently the seat of simple and\\ncavernous angioma. In a lad fifteen years old the writer successfully\\nremoved a tumor the size of a pullet s egg. The excision was greatly\\nfacilitated by elastic constriction of the affected side of the tongue.\\nMuscles. Cavernous angiomata of the voluntary muscles have been\\nobserved by a number of surgeons. In the clinic of Rush Medical\\nCollege, Chicago, such a case came under the care of the writer during\\nthe session of 1894. The patient was a boy sixteen years of age.\\nThe tumor, which was first discovered five years previously, extended\\nfrom a point three inches above the patella, over the outer aspect of the\\nthigh, ten inches in an upward direction. The swelling was oblong,\\nvery prominent and firm when the patient was standing, but disap-\\npeared almost wholly when he was placed in the recumbent position\\nwith elevation of the affected limb. The tumor, which was removed\\nby excision, involved the outer part of the extensor quadratus femoris\\nmuscle, and extended on the outer side as far as the intermuscular\\nseptum. A strip of the muscle three inches wide and eight inches\\nin length was removed, and on examination it was found to contain\\nnumerous vessels the size of a crow s quill. The hemorrhage upon\\nthe removal of the elastic constrictor was very profuse, and about fifty\\nvessels had to be ligated before it was controlled. The boy made a\\ngood recovery and regained perfect use of the limb. The formation\\nof a muscle-hernia was prevented by careful suturing of the fascia lata\\nwith a separate row of buried catgut sutures and rest in bed for six\\nweeks.\\nListon removed a cavernous angioma from the popliteal space\\nin connection with the semimembranosus muscle. Holmes Coote\\nremoved a similar tumor from the deltoid, and Campbell de Morgan\\nremoved one from the semimembranosus in a girl ten years old.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0501.jp2"}, "492": {"fulltext": "464 PATHOLOGY AND TREATMENT OF TUMORS.\\nIn the diagnosis of muscular angiomata the variable size of the\\ntumor in different positions of the body is an important element.\\nLarynx. Except in the tongue and the rectum, angioma of the\\nmucous membranes is very rare. It has been observed in the larynx\\nin a few instances, springing from the vocal cords, the ventricular\\nbands, from the ventricle, and from the sinus pyriformis. Angiomata\\nof the larynx are either sessile or pedunculated. They are rarely\\nlarger than a haricot bean, and are red or purple in color. They should\\nbe removed with the snare, with the aid of the laryngoscope.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0502.jp2"}, "493": {"fulltext": "XXIV. LYMPHANGIOMA.\\nDefinition. A lymphangioma is a tumor composed of lymphatic\\nvessels produced from a matrix of angioblasts. The lymphatic vessels\\nof the tumor are new structures containing lymph, and they constitute\\nthe essential part of the tumor. Their walls are more delicate than\\nthose of angioma, but they are composed of the same histological\\nelements. A lymphangioma is a firmer tumor than an angioma, as\\nthe connective tissue between the vessels is more abundant.\\nAnatomical Varieties. Wagner divides lymphangioma into I.\\nCapillary 2. Cavernous and 3. Cystic. In the capillary variety the\\ntumor is composed of lymph-spaces and lymphatic vessels which con-\\nstitute an anastomosing network. The cavernous variety is composed\\nof a framework of connective tissue with communicating spaces which\\ncontain lymph. The cystic form presents to the naked eye an appear-\\nance of a convolution of large and small vesicles with translucent walls\\ncontaining lymph. These vesicles are dilated new lymphatic vessels\\nwhich have lost in part or completely their connection with the\\nlymphatic system. Such cysts can be produced experimentally in\\nrabbits by forcing atmospheric air under considerable pressure into the\\nabdominal cavity. Under such conditions the air is forced into the\\nlymph-spaces, especially those of the pelvis, producing rapid dilatation.\\nHistology and Histogenesis. In capillary lymphangioma the new\\nvessels are formed by angioblasts in the wall of pre-existing lymph-\\nspaces by a process of budding, in the same manner as in capillary\\nangioma. As the vessels are composed of exceedingly delicate walls\\nlined with endothelial cells, they dilate earlier and under less pressure\\nthan in angioma, consequently cystic dilatation takes place at an earlier\\nperiod and to a greater extent. Capillary lymphangioma is always\\ncongenital, whereas the cavernous and cystic varieties may develop\\nat any time after birth. The beginning of a capillary lymphangioma\\nmanifests more or less swelling before its lymphangiectatic character\\ncan be discerned. Microscopically, lymphangioma of the tongue,\\na comparatively frequent affection, appears in the form of a sym-\\nmetrical swelling of the tongue, while the same affection of the skin\\nbegins in the subcutaneous connective tissue as a softer swelling with\\nill-defined borders. The loose connective tissue is cedematous, and\\n30 465", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0503.jp2"}, "494": {"fulltext": "466\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nonly in cases where large quantities of clear lymphatic fluid escapes\\ncan we suspect the existence of dilated vessels. In specimens that are\\nsomewhat finer, spaces can be seen traversing the tumor, while the\\ndelicate walls of the ectatic lymphatic vessels and cysts collapse so\\nthat the openings in the vessels cannot be seen. Microscopical exam-\\nination, unless carefully conducted, may lead to errors in diagnosis, as\\nthe specimens often present more the appearance of hyperplasia of the\\ntongue than that of dilated lymph-channels. In lymphangioma of the\\nY\\nFig. 315.\u00e2\u0080\u0094 Lymphangioma of the skin X 375 (Surgical Clinic, Rush Medical College, Chicago) a, connec-\\ntive-tissue reticulum b, round cells (lymphoid cells); c, lymph-space d, blood-vessels.\\ntongue young muscle-fibres are met with, which proves that the mus-\\ncular tissue is also increased in quantity. In the subcutaneous tissue\\nthe growth of lymphangioma is attended by an increase of connective\\ntissue (Fig. 315).\\nThe subcutaneous lymphangioma differs from elephantiasis arabum\\nby the tumor being composed of new lymphatic channels instead of\\ndilated diseased pre-existing vessels, as is the case in elephantiasis.\\nLymphangioma of the tongue (Fig. 316), or, as it is called, macroglossia,\\nis always a congenital tumor. It commences with an enlargement of\\nthe blood-vessels the veins are thin-walled, but a new tissue-product", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0504.jp2"}, "495": {"fulltext": "L YMPH ANGIOMA.\\n467\\ncannot be recognized so far. On the contrary, the new lymph-spaces\\nare dilated and are paved with numerous large nuclei. The dilatation\\nof the lymphatic spaces progresses parallel with the new tissue-prolif-\\neration. The muscular bundles are at some points ensheathed by\\nFig. 316. Lymphangioma of the tongue; X 50 (after D. J. Hamilton): a, lymphadenoid deposits; b, a\\ncavernous lymphatic space c, muscular fibres of tongue, d, a small artery.\\nlymphoid tissue. An increase of endothelial cells is apparent, but\\nvessel-dilatation has not as yet occurred. At other points free hyper-\\nplastic lymphatic vessels are seen in the connective tissue. In the\\nfurther development of macroglossia, angiomata as well as multilocular\\nlymph-cysts appear. If angioma predominates, it is interesting to\\nobserve that the blood often circulates through the new dilated lymph-\\nchannels. Lucke observed that on puncturing such cysts, at first\\nlymph escaped, and at subsequent repetitions of puncturing blood\\ninstead of lymph escaped. In such cases the communication between\\nblood-vessels and lymphatic vessels is not accidental, but is due to an\\nembryonal relationship between the two kinds of vessels. The new\\nlymph-spaces contain at first a colorless fluid. Thrombi are also\\nfound, and their occurrence renders a diagnosis less difficult. Wagner\\nfound in the lymph ectatic muscular-sheathed hyaline thrombi, and this\\ndiscovery made it easy to give a correct interpretation of their patho-\\nlogical significance. Lewinski described a case of calcification of\\nlymphatic thrombi in a boy twelve years old suffering from lymph-\\nangioma of the scrotum.\\nCavernous lymphangioma (Fig. 3 1 7) presents upon section a honey-\\ncombed appearance, the spaces being separated by their septa lined", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0505.jp2"}, "496": {"fulltext": "468\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nr\\nFig. 317. Lymphangioma of the lip; X 55 (after Karg and Schmorl). In the connective tissue under\\nthe epithelium numerous lymph-spaces of different size, lined by endothelial cells, are seen these spaces\\ncontain a few finely granular leucocytes in a mass of lymph (coagulated by hardening).\\nwith endothelium. The septa are perforated, so that all the spaces com-\\nmunicate with one another. In other cases the interior of the tumor is\\nFig. 318.\u00e2\u0080\u0094 Lymphangioma of the orbit X 350 (after D. J. Hamilton) a, stroma of the walls of the cavernous\\nspaces b, a cavernous lymphatic space c, endothelium lining the space.\\noccupied by larger spaces, as though coalescence had taken place by\\nthe breaking down of septa (Fig. 318). The spaces not only undergo", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0506.jp2"}, "497": {"fulltext": "L YMPHANGIOMA 4 6 9\\ncystic dilatation, but are enlarged by coalescence. In some cases hyper-\\nplasia of the other tissues also takes place.\\nCystic lymphangioma differs from the cavernous variety only in that\\nthe individual separate spaces arising from new and dilated lymph-\\nchannels possess forms which correspond with their origin they are\\nmore or less globular in shape, corresponding in this respect with the\\nrosary-like appearance of the lymphatic vessels during the early stages\\nof the growth of the tumor. Cysts of large size are produced by the\\nconfluence of numerous smaller spaces. The cystic variety is more\\nprone to progressive growth than the cavernous in this respect the\\ndistinction between the two varieties is of importance from a prognostic\\nstandpoint. This difference in the clinical aspects of these tumors\\napplies only to cases where the cysts are multiple, as when only one\\ncyst is present its increase in size takes place more on account of reten-\\ntion of secretions than by tissue-proliferation. The skin covering the\\ntumor is at first intact. As the tumor increases in size it may become\\nhyperplasic or it is thinned out by pressure from beneath, constituting\\nan important element in the production of ulceration.\\nCystic lymphangioma of the neck has seldom been interpreted\\ncorrectly, and has been described under the vague terms of cyst\\nhygroma, hydrocele of the neck, cystic tumor of the neck, serous\\ncyst, etc. Forster first pointed out the correct histogenesis of cystic\\nlymphangioma of the neck. He demonstrated the endothelial nature\\nof the lining of the cysts by silver-staining. He also showed that these\\ncysts communicated with the lymphatic vessels. Luschka asserted\\nthat the serous cysts of the neck originate from the glandula carotica\\nor from the glomeruli of the arteria inter carotica, but in two cases at\\nleast Arnold was able to show the presence of these organs in a normal\\ncondition in connection with the cysts. Klebs, who found in a large\\ncyst of this kind lymphatic glands in the cyst-wall, believes that the\\nglands occasionally take part in the production of the cyst. In none\\nof these cases was a connection found between the cavity of the skull\\nand the cyst, hence meningocele takes no part in their production;\\nneither was there found any connection between the skull and the cyst,\\nhence meningocele can be excluded as a factor in their causation. If\\nlocated in the neck, the cyst may extend in an upward direction as far\\nas the cavity of the mouth and downward as far as the mediastinum.\\nIf very large the cysts become pendulous. Besides the cysts which\\ncan be seen with the naked eye, endothelial proliferation and the forma-\\ntion of new lymphatic vessels can be seen under the microscope in the\\nadjacent connective-tissue spaces. In the neck the tumor follows the\\ndirection of the lymphatics, along the large blood-vessels and the inter-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0507.jp2"}, "498": {"fulltext": "47o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nmuscular septa. In cases where proliferation is active the blood-vessels\\nare also enlarged, and many of these tumors attain the structure of a\\nFig. 319. Haemo-lymphangioma of the groin. Patient a native of the West Indies. Tumor successfully\\nremoved (Senn).\\nmixed tumor a hcemo-lymphangioma. In such instances the transfor-\\nmation of lymph-cysts into blood-cysts, as first described by Lucke,\\ntakes place.\\nMultilocular lymphangioma is also found in glandular organs.\\nWeichselberg reported a case of lymphangioma of the mesentery.\\nIt was a flat tumor, the size of the palm of the hand, between the\\nlayers of the mesentery at a point corresponding with the upper por-\\ntion of the ileum. It contained a fluid which by chemical tests and by\\nmicroscopical examination was shown to be chyle. In the same cate-\\ngory belong the congenital cysts of the lung described by Virchow.\\nThese cysts might be regarded as dilated lymphatics, but the active\\nendothelial proliferation which is always found present in the smallest\\nlymphatic channels speaks in favor of their being true tumors.\\nThe kidney is another organ in which multilocular lymphangioma\\nis occasionally met with. The histological structure of the cysts in", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0508.jp2"}, "499": {"fulltext": "L YMPHANGIOMA 471\\nthis organ is a counterpart of angioma of the liver. The tumor\\nis composed of multiple spaces lined by a single layer of endothelial\\ncells and communicating freely with one another. The multilocular\\nstructure of the tumors distinguishes them from retention-cysts of the\\nuriniferous tubules. Klebs describes a specimen of multilocular lymph-\\nangioma of the kidney.\\nVaricose lymphangioma must be distinguished from simple dilata-\\ntion of pre-existing lymphatic vessels. It differs from lymphatic vari-\\ncosity by the absence of obstruction and by an abnormal increase in\\nthe amount of lymphatic structures. Dr. Busey, in his monograph on\\nCongenital Occlusion and Dilatation of Lymph-channels (1878), describes\\nminutely a case that came under his observation. The disease was\\ncongenital and involved one of the lower extremities, and, as the post-\\nmortem showed, extended behind the peritoneum far up into the pelvis.\\nThe child lived a little more than a year. He collected in addition\\n8y cases. In some of them the disease was limited to fingers and toes,\\nand resulted in great hypertrophy of all the tissues, including the bones.\\nIn Busey s case the surface of the limb was covered with translucent\\nvesicles which contained a serum-colored fluid. The sweat-glands\\nwere found enormously hypertrophied.\\nA lymphangioma, wherever it occurs, is characterized by the forma-\\ntion of new lymphatic structures, the process extending to places in\\nwhich, in normal condition, no lymphatics are found.\\nLymphangioma may occur almost in any part of the body if it\\nsprings from the perivascular lymph-sheaths. In some cases the pro-\\nliferation is very active and the extension of the disease is progressive.\\nThe endothelial cells are large, and the connective-tissue reticulum is\\ninfiltrated with lymph-corpuscles (Fig. 318). Langhans, in a child\\nseven years old, saw the disease affect the perivascular lymph-sheaths\\nin almost the entire panniculus adiposus, while the large lymphatic\\nvessels were free. The inguinal lymphatic glands were permeable to\\ninjection. Holmes, in a child three years old, saw a case where the\\ndisease was limited to the right leg. Extension to the external genital\\norgans and the lymphatics of the groin and the pelvis took place when\\nthe child reached its seventh year. A somewhat similar case is the\\none reported by Busey. In this instance the disease extended very\\nrapidly, and when the child died the corresponding side of the pelvis\\nwas found extensively involved.\\nRegressive Metamorphoses. The connective-tissue stroma of\\nlymphangioma is subject to nearly all the retrograde tissue-metamor-\\nphoses found in other tumors. The most frequent forms of degenera-\\ntion met with in such tumors are fatty degeneration and calcification.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0509.jp2"}, "500": {"fulltext": "472 PATHOLOGY AND TREATMENT OF TUMORS.\\nMyxomatous degeneration is liable to occur in large tumors in which\\nthe connective tissue is abundant. Cystic degeneration by the break-\\ning down of fibrous septa, caused by pressure-atrophy, is of frequent\\noccurrence, especially in tumors in which the tissue-proliferation is\\nvery active and their growth, consequently, rapid. The pathological\\ncomplication that occurs most frequently is thrombosis. Aseptic throm-\\nbosis renders the affected part of the tumor harder, and frequently\\nresults in arrest of growth, as the removal of the thrombi is followed\\nby obliteration of the vessels by granulation and cicatrization. The\\nenlargement of the tumor caused by this accident under such favorable\\ncircumstances is followed by progressive shrinkage which attends the\\nobliteration of the vessels. Of more serious import is septic thrombo-\\nlympJiangitis, which occurs most frequently in connection with ulcera-\\ntion of the surface of the tumor. The ingress of pyogenic microbes\\nthrough such an infection-atrium results in suppurative inflammation\\nof the walls of the infected lymphatic channels and of the interstitial\\nconnective tissue. If the suppurative infection is severe, the resulting\\ninflammation assumes a phlegmonous character and may successively\\ninvolve the entire tumor, attended by all the risks to life incident to\\nseptic infection and pyemia. The septic thrombo-lymphangitis is usu-\\nally accompanied by a septic thrombo-phlebitis. In septic thrombo-\\nlymphangitis the thrombi are not observed, but they undergo puriform\\nsoftening.\\nThe transformation of a lymphangioma into a lympho-sarcoma is\\npossible, and there is good reason for believing that in cases in which\\nthe disease extended over a large territory in a short time, resulting in\\ndeath, such a transformation had occurred.\\nSymptoms and Diagnosis. Lymphangioma in the majority of\\ncases presents itself as a congenital affection with an intrinsic tendency\\nto increase in size after birth. In some cases the growth is very rapid,\\ninvolving different regions successively, and resulting in death by the\\ntumor interfering with important functions. If the tumor is not com-\\nplicated by inflammation, it is pale and the overlying skin is intact.\\nThe density of the tumor depends on the amount of connective tissue\\nit contains and on the presence or absence of thrombosis. The effect\\nof pressure is more marked if the tumor is composed of new blood-\\nvessels as well as lymphatic channels that is, in cases of hemo-\\nlymphangioma. If the skin or the mucous membrane is broken and\\nthe surface defect communicates with lymphatic spaces, lymph in\\nvarying quantities escapes. The escape of lymph is the most reliable\\ndiagnostic element in the differentiation between a lymphangioma and\\nother tumors or inflammatory swellings. The surface of the tumor is", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0510.jp2"}, "501": {"fulltext": "L YMPHANGIOMA 473\\noften undulated from the presence of superficial cysts. Lymphangioma\\nof the tongue and the lips can usually be recognized without much\\nFig. 320. Author s case of lymphangioma involving the gluteal region and lower extremity. The gluteal\\ntumor was successfully removed no recurrence.\\ndifficulty. In both instances all the tissues implicated by the tumor\\nare in a hypertrophic condition and constitute a part of the swelling.\\nLymphangioma is ordinarily not limited by a well-defined capsule, as the\\nconnective tissue in the periphery of the tumor is progressively invaded\\nby new lymphatic vessels.\\nCystic tumors of the neck, of lymphatic origin, are almost always\\ncongenital, are thin-walled, and contain a clear serous fluid or, if\\nhemorrhage into the cyst has taken place, the serum is discolored by\\nthe admixture of blood. The use of the exploring syringe will fre-\\nquently render material aid in the differential diagnosis between cystic\\nlymphangioma and other cystic tumors and inflammatory swell-\\nings. If the exploratory puncture yields first lymph, and later\\nlymph and blood or pure blood, the diagnosis of hemo-lymph-\\nangioma is established. In the differentiation between a lympho-\\nsarcoma and lymphangioma the use of the microscope may be re-\\nquired.\\nPrognosis. With few exceptions, lymphangioma is a chronic affec-\\ntion and does not tend to destroy life. Great enlargement of the\\ntongue in macroglossia may interfere with speech and deglutition. A\\ncystic lymphangioma of the neck may become a source of danger by\\ninterfering with deglutition and respiration. In rapid-growing tumors\\nthe prognosis should be guarded, more especially if cystic degeneration\\nis a permanent feature. The liability to infection, and also to trans-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0511.jp2"}, "502": {"fulltext": "474 PATHOLOGY AND TREATMENT OF TUMORS.\\nformation into sarcoma, should not be forgotten in the prognosis of\\nlymphangioma.\\nTreatment. Complete excision is indicated if the tumor can be\\nremoved safely. Partial excision is indicated in lymphangioma of the\\nlip and the tongue if the tumor interferes with deglutition, speech, or\\nrespiration, or for cosmetic reasons. In the removal of cystic tumors\\nof the neck, of lymphatic origin, it must be remembered that the cyst-\\nwall is in close relation with the large vessels, and that parts of the\\ntumor often dip deeply into the intermuscular septa. Amputation in\\nuncomplicated lymphangioma of the extremities is not a justifiable pro-\\ncedure. In cystic tumors of the neck not amenable to enucleation or\\nexcision a cure may be effected by free excision, cauterization of the\\ninterior of the cyst with the Pacquelin cautery, and packing of the\\ncavity with iodoform gauze. In progressive inoperable cases paren-\\nchymatous injection of a 10 per cent, solution of chloride of zinc\\nmay be tried with a view of arresting further growth by cicatricial\\ncontraction.\\nTopography.\\nTongue. Lymphangioma of the tongue is known as macroglossia\\n(Fig. 321). Clinically, the condition manifests itself as a congenital\\nenlargement of the tongue, implicating mainly its anterior two-thirds.\\nThe growth is progressive, and when the organ becomes too large to\\nbe accommodated by the cavity of the mouth, its tip protrudes from\\nthe mouth. The irritation and repeated injuries of the enlarged organ\\nby the teeth during mastication, and the exposure of the organ to\\nexternal influences after it protrudes from the mouth, aggravate the\\ncondition by producing inflammation of the surface of the tongue or\\nof the tumor-tissue itself. The disease begins in the submucous con-\\nnective tissue, but later implicates the muscular tissue of the tongue.\\nCapillary lymphangioma of the tongue is limited to its surface, and\\nappears in the form of enlarged papillae.\\nThe proper treatment consists in partial excision of the tongue if\\nthe organ has become sufficiently enlarged to interfere with mastication\\nand speech. In some cases the lymphangioma is complicated by\\nangioma, which calls for special prophylactic precautions to control the\\nhemorrhage during the operation. Lymphangiomata of the cavity of\\nthe mouth have been described by Sachs.\\nLips. Lymphangioma of the lips is called macrochilia. Billroth\\ndescribed a case that came under his own observation. The patient,\\nwho was fifteen years of age, was born with a diffused tumor of the\\nupper lip, which projected considerably beyond the lower lip. The", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0512.jp2"}, "503": {"fulltext": "L YMPHANGIOMA.\\n475\\ntumor was painless, firm, pale, and hard, and could not be diminished\\nin size by pressure. It was often the seat of inflammation, and it bled\\nreadily on being handled or when injured. The tumor was extirpated.\\nA section through it showed that it was composed of a firm framework\\nof connective tissue, the meshes of which were occupied by coagula\\nFig. 321. Macroglossia in a girl eleven years old (after Humphrey).\\nand a serous fluid. The spaces were lined by endothelial cells, and the\\nconnective tissue contained many elastic fibres. The fluid contained\\nlymphoid corpuscles.\\nMacrochilia is very rare, and in the cases which have been described\\nit was always congenital. As the disease is sure to become complicated\\nby repeated attacks of inflammation, it should receive attention during\\ninfancy or childhood. If the tumor is limited in extent, as in Billroth s\\ncase, it should be removed by excision. If it is too extensive for\\ncomplete removal, the size of the lip should be reduced to the desired\\nextent by wedge-shaped excisions. Under such circumstances Lanne-\\nlongue s sclerogenic method of treatment deserves a trial.\\nNeck. Many cases of congenital hydrocele or serous cysts of the\\nneck are of lymphatic origin. Usually, although not always, they are", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0513.jp2"}, "504": {"fulltext": "47^ PATHOLOGY AND TREATMENT OF TUMORS.\\ncongenital. The development of the capsule is very imperfect as com-\\npared with true cystomata in the same locality. Arnold divides these\\ntumors into superficial and deep. The former are situated between the\\nskin and the platysma the latter, beneath the platysma, usually along\\nthe anterior surface of the larger vessels. The deep tumors generally\\nreach the greater size. They may surround the whole neck, and may\\nextend beneath and below the clavicle, in the direction of the axillary\\nspace. In an upward direction they may encroach upon the cavity of\\nthe mouth. Rokitansky and Gurlt believed that these cysts originated\\nin the connective-tissue spaces during intra-uterine life. The formation\\nof multilocular cysts they explained by assuming that collections of\\nserous fluid formed in different parts of the connective tissue at the\\nsame time. It would be impossible to explain why similar hydropic\\nconditions of the connective tissue should not take place in other parts\\nof the body if hydrocele of the neck had such an origin. Luschka\\nmaintained that serous cysts of the neck originated in the ganglion\\ncaroticum a theory which does not deserve further consideration, since\\nArnold found this ganglion intact in two cases of hygroma of the neck.\\nThe existence of an endothelial lining of the cyst in all cases and the\\npresence of lymphoid tissue in the cyst-wall leave no doubt that in the\\nmajority of cases of serous cysts of the neck, of congenital origin, we\\nhave to deal with cystic lymphangioma. The serum contained in these\\ncysts is often stained by the admixture of blood, in which event the cysts\\nlose their translucency. If the diagnosis is not clear, an exploratory\\npuncture will provide the desired information. The tumor either\\nremains stationary after birth or increases very rapidly in size. In the\\nformer case no treatment is indicated, as a spontaneous cure not infre-\\nquently takes place if this should not be the case, operative treatment\\nis postponed until the child is older. In rapid-growing tumors death\\noften results from pressure of the tumor on the trachea, the oesophagus,\\nand the large vessels and nerves of the neck. In such cases urgent\\nsymptoms call for aspiration, which may be repeated as often as the\\npressure-symptoms demand it. In older children strong enough to\\nwithstand the immediate effects of a radical operation, the tumor should\\nbe excised, in whole or in part, under strict antiseptic precautions. If\\ncomplete removal is impracticable, the part of the cyst-wall which\\nremains should be seared with the actual cautery sufficiently deep to\\ndestroy its endothelial lining, and the wound should be packed with\\niodoform gauze. Injections of iodine are too uncertain and dangerous.\\nInjections of carbolic acid after tapping are less objectionable, and\\nshould be resorted to if partial or complete excision of the sac is\\ncontraindicated.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0514.jp2"}, "505": {"fulltext": "L YMPHANGIOMA\\n477\\nSubcutaneous and Submucous Connective Tissue. Most of the\\nchronic lymphatic affections of the subcutaneous connective tissue are\\nof an infective origin and nature. They are caused by the filaria san-\\nguinis hominis, and they are prevalent in southern countries, where this\\nparasite has its habitat. Reference has been made to a case of almost\\ngeneral lymphangioma of non-infective origin. True lymphangioma-\\ntous tumors of the submucous and subcutaneous connective tissue are\\nexceedingly rare (Fig. 322). Steudener described a cavernous lymph-\\nFig. 322. Busey s case of lymphangioma.\\nangioma of the conjunctiva. Biesiadecki found a small lymphangioma\\nin the subcutaneous connective tissue. Gjorgewic found a similar tumor,\\nthe size of a fist, in the subcutaneous tissue of the thigh in a girl nine-\\nteen years old. In this case large quantities of lymph escaped through\\ntwo small openings. Reichel described a congenital lymphangioma,\\nthe size of a pigeon s egg, which he found in the perineum. More\\ncomprehensive statistics of lymphangioma can be found in the mono-\\ngraphs on this subject by Busey and Wagner.\\nUterus. The lymphatic origin of some of the cystic tumors of the\\nuterus has been established by Leopold and Fehling. These cysts\\ncontain a fluid which coagulates on exposure to air, and which is often\\nstained by the admixture of blood. The cyst-wall is lined by endo-\\nthelial cells. Many of these cysts are multilocular, the septa being\\ncomposed of firm fibrous tissue. The new cysts show in their interior,\\non silver staining, the characteristic reaction of endothelium. In most\\ninstances these cysts occur in connection with myofibromata.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0515.jp2"}, "506": {"fulltext": "XXV. LYMPHOMA\\nUpon histogenetic, histological, and physiological grounds tumors\\nof the lymphatic glands should be excluded from tumors of the true\\nglandular organs. The lymphatic glands are mesoblastic structures,\\nand are not secreting organs. They are hematoplastic organs, physio-\\nlogically closely allied to the medullary tissue of bone and the spleen.\\nThey are composed of lymphoid corpuscles and a delicate reticulum\\nof connective tissue enclosed in a firmer capsule\\nof connective tissue. They contain normally no\\nepithelial cells (Fig. 323). The lining of the lymph-\\nsinuses and the follicles is composed of numerous\\nplate-like connective-tissue cells, in places these\\nelements constituting almost an endothelial cover-\\ning. The lymphatic vessels and glands are found\\nwherever blood-vessels are present besides, lymph-\\nspaces are found in the cornea. In the submucous\\ntissue lining the different hollow viscera lymphoid\\ntissue is found as a diffuse infiltration in the form\\nof follicles (Fig. 324).\\nFig. 323. Elements of ade-\\nnoid tissue from partially\\nbrushed section of lymphatic\\nAs a lymphatic gland is not a true gland, the glandofa child (after Piersol)\\ntissue composing it is called, from its resemblance fibres of reticulum t y m-\\n1 1 i 7 7 1 phoid cells c, expanded con-\\nto glandular tissue, adenoid tissue and as it pro- nective-tissue plate.\\nduces the lymph, it is also called lymphoid tissue.\\nIts essential histological element is the lymphoid cell or lymphoid cor-\\npuscle, the product of proliferation of the plate-like connective-tissue cell.\\nDefinition. A lymphoma is a benign tumor formed of lymphatic\\ntissue produced from a matrix of lymplwblasts. In no department of\\nsurgical pathology do we meet with more confusion than in the\\ndifferentiation between benign and malignant tumors and infective\\nswellings of the lymphatic glands. Virchow includes under the term\\nlymphoma all tumors and swellings composed of lymphoid tissue.\\nMany authors still continue to speak of a primary carcinoma of the\\nlymphatic glands. Some pathologists entirely ignore the existence of\\nnon-malignant tumors of the lymphatic glands. This confusion of\\nterms and pathological conditions was increased when Billroth intro-\\nduced the term malignant lymphoma. At the present time it is\\n47S", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0516.jp2"}, "507": {"fulltext": "LYMPHOMA.\\n479\\neasier to say what a lymphoma is not than what it is it constitutes in\\nsurgical pathology at the present time a veritable lucus a non lucendo.\\nLymphoid tissue is exceedingly susceptible to infection, and is\\ntherefore predisposed to acute and chronic inflammation it is also\\nfrequently the seat of sarcoma, but lymphoma, in the restricted sense\\nFig. 324. Diffuse lymphoid tissue occupying\\ndeeper layers of mucosa of human stomach (after\\nPiersol). The lymphoid cells infiltrate the fibrous\\ntissue between the glands without being definitely\\nlimited.\\nFig. 325. Simple lymph-follicle from the con-\\njunctiva of a dog (after Piersol) a, lymphoid tissue\\nlimited by the fibrous capsule {b) c, surrounding\\nconnective tissue.\\nin which this term will be used here, is exceedingly rare. The resem-\\nblance in the structure of tumors and infective swellings of lymphatic\\nglands is so close that a reliable differentiation must be based on the\\nclinical aspects and the etiology of the different affections of the\\nlymphatic glands. Enlargement of the lymphatic glands may be due\\n(1) to infection, (2) to sarcoma, (3) to carcinoma, or (4) to lymphoma.\\nThe acute affections of the lymphatic glands, characterized by rapid\\nenlargement, pain, tenderness, and fever, are produced by the entrance\\ninto the lymphatic system of pyogenic microbes, of the bacillus mal-\\nleus, or of pre-formed septic material. If the process is chronic, the\\nimmediate cause is usually the virus of either syphilis or tuberculosis.\\nIn leukemia and pseudo-leukemia the infection is diffuse and is unat-\\ntended by the usual symptoms which indicate the existence of an acute\\nor a subacute inflammation the glandular affection either appears\\ndiffusely from the beginning or becomes diffuse during its course.\\nThese affections point so strongly to the existence of a microbic origin\\nthat no doubt can be entertained as to their infective origin. Sarcoma\\ninvades successively the glands of the same chain, and frequently\\nterminates fatally by general metastasis. Carcinoma of the lymphatic\\nglands is always a secondary affection it never occurs as a primary\\ndisease, as the lymphatic glands do not contain the essential histological\\nelements epithelial cells. Lymphoma is a tumor of the lymphatic", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0517.jp2"}, "508": {"fulltext": "480\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nglands composed of lymphoid tissue the growth remains as a local\\naffection, and appears clinically as an encapsulated tumor which mani-\\nfests no tendency to implicate adjacent glands, and which is never com-\\nplicated by affections of other blood-producing organs. The lymphoblasts\\nof the matrix of the tumor produce lymph-corpuscles which are not\\ntransformed into leucocytes, but which remain in the reticulum of the\\ntumor as the essential tumor-elements. Lymphoma is a functionless\\ntumor, in this respect differing from the hyperplastic, highly active glands\\nin leukemia.\\nHistology and Histogenesis. A lymphoma is not produced from\\npre-existing adenoid tissue, as are the infective swellings. It is the\\nproduct of tissue-proliferation from an embryonal matrix of lympho-\\nblasts of congenital or post-natal origin. A lymphoma is a tumor which\\nhas no more connection with the adjacent lymphatic channels than an\\nadenoma has with the surrounding ducts of a gland. The connective-\\ntissue plates, modified endothelial cells of the matrix, the lymphoblasts,\\nproduce the lymph-corpuscles\\nwhich are the essential histo-\\nlogical elements of the tumor\\n(Fig. 326).\\nIn its structure a lymphoma\\nbears a strong resemblance to\\nmyeloma (PL 12, Fig. 1). The\\nlymphoid cells are so numer-\\nous that often they almost\\ncompletely obscure the stroma.\\nThe capsule of the tumor is\\nfirm, being composed of con-\\ncentric layers of fibrous tissue.\\nThe atypical structure of the tumor is characterized by the absence of\\nwell-defined lymph-sinuses, while the follicular structure is well pre-\\nserved. The surface of the tumor is smooth, and lacks completely the\\nprolongations into the surrounding connective tissue that are such\\nconspicuous features of lymphangioma. The lymphoid corpuscles,\\nwhich are only occasionally present in lymphangioma, form the bulk\\nof the tumor in lymphoma.\\nRetrograde Metamorphoses. Permanency of the tumor-tissue as\\ncompared with the inflammatory products which constitute the infective\\nswellings is one of the most important elements in the differentiation\\nbetween a lymphoma and the different forms of inflammatory swellings\\nof the lymphatic glands, both acute and chronic. Suppuration can\\noccur only if the tumor becomes the seat of infection with pyogenic\\nFig. 326.\\nLymphoma, showing lymphoid cells and delicate\\nreticulum (after Paget).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0518.jp2"}, "509": {"fulltext": "LYMPHOMA.\\nPlate 12.\\n1. Myeloma of rib (after Klebs) myeloid cells with large nuclei in a delicate network of connective tissue.\\n2. Hyaline degeneration of a lymphatic gland (after Kara; and Schmorl). The reticulum of the gland has been\\ntransformed into a shining, structureless framework. The hyaline masses are continent in some places;\\nbetween the masses in the centre of the field are scanty remnants of gland-tissue. The glandular structure is\\nmore abundant in the peripheral portions of the picture.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0519.jp2"}, "510": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0520.jp2"}, "511": {"fulltext": "LYMPHOMA. 481\\nmicrobes, and caseation can take place only in the event of the tumor\\nbecoming infected with tubercle bacilli. A lymphoma may attain con-\\nsiderable size before any degenerative changes occur, in this respect\\ndiffering greatly from suppurative, tubercular, glandulous, septic, and\\ngonorrheal adenitis. Myxomatous degeneration of the stroma may\\noccur a change which renders the tumor softer or the tumor\\nmay become harder by an increase of the connective-tissue reticulum.\\nA hyaline degeneration such as that shown on Plate 12 (Fig. 2) some-\\ntimes inaugurates graver degenerative changes in a lymphoma. Calcare-\\nous degeneration preceded by fatty degeneration has been observed.\\nSmall cysts occasionally form by dilatation of follicles. A lymphoma,\\nafter having remained stationary for a long time, may become trans-\\nformed into a sarcoma.\\nSymptoms and Diagnosis. Lymphoma is a rare tumor of the\\nlymphatic glands, if we exclude, as should be done, all infective swell-\\nings. It is found most frequently in the region of the neck, in the\\ngroins, the axillae, the mediastinum, and the retroperitoneal space that\\nis, in localities in which the lymphatic glands are most numerous.\\nLymphoma occurs most frequently in young adults. If several tumors\\nappear at the same time, they increase in size at the same rate, and are\\nmovable, painless, and not tender on pressure. The skin over the\\ntumor remains intact. The tumor is smooth and is surrounded by\\na perfect capsule. Extension to other glands never takes place, as is\\nthe case in sarcoma and in infective swellings. All signs and symptoms\\nof inflammation are absent. The general health is not impaired. The\\ntumor or tumors, if large, may cause pressure upon important organs,\\nand in this way may become a source of danger. In the differential\\ndiagnosis between lymphoma and other tumors and swellings of the\\nlymphatic glands it is important to consider the following affections\\nlymphangioma, sarcoma, lymphadenitis, tuberculosis, glanders, leu-\\nkemia, pseudo-leukemia, and syphilis.\\nLymphangioma. Lymphangioma occurs as a more diffuse tumor\\nand is not encapsulated. In many cases lymph escapes from one\\nor more openings in the tumor an occurrence never observed in\\nlymphoma.\\nSarcoma. Lympho-sarcoma appears first as a single tumor, which\\nis followed by successive infection of glands in the same region, usually\\nin the direction of the lymph-stream. The tumors grow very rapidly,\\nand general infection not infrequently takes place.\\nLymphadenitis. Acute suppurative lymphadenitis is attended by\\nfever and all the local signs and symptoms of inflammation, and is\\nalways attended by lymphangitis between the infection-atrium and the\\n31", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0521.jp2"}, "512": {"fulltext": "482 PATHOLOGY AND TREATMENT OF TUMORS.\\ninflamed glands. In the chronic form the symptoms of inflammation\\nare often masked, so that the source of infection is overlooked and the\\naccompanying or preceding lymphangitis is not recognized. The\\ndisease may be limited to one or two glands, which renders it still\\nmore obscure. Some tenderness is, however, always present, and\\nfoci of suppuration can often be detected by palpation or by explor-\\natory puncture.\\nTuberculosis. Glandular tuberculosis is a progressive disease. The\\naffection extends from gland to gland in the infected region. Regres-\\nsive metamorphoses, coagulation-necrosis, caseation, and liquefaction\\nof the cheesy product are early and almost constant manifestations.\\nThe extension of the disease beyond the capsule of the gland in\\nadvanced cases is also an important factor in distinguishing between\\na lymphoma and swellings of an infective origin.\\nGlanders. Glanders occurs, if it affects the glands, as an acute or\\na subacute diffuse affection, in this respect differing entirely from\\nlymphoma, which remains as a local tumor. The discovery of the\\nbacillus of glanders in the inflammatory product will render the diag-\\nnosis positive.\\nLeukemia. Leukemia, as was correctly shown by Virchow in 1845,\\nappears as a hyperplasia of all hematoplastic organs the spleen, the\\nlymphatic glands, and the marrow of bone and is characterized by a\\nspecific pathological change in the blood an excess of white blood-cor-\\npuscles. The increase in the number of leucocytes that typifies this dis-\\nease led Bennet to apply to it the term leucocythemia. Neumann added\\nto the splenic and lymphatic forms the myelogenous variety. The\\nlymphatic glands in different parts of the body become enlarged and\\nhard, and, as a rule, this process is attended by enlargement of the\\nspleen and by a simultaneous affection of the marrow of the bone,\\nwhich affection is often manifested by tenderness over the junction\\nof the xiphoid cartilage with the sternum and over the epiphyseal\\nextremities of the long bones. The excess of leucocytes in the blood\\nis never absent, and from a slight change during the incipiency of the\\ndisease may reach such an extent that the red and white corpuscles\\nare present in the same proportion. Neumann traced in the blood of\\nleukemic patients cells intermediate between the red and the white cor-\\npuscles small nucleated red corpuscles.\\nIn the commencement of the disease it is often difficult, if not\\nimpossible, to differentiate simple leucocytosis and leukemia by micro-\\nscopical examination of the blood. Huss thinks that if the pro-\\nportion of white to red corpuscles is increased to 1 20, such blood\\nis leukemic blood but this is not always the case. Staining of the", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0522.jp2"}, "513": {"fulltext": "L YMPHOMA. 483\\nblood-corpuscles with eosin is an important diagnostic aid. Leukemic\\nblood always contains eosinophilous cells. In doubtful cases micro-\\nscopical examination of the blood will succeed in making a positive\\ndifferential diagnosis between lymphoma and enlargement of the glands\\nattending leukemia. W. S. Church reports a case of leukemia in which\\ng 1\\njb.\\nJ\\nW\\nFig. 327. The blood in leukemia (after Karg and Schmorl). Besides the pale-red blood-corpuscles are\\nleucocytes in various forms, the number of the leucocytes being immensely increased. The smaller leucocytes\\ncontain irregular lobulated nuclei the larger ones contain large nuclei equally stained throughout; a, nucle-\\nated red blood-corpuscles.\\nonly the thoracic and abdominal lymphatic glands were found enlarged\\nat the post-mortem examination. Murchison records the case of a\\nchild twelve years old, in whom no enlargement of any subcutaneous\\nlymphatic glands existed, who died with lymphatic new formations\\nin the liver and enlargement of the glands in the fissure of the liver.\\nIn Church s case the disease was attended by fever, which he regards\\nas of diagnostic importance in the differentiation between leukemia and\\nmalignant tumor.\\nPseudo-leukemia This affection of the lymphatic glands, known\\nalso as anaemia lymphatica, Hodgkin s disease, adenie (Trous-\\nseau), malignant lymphoma (Billroth), and lympho-sarcoma (Vir-\\nchow), resembles lymphoma more closely than leukemia. It is unques-\\ntionably an infective disease in which the undiscovered microbe selects\\nthe lymphatic tissue as its field of action. The lymphatic glands of\\none region of the body, most frequently the cervical, become success-\\nively enlarged, forming hard masses, to be followed by a similar con-\\ndition of the glands in other regions of the body. The disease is\\nattended by progressive anemia, but the blood-changes which have\\nbeen described as occurring in leukemic blood are absent. In this", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0523.jp2"}, "514": {"fulltext": "484 PATHOLOGY AND TREATMENT OF TUMORS.\\ndisease the lymph-cells are increased in number in the meshes of the\\nenlarged glands, and the cortical and medullary portions of the glands\\ncannot be distinguished from each other. The disease sometimes\\nremains stationary for a certain length of time. The spleen, the ton-\\nsils, and the marrow of the bones are frequently implicated. Meta-\\nstasis in the liver and kidneys has frequently been observed. The\\ndisease terminates fatally in from one to two years. The appearance\\nof enlarged glands in the different regions of the body distinguishes\\nthis disease sufficiently from lymphoma, in which such a dissemination\\nis never observed. Lymphoma, being a strictly local disease, is not\\nattended by impairment of the general health.\\nSyphilis. Enlargement of lymphatic glands in syphilis after the\\ndisease has become general is not limited to one region all the glands\\nare more or less implicated. In primary syphilis the extension of the\\ndisease to the lymphatic structures is indicated by enlargement (bubo)\\nof the glands which are in connection through lymphatic channels\\nwith the primary sore. We must restrict the term lymphoma to\\nnon-malignant tumors of the lymphatic glands, single or multiple, but\\ntheir number is limited and usually confined to one region in which\\nan infective origin can be excluded either by a careful study of the\\nclinical aspects or by bacteriological examination. As has previously\\nbeen stated, lymphoma is quite rare. The writer has seen these tumors\\nin the cervical and axillary regions and in the groins. The tumors are\\nmovable, painless, and firm, and may in the course of several years\\nattain the size of a hen s egg. The tumors may occur at any time of\\nlife, but they are most frequently met with in young adults. After the\\ntumors have reached a certain size they become stationary throughout\\nlife, unless they become the seat of infection or undergo transformation\\ninto sarcomata. They do not return after extirpation, and they become\\ndangerous only when from their size they exert harmful pressure upon\\nimportant adjacent organs.\\nTreatment. The proper treatment of lymphoma is enucleation.\\nThe tumors are always well encapsulated, and there is no danger of\\nrecurrence after complete removal by this method.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0524.jp2"}, "515": {"fulltext": "XXVI. MYOMA.\\nMyoma was first described as a distinct variety of tumors by Virchow.\\nIt has often been mistaken for fibroma, on account of the predominance\\nof fibrous tissue in many of the myomatous tumors. Fibrous tumors\\nwhich contain muscular fibres should be classified with the myomata,\\nand not with the fibromata, as the muscle-fibres constitute, from a\\nhistogenetic standpoint, the essential part of the tumor. In myoma\\nthe concentric striated appearance so characteristic of a proper fibroma\\nis frequently less marked, and the substance of the tumor seems to be\\nmore homogeneous in its structure. Fibrous tissue is always present\\nin varying proportions, and often is so abundant as almost to obscure\\nthe essential tumor-tissue.\\nDefinition. A myoma is a tumor composed of muscle-tissue produced\\nfrom a matrix of myoblasts. Vogel called them muscular tumors\\nVirchow, myomata. Zenker made a subdivision of this group of\\ntumors necessary, as he described tumors which were composed of\\nstriated muscular fibres, while before his time it was believed that all\\nmyomatous tumors were composed of unstriped muscular fibres.\\nA tumor composed of striped muscular fibres is called a rhabdo-\\nmyoma or myoma striocellulare, whereas a tumor composed of\\nunstriped muscular fibres is called a leiomyoma or myoma laevi-\\ncellulare. For the sake of brevity we shall describe the two histo-\\nlogical varieties as rhabdomyoma and leiomyoma. There are many\\nreasons to believe that a myoma springs from a matrix of myoblasts\\nindependently of the pre-existing muscular fibres between which the\\ntumor takes its origin.\\nEmbryology. According to Rabl, the muscular tissue in the\\nembryo is derived from a part of the mesoblast enclosed by the\\nthree-faced original vertebrae at a point, corresponding with the mesial\\njunction, which is in contact with the nerve-tube, while the ventral-\\nborder surface, which adjoins the primitive aorta, becomes the sclero-\\ntoma, which forms the axial connective tissue, while the upper wall\\nfurnishes the skin with its connective tissue. The embryonal tissue\\ndestined to become transformed into muscular tissue develops into a\\nlarge plate under the connective tissue of the skin, and sends forth, in\\nthe form of muscular buds, projections to the extremities. The con-\\n4S5", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0525.jp2"}, "516": {"fulltext": "486\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nnective tissue cannot produce muscle-tissue, and when muscular fibres\\nare found in a locality not normally supplied with this tissue, its occur-\\nrence is always due to an erratic deposition of embryonal cells during\\nearly life.\\nRhabdomyoma. Benign tumors composed of striated muscular\\nfibres are exceedingly rare. They were first described by Zenker.\\nMarchand, Eberth, and Cohnheim confirmed Zenker s observation and\\nreported new cases. The tumors usually grow in connection with the\\nkidney, sometimes in the testis, and they are always congenital. Reck-\\nlinghausen found in several new-born children myomata the size of a\\npigeon s egg in the heart-muscle. Fibromatous and myomatous tumors\\nof the heart have been described by Zander, Bostrom, and others.\\nmm\\nfm\\nV\\nH\\nFig 328. Adeno-rhabdosarcoma of kidney (after Karg and Schmorl) the tumor (a) is composed of bun-\\ndles of striated muscular fibres arranged in different directions the striations can be seen by the aid of a\\nmagnifying lens. The interstitial tissue at b is scanty and the nuclei are small at c the nuclei are larger and\\nmore numerous, and appear as round-celled sarcoma arranged in spaces (d) lined by cylindrical cells.\\nRokitansky found a rhabdomyoma in the scrotum. Neumann observed\\na similar tumor in the same locality in a boy three and a half years old.\\nIt took its origin at the lower pole of the testicle, where the gubernac-\\nulum Hunteri has its point of attachment. The muscular fibres con-\\ntained no glycogen, and the sarcolemma was imperfectly developed.\\nPrudden found striated muscular fibres in a tumor of the parotid gland\\nin a boy seven years old Virchow, in the stroma of ovarian tumors\\nSenftleben, in cystoid tumors of the testicle and Cattani, in a vesical", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0526.jp2"}, "517": {"fulltext": "MYOMA.\\n487\\npolypus in a boy twelve years of age. Huber, Bostrom, Marchand,\\nand others have described cases of striated myosarcoma of the kidney\\nin children. Striated muscular fibres are found more frequently as a\\nconstituent part of sarcoma of the urogenital organs than as the sole\\ncharacteristic constituent of benign muscular tumors. The structure\\nof such a complicated tumor is shown in Figure 328. Rhabdomyoma\\nis interesting from an etiological standpoint, but it presents itself to the\\nsurgeon only as a pathological curiosity. We shall discuss in this\\nsection more in detail leiomyoma, which is of vastly more practical\\ninterest to the surgeon.\\nLeiomyoma. Histology and Histogenesis. Leiomyoma occurs\\nmost frequently in the uterus, Fallopian tubes, and gastro-intestinal\\ncanal. The tumor seldom pre-\\nsents the same parallel arrange-\\nment of the muscular fibres which\\nin normal condition is the rule.\\nThe muscular fibres cross one\\nanother in all possible directions,\\nso that in sections they are cut\\ntransversely, obliquely, and longi-\\ntudinally (Fig. 329). Parallel with\\nthe bundles of muscular fibres\\nare found the blood-vessels,which\\nwould indicate that the irregular\\nw v^wy r\\nFig. 329.\u00e2\u0080\u0094 Myofibroma of the broad ligament; X\\n480 (Surgical Clinic, Rush Medical College, Chicago)\\na, muscle-fibres in cross-section b, muscle-fibres in\\nlongitudinal section c, interstitial elastic fibres.\\ndistribution of fibres is determined\\nby the irregular course of the\\nblood-vessels (Fig. 330).\\nThe irregularity in the arrange-\\nment of the muscular fibres is\\nunfavorable to functional activity, as muscular contraction would pro-\\nduce a diminution in size of the tumor in all directions, and would thus\\ndiminish the lumina of all the vessels. In consequence of this arrange-\\nment the muscular tissue with the growth of the tumor is diminished,\\nand is replaced largely by fibrous tissue. Even if the muscular tissue\\nalmost disappears during the growth of the tumor, its original character\\nas a myoma is preserved from a genetic standpoint, and this tumor\\nshould be called a myoma, and not, as was suggested by Miiller,\\na desmoid, or by Rokitansky, a fibroid. As the connective tissue\\nbecomes more abundant, the muscle-fibres are compressed into streaks\\nwhich are sometimes difficult of recognition.\\nThe structure of a leiomyoma is influenced by the character of the\\nmuscular tissue in which it develops. The muscle-fibres are spindle-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0527.jp2"}, "518": {"fulltext": "PATHOLOGY AND TREATMENT OF TUMORS.\\n.K.?\\nHB\\n*^#s\\nFig. 330. Myofibroma of the uterus X 75 (Surgical Clinic, Rush Medical College, Chicago) a, fibrous\\ntissue b, longitudinal section of muscle-fibres c, large blood-vessels.\\nshaped, tapering into filamentous points, and contain near their centre\\nthe typical hammer-shaped nucleus (Fig. 331). In tumor-sections these\\nfilamentous ends of the cells are not shown, even if the section happens\\nto fall parallel with the fibres (Fig. 332).\\nFig. 331. Muscle-cells from myoma of the uterus, isolated by the aid of caustic potash X 250 (after Perls).", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0528.jp2"}, "519": {"fulltext": "MYOMA. 489\\nIn the uterus myofibroma is found as a round, firm-on-the-surface,\\nuneven tumor. On section the surface is not smooth, as the fibres that\\nare cut transversely contract more than those cut longitudinally. The\\ncolor of the tumor is either a pure white or somewhat translucent,\\naccording to the preponderance of the muscular or of fibrous tissue.\\nJ--.-:\\n5 \u00e2\u0096\u00a0-M\\nFig. 332.\u00e2\u0080\u0094 Myofibroma of broad ligament X 510 (Surgical Clinic, Rush Medical College, Chicago)\\na, muscle-cells b, intercellular fibrous tissue.\\nThe section is mapped out into lobes by dense septa of fibrous tissue\\nwhich traverse the tumor from the surface toward the centre. In these\\nsepta are found the larger arteries which supply the tumor with blood.\\nThe capillaries are collected mostly on the surface of the tumor, and ter-\\nminate in veins which, if any obstruction exists, which is frequently the\\ncase, are often dilated into large channels. The capsule of the tumor\\nforms at a late stage, when from pressure the surrounding tissue disap-\\npears by atrophy, and from its connective tissue the capsule is formed.\\nThe earliest stages of the development of a uterine myoma has not\\nbeen investigated sufficiently. Runge traces the origin of such tumors\\nto round indifferent cells Virchow, to a hyperplasia of existing\\nmuscular fibres. Kleinwachter found the smallest myomata supplied\\nwith a muscular pedicle which he believes springs from a blood-vessel.\\nAs endothelial cells cannot be transformed into muscular fibres, such\\na mode of origin is not probable. Kleinwachter s observations, how-\\never, show that muscular fibres are produced along capillary vessels,\\nand the pedicle which he described may correspond to one of these\\nvessels. The most recent observations of Hauser would indicate that\\nthe remains of the Wolffian ducts have something to do with causing\\nthe surrounding muscular tissue to develop into myomata. A number\\nof observers have found inside of myomata epithelial collections in the\\nform of cavities, canals, and cysts a few containing ciliated epithelium.\\nThese structures need not necessarily have come from the Wolffian\\nbodies they might, as Hauser suggested, be derivatives from the\\nuterine mucous membrane. Ribbert has a specimen in which a chain\\nof epithelial cells extends seven or eight millimetres into the uterine", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0529.jp2"}, "520": {"fulltext": "49\u00c2\u00b0 PATHOLOGY AND TREATMENT OF TUMORS.\\nwall, and which in the section appear as isolated epithelial islands. The\\nextreme tip of this chain lies against a small myoma, but does not\\npenetrate into its substance.\\nRicker found frequently in myomatous tumors epithelial structures,\\nchannels, etc., which he believed were derived from Miiller s ducts.\\nFrom such epithelial nests adenomata and cystic tumors may develop\\nwithin or independently of myomatous growths. In the majority of\\ncases the tumor no doubt springs from a matrix of myoblasts in the\\nuterine tissue, while in exceptional cases the tumor may start from a\\nsimilar matrix in the walls of blood-vessels. The round cells which\\nhave been found within and in the vicinity of recent myomata are\\nfibroblasts, which always take part in the production of a myo-\\nfibroma.\\nThe shape of a myoma is also subject to influences exerted by the\\nsurrounding tissues. Pedunculation of submucous and subserous\\nmyofibromata of the uterus is of frequent occurrence. The tumor in\\nFig. 333. Very vascular uterine myoma seen in section (after Virchow).\\neither of these localities grows in the direction offering the least resist-\\nance, carrying before it the mucous membrane or the peritoneum, which,\\nwith the blood-vessels that supply the tumor, forms the pedicle.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0530.jp2"}, "521": {"fulltext": "MYOMA.\\n49 1\\nIntestinal myofibroma develops usually not in the submucous mus-\\ncular fibres, but in the middle coat, giving rise to diffuse thickening, and\\nresulting often in the formation of a ring of tumor-tissue including the\\nwhole circumference of the tube.\\nThe vascular supply of a myoma varies greatly. In dense tumors\\ncomposed principally of fibrous tissue it is often exceedingly scanty.\\nVirchow described an angiomatous myoma of the uterus. In tumors\\nof this kind there are found numerous larger venous channels which\\ncommunicate freely with one another. Wesener described a telangi-\\nectatic myoma of the duodenum.\\nRegressive Metamorphoses. One of the most frequent causes of\\ndegeneration of the tissues of a myofibroma is oedema. The oedema is\\nproduced by venous obstruction resulting from twisting or flexion in\\nthe case of pedunculated growths, or from pressure or thrombosis\\nin interstitial tumors. The serum distends the connective-tissue spaces,\\nmacerates the fibrous tissues, and crowds apart the muscular fibres,\\nwhich at the same time become narrower from compression (Fig.\\n334)-\\nCystic degeneration is another regressive change quite frequently\\nmet with in uterine myofibroma. As recent investigations have shown,\\nthe formation of cysts is in all probability in the majority of cases due\\nto distention of lymphatic spaces.\\nHyaline degeneration and dis-\\nappearance of the tumor-tissue\\nby pressure-atrophy accompany\\nthe growth of lymphatic cysts.\\nIn a case, described by Klebs,\\nof endotheliomatous prolifera-\\ntion in a uterine myofibroma the\\nprimary tumor was surrounded\\nby round nodules, and in the\\nkidney myomatous metastatic\\ndeposits were found. It is to be\\ntaken for granted that metastasis\\nof the myoblasts was caused by infiltration of the tumor by endothelial\\ncells. Fatty degeneration and calcification in parts of the tumor are\\nof frequent occurrence. Myxomatous degeneration of the fibrous part\\nof the tumor is another not uncommon form of regressive meta-\\nmorphosis. Finally, myofibroma may undergo transformation into\\nsarcoma.\\nSymptoms and Diagnosis. Myofibroma begins insidiously and\\ngrows slowly. Frequently its existence is suspected only after the\\nFig. 334. CEdematous myofibroma of the uterus\\nX 590, reduced one-third (Surgical Clinic, Rush Medical\\nCollege, Chicago) a, muscle-cells; b, cedematous inter-\\ncellular substance.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0531.jp2"}, "522": {"fulltext": "492 PATHOLOGY AND TREATMEN7 OF TUMORS.\\ntumor has produced symptoms. A circular myofibroma of the oesoph-\\nagus by encroaching upon the lumen of the organ may give rise to\\ndifficulty in deglutition and to other symptoms which suggest the\\npresence of a progressive stenosis of the tube. A myoma of the intes-\\ntine gives rise to no symptoms until the tumor produces intestinal ob-\\nstruction by stenosis, invagination, volvulus, or flexion. An interstitial\\nor subserous myofibroma of the uterus may attain large size before it\\nproduces pathognomonic symptoms. Its presence is discovered either\\nduring an examination for the cause of obscure symptoms, or acci-\\ndentally by the patient after the tumor has become palpable above the\\npubes. A submucous myofibroma of small size may become the cause\\nof severe and repeated hemorrhages. Myoma of the uterus is often\\nmultiple, converting the organ into a nodular, shapeless mass. Biman-\\nual palpation shows that the tumor or tumors are attached to the\\nuterus. In intra-uterine growths the cervix is often considerably\\ndilated, and the tumor can be discovered by inserting the right index\\nfinger into the uterine cavity and pressing the organ with the opposite\\nhand well down into the pelvis.\\nPrognosis. The danger which attends myofibroma depends on the\\norgan or part of an organ from which the tumor springs and upon\\nthe histological structure of the tumor. A circular myoma of any of\\nthe different parts of the digestive tube is more likely to result in\\nobstruction than is a tumor involving only a part of the circumference\\nof the tube. Progressive growth will take place in proportion to the\\namount of muscular tissue in the tumor. Tumors in which the muscle-\\nfibres predominate grow more rapidly and attain larger size than the\\nhard, fibrous variety. Great vascularity also tends to increase the\\ngrowth of the tumor. Submucous tumors of the uterus undermine\\nthe health and shorten life from hemorrhages. Large interstitial and\\nsubserous tumors of the uterus may interfere mechanically with the\\nfunctions of important abdominal organs. Uterine myomata sometimes\\ngive rise to sepsis from infection with pus microbes. Not infrequently\\na pregnancy results in dangerous, and occasionally in fatal, complica-\\ntions. The possibility of myofibroma undergoing transformation into\\nsarcoma must not be lost sight of in rendering a prognosis.\\nTreatment. Medical treatment in the management of myoma\\nshould be restricted to alleviation of the symptoms which a tumor\\nmay produce. The administration of ergot as a curative agent has not\\nmet the expectations of those who have given this drug a fair and\\nprolonged trial. In bleeding uterine myomata rest and the internal\\nadministration or injection of ergot have yielded good results, but\\nhave no effect in arresting the growth of the tumor. The treatment", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0532.jp2"}, "523": {"fulltext": "MYOMA.\\n493\\nof uterine myoma by electricity, so strongly advocated by Apostoli, is\\nstill on trial. It has not yielded the results claimed for it, and seems\\nfast giving way to operative measures. In the treatment of uterine\\nmyoma demanding operative measures the surgeon either resorts to\\nremoval of the tumor through the vaginal route, by abdominal hyster-\\nectomy or by myomectomy, or he seeks to arrest further growth of\\nthe tumor by diminishing its blood-supply by removal of the uterine\\nappendages.\\nMyomata of the intestinal canal are not diagnosed before they give\\nrise to intestinal obstruction, in which event a positive diagnosis should\\nbe made by opening the abdominal cavity, when the tumor is dealt\\nwith according to the indications that present themselves.\\nTopography.\\nUterus. The uterus is by far the most frequent seat of myomatous\\ntumors. For anatomical, clinical, and pathological reasons it has been\\nFig. 335-\u00e2\u0080\u0094 Myoma at the fundus of the uterus,\\ngrowing outward (after Winckel) a, anterior lip\\nb, posterior lip; c, cavity of the uterus; d, tumor.\\nFig. 336.\\n-Myoma from fundus, growing inward\\n(after Winckel).\\ncustomary to describe these tumors, according to their location, as\\nI. Interstitial; 2. Submucous; 3. Subserous. A tumor that is primarily\\ninterstitial may eventually grow in the direction of the mucous or serous\\nsurface, and become a submucous or subserous tumor (Figs. 335, 336).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0533.jp2"}, "524": {"fulltext": "494 PATHOLOGY AND TREATMENT OF TUMORS.\\nInterstitial or, as they are also called, intraparietal tumors may\\nFig. 337. Two interstitial myomata near cervix\\n(after Winckel).\\nFig. 338. Two interstitial myomata near fundus\\n(after Winckel) a, posterior lip b, bladder.\\nstart in any part of the uterine wall. A frequent location is near\\nthe cervix (Fig. 337). Another favorite locality is at the fundus\\nFig. 339. Subserous and submucous myomata (after Winckel) a, cavity of the uterus b, submucous\\ntumor c, subserous tumor.\\n(Fig. 338). Not infrequently subperitoneal and submucous tumors\\nare found in the uterus at the same time (Fig. 339). In multiple", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0536.jp2"}, "525": {"fulltext": "MYOMA.\\n495\\nmyofibromata of the uterus tumors are often found in all three\\nlocalities, and sometimes also in the broad ligaments.\\nFig. 340.\u00e2\u0080\u0094 Multiple myofibromata of the uterus and broad ligament (after Winckel) a, right ovary\\nb, right Fallopian tube; c, interstitial myoma; d t submucous myoma; e, subserous myoma; f, orifice of\\nuterus; g, interstitial myoma; h, intraligamentous myoma.\\nUterine myomata become encapsulated at an early stage and grow\\nin the direction offering the least resistance. If they are located nearer\\nthe external than the internal surface, they\\nbecome prominent on the serous surface, and\\neventually may become pedunculated. If the\\nreverse is the case, they finally become sub-\\nmucous, and pedunculation in this direction\\nmay take place. If the resistance is equal on\\nall sides, they remain as interstitial growths.\\nThe vessels in the uterine wall, from which the\\ntumor receives its nourishment, become dilated,\\nforming a system of channels which communi-\\ncate freely with one another and with the vessels\\nof the tumor. The vessels appear like channels,\\ndevoid of a proper vessel-wall, but lined by an\\nintima resembling the sinuses of the pregnant\\nuterus (Fig. 341). In some instances myoma\\nof the uterus is associated with other tumors\\nof a benign type, the increased vascularity at-\\ntending the presence of growths of the mucous\\nmembrane acting as an exciting cause in the production of the myoma\\nFig. 341. Cavernous wall of the\\nuterus as found in connection with\\nlarge myomata (after Winckel).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0537.jp2"}, "526": {"fulltext": "496\\nPATHOLOGY AND TREATMENT OF TUMORS.\\n(Fig. 342). There is also reason to believe that the engorgement of\\nthe uterus which attends the presence of a\\nmyoma is favorable to the development of\\npapilloma and adenoma of the uterine mucous\\nmembrane.\\nHistology and Histogenesis. The propor-\\ntion between the muscular fibres and fibrous\\ntissue varies greatly. The hardness of the\\ntumor increases with the amount of fibrous\\ntissue it contains. The muscular fibres are\\nlarger than in the non-pregnant uterus and con-\\ntain large nuclei. The arrangement of the fibres\\nis very irregular they interlace freely with one\\nanother and with the stroma of connective tissue.\\nIn sections the fibres that have been cut trans-\\nversely retract much more than those divided\\nan uneven surface to the section (Fig. 343).\\nJ\\nFig. 3\\n4--\\n-Myoma and adeno-\\nma of the uterus (after Winckel)\\na, adenoma of mucosa b, inter-\\nstitial myoma.\\nlongitudinally, imparting\\nFig. 343 Myoma of the uterus; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, longitudinal\\nsection of muscle-fibres b, transverse section of muscle-fibres.\\nTumors in which the fibrous tissue predominates are firmer, less vas-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0538.jp2"}, "527": {"fulltext": "MYOMA. 497\\ncular, and grow more slowly than those in which muscle-cells pre-\\ndominate. The vessels in the tumor itself are usually not large, and\\nsuch tumors can be enucleated without difficulty so far as hemorrhage\\nis concerned, provided the uterine tissue is not torn. In rare cases the\\ntumor is very vascular and is permeated in all directions by cavern-\\nous spaces like those of the uterine wall, when the tumor is called\\nmyoma telangiectodes. If the lymphatic vessels between the muscular\\nbundles and in the vicinity of the vessel-sheaths are dilated, we speak\\nof a myoma lymphangiectodes (Leopold).\\nRecklinghausen has confirmed the theory of Coblenz, Doran,\\nand Sutton that relics of the Wolffian body are very frequently\\nthe starting-point for many cystic and solid tumors in the append-\\nages and the uterus. He advances the theory, however, very much\\nfurther than any of the other observers. Following Babes, who in\\nthe year 1882 detected true epithelial growths in the interior of\\nuterine myomata, he traces these growths, lined with epithelial\\ncells, to the Wolffian ducts. He first discovered these adenomata\\nin a large myoma, and afterward found similar growths minute as\\na rule in the tubes postmortem, mostly in old women. In cystic\\nmyomata of the uterus he makes a distinction between true gland-\\nular cysts and dilated lymphatic spaces and pseudocysts, developing\\nin consequence of degeneration of the parenchyma of myomatous\\ntumors.\\nGreat dilatation of the lymphatic spaces in a myofibroma is the\\nmost frequent cause of cyst-formation. The muscle-fibres and the\\nconnective tissue are arranged in concentric layers around the vessels\\nof the tumor a condition which has induced some pathologists to\\nassert that myofibroma of the uterus springs from the wall of pre-\\nexisting blood-vessels. The blood-vessels in a myofibroma, like those\\nin any other tumor, are new structures formed from pre-existing blood-\\nvessels in the vicinity of the tumor-matrix. Nerves have been found\\nonly in a few instances in myomatous tumors of the uterus. Bidder\\nfound nerve-fibres in one of these tumors.\\nRegressive Metamorphoses. The degenerative changes that occur\\nin a myoma of the uterus are dependent largely upon the location\\nof the tumor. They occur most frequently, according to Lee, if the\\ntumor is located in the body of the uterus. Originally most of the\\ntumors are interstitial. Pedunculation diminishes the blood-supply of\\nthe tumor and brings about regressive metamorphoses. Pedunculated\\nsubserous tumors frequently undergo fatty degeneration and calcifica-\\ntion. Calcification occasionally takes place in interstitial tumors, but,\\n32", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0539.jp2"}, "528": {"fulltext": "49 8 PATHOLOGY AND TREATMENT OF TUMORS.\\naccording to Virchow, it has never been observed in polypoid growths\\nprojecting into the uterine cavity.\\nSubserous myomata frequently form adhesions with the surrounding\\nviscera, and then receive a new blood-supply from this source. Whether\\npedunculated subserous tumors ever become completely detached is,\\naccording to Virchow, questionable. That such an occurrence is pos-\\nsible the writer is satisfied, as in one instance, in making a laparotomy\\nfor the removal of multiple myofibromata, there was found in the\\nabdominal cavity a detached tumor as large as a small pear the apex\\nof the tumor tapered to a very small point, marking the place where\\nthe pedicle became detached.\\nThe uterus may undergo serious pathological changes from traction\\non the part of a large pedunculated tumor, resulting in great elongation\\nof the organ hydrometra and instances are on record in which the\\nbody of the uterus was severed from the cervix. If the tumor is sur-\\nrounded on all sides equally by uterine tissue, pedunculation does not\\ntake place.\\nIntramural tumors frequently attain great size. Walter reports a\\ncase in which such a tumor weighed seventy pounds. The posterior\\nwall at a point a little below the fundus is the favorite location for intra-\\nmural tumors. The uterine cavity in such cases, if the tumor is large,\\nmay reach the size of the cavity of the pregnant uterus at full term.\\nLateral growth of a uterine myofibroma involves the broad ligaments,\\nand the tumor becomes partly or wholly intraligamentous.\\nIntra-uterine growths attached by a broad surface result in enlarge-\\nment of the uterine cavity in all directions, and the cervix becomes\\ngradually obliterated in the same manner as in pregnancy. Intramural\\ntumors may undergo fatty degeneration in the same manner as the\\nmuscular fibres of a pregnant uterus after delivery. Calcification fre-\\nquently follows fatty degeneration. Myxomatous degeneration fre-\\nquently takes place, during which mucin, nucleated round cells, and\\nmucous cells appear, changing the tumor into a myxomyoma. The\\ncysts which form in consequence of this form of degeneration are\\nempty spaces between the bundles of muscle-tissue, and do not possess\\na proper cyst-wall. CEdema of the tumor-tissue also gives rise to the\\nformation of spaces which resemble cysts. The so-called fibrocysts\\noriginate in this way or develop in consequence of an interstitial\\nextravasation of blood. The cysts contain a synovia-like fluid often\\nstained by the admixture of blood. In rare cases the tumor becomes\\nexceedingly vascular by the formation of large venous spaces, when\\nthe tumor resembles a venous angioma. Such tumors increase in size", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0540.jp2"}, "529": {"fulltext": "MYOMA. 499\\nunder influences which produce intravascular tension. The venous\\nspaces occasionally, by such influences or by distention, become con-\\nverted into blood-cysts. If in a myxomyoma the intercellular con-\\nnective tissue begins to proliferate actively, the tumor undergoes trans-\\nformation into a sarcoma.\\nSuppuration in myofibroma of the uterus has repeatedly been\\nobserved. This complication is announced by temperature, rapid pulse,\\nand other symptoms indicative of pyogenic infection, and is attended\\nby a sudden increase in the size of the tumor, by pain, and by tender-\\nness. If the tumor takes its starting-point near the mucous membrane,\\nit pushes the tissues before it as it projects in the direction of the\\nuterine cavity, and soon it becomes submucous. Pedunculation of\\nsubmucous myofibromata takes place most rapidly if the growth of the\\ntumor toward the uterine cavity is not retarded by strong layers of\\nmuscular fibres. The nearer the tumor is to the mucous membrane,,\\nthe more rapidly does pedunculation take place. Spontaneous detach-\\nment and escape of such tumors has repeatedly been observed. Intra-\\nuterine myofibromata undergoing ulceration and sloughing have often\\nsimulated carcinoma of the cavity of the uterus. Transformation of\\nintra-uterine myofibroma into carcinoma has never yet been demon-\\nstrated.\\nEtiology. Myoma of the uterus has never been observed as a\\ncongenital tumor. The most important cause in exciting tissue-pro-\\nliferation from the essential matrix of myoblasts is the congestion of\\nthe organ during menstruation. Winckel found in his cases the tumors\\nsubserous in 25 per cent., intramural in 65 per cent., and submucous\\nin 10 per cent. Of 528 cases collected by Chiari, West, Beigel,\\nSchroeder, and Winckel, 18 per cent, occurred in women between\\ntwenty and thirty years of age, 3 per cent, between thirty and forty,\\none-third of the whole number before the age of thirty-five, and one-\\nfourth of the whole number had symptoms before the age of thirty.\\nIt is safe to assume that in the majority of cases the tumors appear\\nduring the latter part of the third and the beginning of the fourth\\ndecennium. The youngest patients suffering from myofibroma have\\nbeen ten years of age (Beigel). Marriage increases the frequency of\\nmyoma of the uterus. In 33 per cent, of the married women the\\ntumors caused sterility. Abortions and injuries to the uterus of all\\nkinds must be regarded as exciting causes. Chronic inflammation\\nof the uterus and its appendages is another fruitful source of tumor-\\nformation.\\nSymptoms and Diagnosis. The degree of suffering caused by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0541.jp2"}, "530": {"fulltext": "500 PATHOLOGY AND TREATMENT OF TUMORS.\\na uterine myoma does not depend on the size of the tumor a tumor\\nthe size of a pea or a hazel-nut frequently produces graver symptoms\\nthan a tumor the size of a child s head. Small myomata often pro-\\nduce a complexus of nervous symptoms frequently mistaken for\\nhysteria. The uterus is exceedingly tender to the touch the organ\\nis turgid and occasionally displaced, and rectal and vesical distress\\noften obscures the original difficulty. As soon as the tumor is large\\nenough to escape from the pelvis the subjective symptoms may\\ndisappear almost completely, and the patient, who has been, per-\\nhaps, a sufferer for years, is suddenly relieved and apparently restored\\nto health. As the tumor increases in size new symptoms arise by\\nits pressure anteriorly upon the bladder or posteriorly upon the rec-\\ntum circumscribed peritonitis, rotation of the uterus, or torsion of\\nthe pedicle gives rise to new symptoms which often force the patient\\nto seek medical advice. If the tumor ascends into the abdominal\\ncavity and does not become pedunculated, its growth is usually\\nrapid, and the tumor often reaches an enormous size in the course of\\na few years. The abdominal cavity becomes greatly distended and its\\ncontents are subjected to pressure. If the tumor involve the lower\\nsegment of the uterus, its ascent into the abdominal cavity is impeded,\\nand its increasing size results in impaction of the tumor in the pelvis,\\nattended by the unavoidable pressure-symptoms which accompany\\nsuch a condition.\\nThe pain which attends a uterine myoma is caused by tension of\\nthe uterine wall and by pressure upon adjacent organs, and especially\\nupon nerves. Pressure upon the sciatic nerve on one side will often\\nproduce sciatica, which, unless its cause is investigated, is often treated\\nuselessly for months. Intra-uterine myoma is often the cause of ex-\\npulsive pains which occur at irregular intervals. During the begin-\\nning of menstruation the symptoms are usually aggravated. Profuse\\nmenstruation is the most important symptom in submucous tumors.\\nIt is less constantly present in the interstitial form, and is entirely\\nabsent in subserous tumors. Menstruation is not only more profuse,\\nbut the duration of the period is also increased. The loss of blood\\nnot only undermines the patient s general health, but may become a\\nsource of danger to life. Hemorrhage is frequently aggravated by the\\ncoexistence of adenomata and by great vascularization of the tumor.\\nThe menorrhagia is variable in its intensity. Sometimes several months\\nwill elapse without undue loss of blood, when, without any obvious\\ncause, the hemorrhage returns with menstruation.\\nIn submucous myoma there is present between the menstrual", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0542.jp2"}, "531": {"fulltext": "MYOMA. 501\\nperiods a copious catarrhal discharge caused by the great vascularity\\nof the uterine mucosa and the hypertrophic condition of the glandular\\nappendages. The cervix is soft and easily dilatable, and when the\\ntumor has reached the internal os it can readily be discovered by a\\ndigital examination. Expulsion of the tumor by uterine contractions\\nand traction upon the tumor not infrequently result in inversion of\\nthe uterus. After the tumor has reached the vagina it is exposed to\\ninfection ulceration and sloughing may occur, and under such cir-\\ncumstances the patient s life is in danger from pyemia and septic\\nperitonitis.\\nThe growth of uterine myomata is usually arrested with the cessa-\\ntion of menstruation. The tumors at this time, as a rule, not only\\ncease to grow, but are also reduced in size by fatty degeneration and\\nshrinkage. The danger to be apprehended from uterine myomata is\\ngreater if the tumors occur at an early age.\\nThe progressive anemia which inevitably attends the repeated\\nhemorrhages and bleeding myomatous tumors of the uterus, and the\\nprofuse offensive discharges caused by ulceration and sloughing, have\\noften given rise to mistakes in diagnosis, prognosis, and treatment.\\nTumors producing such conditions differ clinically from malignant\\naffections principally in the length of time since the first symptoms\\nappeared.\\nThe diagnosis of small myomata is always difficult and frequently\\nimpossible. An increased localized resistance in some part of the\\nuterine wall is often the only evidence of the existence of a small\\nmyoma. As soon as the tumor becomes prominent on the surface of\\nthe uterus, its presence can be ascertained by bimanual palpation, as it\\nmoves with the uterus, which is not the case if the swelling consists of\\nthe remnants of a hematocele or of pelvic peritonitis. Repeated exam-\\ninations are at times necessary to avoid errors in diagnosis. A careful\\nuse of the uterine sound is often invaluable in distinguishing between\\ntumors of the uterine wall, ovarian tumors, and inflammatory swellings.\\nIt is understood that the use of the sound should be restricted to cases\\nin which a pregnancy can safely be excluded. Auscultation should\\nnever be omitted, as in more than one-half of all cases of large uterine\\nmyomata a bruit can be heard. The removal of fragments of tissue\\nby harpooning is a harmless procedure if done under proper antiseptic\\nprecautions, and the microscopical examination of sections made from\\nsuch fragments is of great value in differentiating between a benign and\\na malignant tumor of the uterus. Digital exploration of the uterine\\ncavity for submucous myomata can be done to greatest advantage", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0543.jp2"}, "532": {"fulltext": "502 PATHOLOGY AND TREATMENT OF TUMORS.\\nduring menstruation, as at this time the cervix is most dilatable. If the\\ntumor involve one of the lips of the cervix, its presence should be\\nsuspected if the lip is enlarged and unusually vascular. If the tumor\\nin this locality is large, it is often difficult, if not impossible, to find the\\nos uteri, which may be displaced above the pubes or against the prom-\\nontory of the sacrum, according to whether the tumor involves the\\nposterior or the anterior lip.\\nThe greatest difficulties are often encountered in making a differen-\\ntial diagnosis between myofibroma and pregnancy. Numerous are the\\ninstances in which experienced surgeons have opened the abdominal\\ncavity with the expectation of removing a myofibroma or an ovarian\\ntumor, when a direct examination revealed a pregnancy. Such mis-\\ntakes have frequently been made, and will continue to be made in the\\nfuture. The surgeon is often misled by misstatements on the part of\\nthe patient. Exploratory laparotomy will occasionally be resorted to\\nin settling the doubt in certain obscure cases this is as far as the sur-\\ngeon should go. After the abdomen has been opened and the uterus\\nexposed to sight and touch, it is not difficult to recognize a pregnant\\nuterus. The thoughtless use of the trocar under such circumstances\\nhas brought great reproach upon surgery in many a community. The\\nwriter has twice been in the unenviable position of having to close the\\nabdomen over a pregnant uterus in one instance a double uterus mis-\\nled him, and in the other a pregnancy was overlooked in a woman over\\nfifty years of age who had not borne children for twenty-five years.\\nFortunately, both patients recovered without any untoward symptoms,\\nand were delivered at full term of healthy children. In myoma the\\nresistance is greater than that of a pregnant uterus, and the swelling is\\nmore circumscribed. In pregnancy the lower segment of the uterus\\npresents a characteristic bluish-red color, and both uterine arteries\\nare enlarged conditions that are not present to the same degree\\nin myoma. Examination of the breasts should never be omitted.\\nRepeated examinations are often necessary to exclude the possibility\\nof a pregnancy. In doubtful cases not calling for prompt active\\ninterference it is advisable to postpone operative measures until a\\nsufficient time has elapsed to exclude a pregnancy. If for any reason\\nit is deemed necessary to establish a positive diagnosis, an explora-\\ntory laparotomy is justifiable, but the trocar should not be used until\\nby careful examination the possibility of a pregnancy can safely be\\nexcluded.\\nThe affections that call for special attention in the differential diag-\\nnosis of uterine myoma are retroflexion, endometritis and parenchym-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0544.jp2"}, "533": {"fulltext": "MYOMA. 503\\natous metritis, hematocele, pelvic peritonitis, ovarian tumors, pyosal-\\npinx and hydrosalpinx, chronic inversion of the uterus, retroperito-\\nneal tumors, and malignant tumors of the uterus. Myofibromata of\\nthe uterus appear more frequently as multiple tumors than as an iso-\\nlated affection, and, unless the uterus has become adherent, if it is the\\nseat of multiple tumors the nodulated mass is movable. Chronic\\ninversion can readily be distinguished, by the use of the sound, from\\npartial or complete inversion produced by a myoma. In affections\\nof the ovaries and tubes the swelling can usually be separated from\\nthe uterus, especially if the patient be examined under the influence\\nof an anesthetic, which examination should never be omitted in doubt-\\nful cases.\\nPrognosis. The prognosis of myofibroma of the uterus is more\\ngrave than is generally supposed. Winckel s statistics show that in\\nabout 10 per cent, of all cases death ensues after a longer or shorter\\nduration of the affection. Hemorrhage and uremia are the most fre-\\nquent immediate causes of death. The profound anemia which is such\\na common occurrence in submucous tumors is incompatible with the\\nperformance of important functions for any length of time, and, besides,\\na chronic progressive anemia engenders fatal complications, such as\\nthrombosis, embolism, and pulmonary oedema. In rare cases the\\npatients succumb to the Immediate effects of hemorrhage alone, when\\ndeath is usually preceded by convulsions and coma. Organic disease of\\nthe kidneys is produced by compression of the ureters. If the tumor\\ndistends the abdominal cavity, death results in consequence of dyspnea\\ncaused by compression of the contents of the thorax. Infection of the\\ntumor has resulted in death from sepsis, pyemia, peritonitis, and ex-\\nhaustion from prolonged suppuration. In other cases death is pro-\\nduced by the complications arising from abortion or from delivery at\\nfull term. In 119 cases of myomata of the uterus complicated by\\npregnancy, collected by Soloczinow, in 21 cases the patients aborted,\\nand in 98 they were delivered at full term.\\nIt has been observed that tumors that remained perhaps stationary\\nfor a long time begin to grow rapidly during pregnancy. This is\\nparticularly true of the soft variety and of cavernous myoma. Both\\nthese forms of uterine myoma are interstitial, and hence become sur-\\nrounded on all sides with large blood-vessels which develop during\\npregnancy.\\nA great deal has been said regarding the spontaneous disappearance\\nof uterine tumors and the curative effects of certain non-operative\\nmeasures. A myoma seldom if ever diminishes in size during the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0545.jp2"}, "534": {"fulltext": "504 PATHOLOGY AND TREATMENT OF TUMORS.\\nactive sexual life of the patient, whereas the menopause, whether nat-\\nural or brought about by the removal of the uterine appendages, has\\na decided influence in arresting further tumor-growth, and is usually\\nfollowed by fatty degeneration of the muscular fibres and shrinkage,\\nif not total disappearance, of the tumor. Virchow thinks it unlikely\\nthat complete disappearance by retrograde metamorphoses ever takes\\nplace, and it has never, to the writer s knowledge, been proved by dis-\\nsection. The muscular fibres under favorable circumstances degenerate\\nand are removed by absorption, but the connective-tissue stroma\\nremains hence it is the soft myomata that are diminished in size under\\nconditions which induce fatty degeneration of the parenchyma of the\\ntumor.\\nThe liability of a myofibroma to undergo transformation into a\\nsarcoma has repeatedly been referred to. Virchow has described\\na number of such cases. A most interesting case of malignant trans-\\nformation of a myoma of the stomach has been reported by Brodowski.\\nThe tumor, after it had undergone this transition, caused myosarcoma-\\ntous metastatic deposits in the liver. The metastasis of muscle-fibre\\nis almost unique, but it has been observed in a case of myosarcoma\\nof the kidney that produced similar metastatic deposits in the dia-\\nphragm (Eberth).\\nThe prognosis of the operative treatment of myofibroma of the\\nuterus has become vastly better since aseptic surgery has more gen-\\nerally been adopted, and since the technique of the different operative\\nprocedures has been so decidedly improved during the last ten years.\\nOnly twelve years ago laparo-hysterectomy had a mortality of from 30\\nto 35 per cent, in the hands of expert surgeons; to-day the mortality\\nprobably does not exceed 10 per cent., and some operators have\\nreduced it to 5 per cent. The success of the operative treatment will\\nbe improved with a better selection of cases and a still more improved\\ntechnique of the different operative procedures.\\nTreatment. The treatment of uterine myofibroma should not be\\nneglected, as much can be done in retarding the growth of the tumor\\nby rational treatment. All measures that diminish the blood-supply\\nto the uterus are calculated to diminish tissue-proliferation, and thus\\nretard tumor-growth. The patient must be advised to avoid active\\nexercise, such as dancing, skating, horseback riding, or the climbing of\\nheights, and should remain the greater part of the time in the recum-\\nbent position during menstruation. Constipation is a common evil in\\nnearly all patients suffering from uterine myoma. The bowels should\\nbe kept in a soluble condition by the administration of saline laxatives,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0546.jp2"}, "535": {"fulltext": "MYOMA. 505\\nenemata, or by the use of glycerin suppositories. If pain is a con-\\nspicuous symptom, it should be controlled by the administration of the\\nmilder narcotics, such as potassic bromide, hyoscyamus, and belladonna.\\nPreparations of opium and of chloral hydrate must be used with the\\ngreatest caution and restriction, lest patients become habituated to their\\nuse. Warm baths are nearly always beneficial and grateful to the\\npatients. The use of pessaries is occasionally indicated if the uterus\\nhas become displaced, and can be replaced and held in its normal posi-\\ntion by a proper mechanical support. The internal use of ergot was\\nstrongly recommended by the late M. H. Byford. Favorable results\\nwere also obtained by its subcutaneous administration in the clinic of\\nHildebrandt at Konigsberg. The writer believes the general experience\\nin the use of this drug coincides with that of Winckel, who states that\\nhe has observed in several instances, under the prolonged use of ergot,\\ndecided diminution in the size of the tumor, but in none of them\\nwas there a complete disappearance.\\nErgot has little or no effect in the treatment of hard myofibromata.\\nIts therapeutic value as a palliative is limited to the soft myomatas and\\nteleangiectatic varieties. Large and long-continued doses not infre-\\nquently produce ergotism, especially in very anemic patients. The\\nwriter has found a combination of ergotin, extract of nux vomica, and\\nsulphate of iron to be of more value in checking hemorrhage than\\nergot alone. Parenchymatous injections of ergotin, as advised and\\npractised by Delore, have yielded no better results than the internal or\\nsubcutaneous use of this drug; besides, the procedure is attended by\\nconsiderable risk of infection.\\nCuretting of the uterine cavity has yielded good results in diminish-\\ning the hemorrhage. The effect of this treatment is particularly well\\nmarked if the mucous membrane is the seat of adenomata, as is so\\noften the case. The insertion of strips of gauze saturated with tincture\\nof the sesquichloride of iron into the uterine cavity has also been found\\nuseful in diminishing the hemorrhage. Hot vaginal douches have also\\nproved beneficial. The tincture of digitalis alone or in combination\\nwith ergot has a well-earned reputation for diminishing hemorrhage,\\nespecially in patients suffering at the same time from a weak heart.\\nDuring the interval between the menstrual periods the different prepa-\\nrations of iron with strychnia have a salutary effect. In patients greatly\\nreduced from repeated and severe hemorrhages intravenous infusions\\nof a physiological solution of salt will be indicated if stimulation by\\nordinary means is not sufficient to maintain the requisite degree of\\nintravascular tension.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0547.jp2"}, "536": {"fulltext": "506 PATHOLOGY AND TREATMENT OF TUMORS.\\ni\\nElectrolysis has had quite an extended trial, but it has not yielded\\nthe anticipated results. Kimbal and Cutter inserted strong needles\\nseven and a half inches in length not far apart into the substance\\nof the tumor and passed through\\nthem the electrical current. In\\n2 cases death resulted from peri-\\ntonitis in 23 the tumor is said\\nto have diminished in size in\\n10 no effect whatever was pro-\\nduced. Apostoli and his followers\\nhave revived this treatment, and\\nhave claimed that in some in-\\nstances the tumor disappeared\\ncompletely. Apostoli increased\\nthe strength of the current from\\n100 milliamperes, used first, to\\n250 milliamperes. One of the\\npoles is applied to the abdomen\\nby means of a moist clay elec-\\ntrode, and the other pole is intro-\\nduced into the uterine cavity in\\nthe form of an insulated sound.\\nThe electrode is pushed into the\\nsubstance of the organ after\\npreliminary puncture where we\\ndesire to hasten the demolition\\nof the neoplasm, or where the\\ncervix is impermeable or inaccess-\\nible.\\nIt is difficult to conceive in\\nwhat way complete removal of\\nthe tumor is accomplished. That electrolysis combined with rest will\\ndiminish hemorrhage and in a certain percentage of cases bring about\\nreduction in the size of the tumor no one will deny, but as a curative\\nmeasure its claims have been, to say the least, over-estimated. In\\nmany cases the treatment has produced complications that proved fatal,\\nand in others it has necessitated operative treatment. The. reputation\\nof this method of treatment will diminish with the improved results\\nfollowing operative procedure.\\nOperative Treatment. Myomata of the lower segment of the\\nuterus accessible from the vagina should be removed by enucleation.\\nThe use of the ecraseur and of the galvano-caustic wire should be\\nFig. 344. Apostoli s uterine electrode a, natural\\nsize of the instrument a, ordinary hysterometer b,\\ntrocar for puncture ;f, notch marking average depth of\\nuterus b and c, entire instrument, reduced to one-\\nthird size, in c, celluloid handle, to protect the vagina\\ne, electrode d, thumb-screw, to regulate length of\\nexposed sound; d, carbon electrode for galvano-chem-\\nical cautery, one-third size.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0548.jp2"}, "537": {"fulltext": "MYOMA.\\n507\\ndisplaced by this operation. In cases of intra-uterine tumors the\\nadjustment of the wire is attended by the greatest difficulties, and not\\ninfrequently there is left a part of the tumor, which is responsible for\\nmany recurrences of pedunculated benign tumors. The twisting off\\nof a pedunculated growth if the pedicle is narrow is usually attended\\nby satisfactory results, but the operation of enucleation is applicable\\nin all such cases and is attended by less risk.\\nVaginal Enucleation. This operation is the ideal one in all cases\\nin which the base of the tumor can be reached. In tumors of the\\ncervix and in pedunculated tumors of the uterine cavity the base of\\nthe tumor can be reached without much difficulty. The\\ntumor should be brought down as far as possible by the\\nuse of one or more vulsellum forceps, when the mucous\\nmembrane covering the pedicle is divided by a circular\\nincision sufficiently far away from the attached part of the\\npedicle to allow the cuff of mucous membrane to cover\\nthe entire wound after the enucleation has been com-\\npleted. The mucous membrane is then detached with\\na pair of blunt-pointed scissors or with Pozzi s enucle-\\nator (Fig. 345). Very little hemorrhage is caused during\\nthis part of the operation. By reflection of the cuff of\\nmucous membrane the pedicle, containing the principal\\nblood-vessels of the tumor, is reduced considerably in size,\\nand at the same time the capsule of the tumor is exposed\\nthoroughly at the base of the tumor. The tumor is then\\nenucleated if the pedicle is broad, or if it is narrow the\\ntumor is wrenched from its base by twisting it around its\\naxis. The danger of hemorrhage attending this opera-\\ntion has been over-estimated greatly. If the mucous\\nmembrane is divided by a circular incision and reflected,\\nand the tumor is removed by the use of blunt instruments\\nor by torsion, the hemorrhage is very slight. After the\\nremoval of the tumor the wound is tamponed with a long\\nstrip of iodoform gauze, which is allowed to remain for\\nthree or four days. After the removal of the gauze the mucous mem-\\nbrane will cover the granulating surface, and healing of the entire\\nwound is effected in a few days.\\nThe writer has enucleated in this manner tumors the size of a child s\\nhead attached by a pedicle to the fundus of the uterus. If the pedicle\\nis short, traction upon the tumor sufficient to partially invert the uterus\\nwill facilitate the operation. After the removal of the tumor the in-\\nversion usually corrects itself, otherwise the fundus is pushed into its\\nFig. 345-\u00e2\u0080\u0094 Pozzi s\\nenucleator.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0549.jp2"}, "538": {"fulltext": "508\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nnormal position. If the tumor occupies either the anterior or posterior\\nlip and is sessile or interstitial, it is exposed by an incision parallel with\\nthe long axis of the uterus, and as soon as its capsule has been reached\\nit is grasped with vulsellum forceps and is removed by enucleation.\\nCare must be exercised to make the blunt dissection close to the\\ncapsule, as otherwise the laceration of uterine tissue might result in\\ntroublesome hemorrhage.\\nVaginal Myomotomy. If the tumor is too large to be removed\\nthrough the vagina by enucleation, it often becomes necessary to\\nremove the growth by fragmentation or morcellement. Pean, who\\npractised this operation on a large scale and carried its indications\\nto their utmost limits, successfully removed through the vagina\\nby this method many large myomata which other surgeons would\\nhave attacked by an abdominal section. The operation is especially\\nintended for sessile and interstitial myofibromata of the body of the\\nuterus. Pean employs in this operation forceps of special construction\\nFig. 346.\u00e2\u0080\u0094 Pean s\\nforceps, serrated and with teeth, for morcellation of myofibromata.\\n(Fig. 346), with which he performs morcellation of the tumor. It is\\nthe object of the operation to remove the tumor piecemeal, and not\\nby enucleation. The tumor is attacked from the centre, and fragments\\nare removed in the direction of the periphery until all tumor-tissue\\nhas been removed.\\nThe first step of the operation consists in rendering the tumor\\naccessible. This is done by detaching the cervix in the same manner\\nas in performing a vaginal hysterectomy, only that opening of the\\nperitoneal cavity is carefully avoided. Hemorrhage during this step\\nof the operation is controlled by the use of hemostatic forceps. After\\nthe cervix has been isolated it is incised, and the incision is carried into\\nthe uterus as far as the tumor. The tumor is then carefully located\\nwith the finger, after which the morcellation is begun in the centre\\nof the growth. The vagina is retracted by elbow retractors, so as to", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0550.jp2"}, "539": {"fulltext": "MYOMA. 5\u00c2\u00b09\\nexpose the field of operation as thoroughly as possible for the fingers\\nand forceps. When the tumor has been reached it is drawn down\\nwith vulsellum forceps and a deep incision is made into it parallel with\\nits long axis. The sides of the tumor are then grasped with forceps,\\nretracted, and fragment after fragment is drawn down with forceps\\nand removed with scissors or with a bistoury (Fig. 347).\\nFig. 347. Removal of myofibroma by morcellement (after Pean).\\nAfter the removal of the lower part of the tumor by this method\\nthe upper portion can often be detached by traction and twisting.\\nBleeding vessels are caught with forceps and tied. When the tumor\\nis very large, Pean excises the two cervical lips, and after the removal\\nof the tumor sews the lips of the vaginal wound. If the peritoneal\\ncavity is opened, Pean advises that the wound should be closed with\\nsutures. If more than one tumor is present, the operation is repeated\\nuntil all the tumors are removed. After the removal of the tumor,\\nif the cervical lips have not been amputated which is necessary only\\nin exceptional cases the cavity is cleansed thoroughly by mopping, and\\nafter hemorrhage has been attended to carefully it is packed with a\\nlong strip of iodoform gauze. If compression-forceps are used in\\narresting the hemorrhage, they are removed after thirty-six or forty-\\neight hours. The cervical as well as the circular incision is closed by", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0551.jp2"}, "540": {"fulltext": "510 PATHOLOGY AND TREATMEN1 OF TUMORS\\nsuturing. The iodoform-gauze tampon is brought out of the cervix\\ninto the vagina.\\nThere can be but little doubt that Pean and his followers have\\ncarried vaginal myomotomy by morcellation too far. The average\\naseptic surgeon will obtain better results by laparotomy than by piece-\\nmeal extraction if the tumors are large, multiple, and subperitoneal.\\nThe operation, however, has a legitimate field, and it will undoubtedly\\nfind favor with many operators.\\nVaginal Hysterectomy. Removal of the entire uterus for myofi-\\nbroma has been performed by Pean, Sanger, Richelot, Terrier, Leopold,\\nand others. The mortality has been about 13 per cent. Tumors not\\ntoo large to be removed through the vagina should be removed by\\nenucleation or morcellement operations that have yielded better\\nresults than vaginal hysterectomy, and with less mutilation.\\nLaparotomy. The removal of myofibromata through an abdominal\\nincision or the removal of the uterine appendages to arrest further\\ntumor-growth is indicated in cases of myofibromata in which vaginal\\noperations are inapplicable and the tumors threaten to destroy life, or\\nincapacitate the patient from following her occupation, or cause sufficient\\nsuffering to warrant an operation. Contraindications are cessation of\\ngrowth of the tumor, unimpaired health of the patient, and advanced\\nage. If a tumor at the menopause causes no serious inconvenience,\\nconservative treatment should be pursued. Soft myomata are more\\nfrequently subjected to operative treatment than hard tumors, because,\\nas a rule, they grow more rapidly and occur more frequently in the\\nyoung than in women approaching the menopause.\\nAbdominal section for myofibroma should be done under the same\\nstrict aseptic precautions as in other operations requiring opening of the\\nabdominal cavity. The patient should be placed on a course of pre-\\nliminary treatment, including a daily warm bath, laxatives, and a\\nrestricted diet, for at least three or four days before the operation.\\nSalpingo-oophorectomy The removal of the uterine appendages is\\nindicated in the operative treatment of myofibroma of the uterus in\\nwhich enucleation is impossible and the tumor or tumors have not pro-\\nduced serious pressure-symptoms. Arrest of menstruation, effected by\\nthe removal of the uterine adnexa, exerts the same effect on uterine\\nmyofibroma as the natural menopause. The tumors, as a rule, not only\\ncease to grow, but also are materially reduced in size by fatty degene-\\nration and shrinkage. Salpingo-oophorectomy yields the best results in\\nsoft multiple myomata occurring in women from twenty to thirty-five\\nyears of age. The danger attending this operation in well-selected cases\\nis very small. The first operation of this kind for uterine myoma was", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0552.jp2"}, "541": {"fulltext": "MYOMA.\\n511\\nperformed in 1876 by Trenholme. Tait and Hegar prefer it to other\\noperations in the majority of cases. If the uterus is movable and the\\ntumors are not large, the uterine appendages can be removed through\\nFig. 348. Hegar s forceps for cauterizing the pedicle in castration a, upper surface b, under surface with\\nivory plate.\\na two-inch median incision. If the ovaries are imbedded in inflamma-\\ntory adhesions, it is often exceedingly difficult to find and isolate them.\\nUnder such circumstances it is advisable to enlarge the incision to the\\nFig. 349.\u00e2\u0080\u0094 Castration (after Pozzi): the tube and the ovary are seized in Hegar s forceps; the ligature is\\npassed around the pedicle by a blunt needle.\\nrequisite extent, so that the surgeon can not only feel but see what he\\nis doing. The operation will prove of value only if every vestige of\\novarian tissue is removed or destroyed. For this reason many opera-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0553.jp2"}, "542": {"fulltext": "512 PATHOLOGY AND TREATMENT OF TUMORS.\\ntors advise that the stumps should be cauterized thoroughly after the\\novaries and the tubes have been removed. For this purpose a forceps\\nof suitable construction should be employed (Fig. 348). The pedicle\\nbelow the forceps, consisting of the broad ligament, the Fallopian tube,\\nand the ovarian ligament, should be transfixed with a blunt needle\\narmed with medium-sized Chinese silk the silk is then cut in the centre\\nand each part is tied on its respective side, after which one of the liga-\\ntures is made to encircle the whole pedicle. The tying must be done\\nslowly and with jerks, so that the ligatures may cut their way deeply\\ninto the tissues to prevent slipping. The ligatures are then cut short\\nto the knot.\\nThe cauterization of the stump outside the compression-forceps is\\nan additional safeguard against hemorrhage, and frequently destroys\\novarian tissue that has escaped the scissors. For the purpose of aiding\\nthe mummification of the stump the writer has been in the habit of\\ncovering it with a thin film of iodoform before dropping it into the\\nabdominal cavity.\\nWiedow collected 149 cases of castration for myofibroma, and found\\nthat in 54 cases the tumors underwent shrinkage and hemorrhages\\nceased. In 15 cases the result was fatal. The mortality of this opera-\\ntion has been reduced greatly since Wiedow s statistics, and at the\\npresent time probably does not exceed 5 per cent. Menstruation is\\neither arrested at once by the operation, and with it the hemorrhages,\\nor it ceases a few months later. The writer has seen tumors the size\\nof a fist shrink to the size of a hen s egg in the course of three or four\\nmonths after the operation.\\nLaparo-myomectomy In pedunculated intraperitoneal myofibroma\\nof the uterus the pedicle should be transfixed and securely tied, close\\nto the uterus, with medium-sized Chinese silk. As little of the uterine\\ntissue as possible should be included in the ligatures. The uterine\\ntissue in the vicinity of a tumor is always quite vascular and is easily\\ncut by the ligature an accident which is invariably followed by trouble-\\nsome hemorrhage. In a case where this occurred the writer was forced\\nto suture the margins of the wound to the parietal peritoneum of the\\nmargins of the external wound, when he was able to make efficient\\nuse of the antiseptic tampon, which was placed over the now extra-\\nperitoneal wound and compressed under the deep sutures which con-\\ntrolled the hemorrhage. Two days after the operation the sutures\\nwere cut and re-tied after the removal of the tampon.\\nIntraperitoneal Enucleation. This operation is adapted for single\\ntumors of moderate size. The uterus should be brought well forward\\ninto the wound and be surrounded by a gauze compress wrung out of", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0554.jp2"}, "543": {"fulltext": "MYOMA.\\n513\\nwarm sterilized water. As a provisional hemostatic precaution the\\nuterus is constricted by an elastic cord above the cervix (Fig. 35\u00c2\u00b0)-\\nThe uterine tissue covering the tumor is then incised at a point where\\nFig. 350.\u00e2\u0080\u0094 Enucleation of an interstitial myoma a, disposition of sutures after enucleation (after Pozzi).\\nthe large vessels can be avoided, when the tumor can easily be shelled\\nout from its bed with the fingers or with the aid of blunt instruments.\\nOccasionally strong septa of fibrous tissue passing from the adjacent\\ntissues into the tumor have to be cut with\\nscissors. Bleeding points are at once ligated\\nwith catgut. When the cavity is large Martin\\nuses a cross-drain passed through the cervix\\ninto the vagina. The cavity is closed by\\nseveral rows of catgut sutures, as shown in\\nFigure 350, a. It has happened in 10 cases\\nout of 16 in Martin s practice that the uterine\\ncavity was opened. He recommends suturing\\nof the mucous membrane with a continuous\\ncatgut suture. The writer has had excellent\\nresults from tamponing the cavity with a long\\nstrip of iodoform gauze which was brought\\ninto the vagina through the cervix as shown\\nin Figure 351. The wound over the gauze tampon is sutured in the\\nsame manner as after Cesarean section.\\nThe gauze tampon answers an excellent purpose in arresting the\\n33\\nFig. 351. Vaginal drainage of\\ncavity after intraperitoneal enucle-\\nation.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0555.jp2"}, "544": {"fulltext": "514 PATHOLOGY AND TREATMENT OF TUMORS.\\nparenchymatous oozing, and serves also as an efficient capillary drain.\\nIt should not be removed before the third or fourth day after operation.\\nIn favorable cases several subserous and interstitial myofibromata\\ncan be removed successfully by enucleation. Should the hemor-\\nrhage prove troublesome, the wound can be made extraperitoneal\\nby suturing the margins of the visceral wound to the margins of\\nthe external wound, after which the hemorrhage can be controlled\\nby the antiseptic tampon placed under the provisional deep su-\\ntures.\\nLaparo-hysterectomy. Laparo-hysterectomy has been performed too\\nfrequently in the treatment of myofibromata. It is a mutilating opera-\\ntion, and as such it should be limited to cases not amenable to success-\\nful treatment by less heroic measures. The operation includes the\\nremoval of a part or the whole of the uterus with the tumors in one\\nmass. This operation is undergoing rapid changes in its technique.\\nThe methods now being discussed and advocated by different surgeons\\nare (1) Complete laparo-hysterectomy; (2) Partial hysterectomy with\\nintraperitoneal treatment of the stump and (3) Partial hysterectomy\\nwith extraperitoneal treatment of the stump.\\nComplete Abdominal Hysterectomy. Bar, Krug, and others have\\ntaken advantage of Trendelenburg s position in the complete removal\\nof the uterus for myofibroma. The operation is not a difficult one, as,\\nafter tying off the broad ligaments and ligation of the uterine arteries,\\nhemorrhage is under control, and Trendelenburg s position secures\\nready access to the floor of the pelvis in suturing the pelvic wound.\\nIt is well known, however, that myofibromata of the uterus, with few\\nexceptions, involve the upper part of the organ, and that the cervix\\nand the lower part of the uterus are free, and do not require removal\\non account of pathological indications. The best surgery is always\\nconservative surgery. In operations for benign tumors healthy organs\\nor parts of healthy organs should not be sacrificed unnecessarily. The\\nwriter is inclined to believe, notwithstanding the satisfactory results of\\nthis operation so far as the mortality is concerned, that its popularity\\nwill be of short duration.\\nLaparo-hysterectomy with Lntra-abdominal Treatment of the Pedicle.\\nThis operation, which was introduced by Schroder, has been but little\\nmodified since his time. The broad ligaments in each side are tied off\\nwith two or three separate ligatures of silk or with the chain ligature\\n(Fig. 352) before they are cut between the ligatures and compression-\\nforceps on the uterine side. After the uterus has been brought well\\nforward upon the surface of the abdomen it is constricted above the\\ncervix with a strong rubber cord. The uterus is then surrounded with", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0556.jp2"}, "545": {"fulltext": "MYOMA.\\n515\\ncompresses of guaze, which are also made use of to prevent intestinal\\nprolapse. The incisions through the uterus below the tumors are\\nthen made behind and in front in an oblique downward direction,\\nFig. 352.\u00e2\u0080\u0094 Chain ligature (after Pozzi) a, separate ligatures as introduced, showing the method of looping;\\nb, the same, tied.\\nso that the lower portion of the part removed presents the shape\\nof a wedge. All visible vessels are tied. The mucous membrane\\nbelow the cone-shaped excision, to the depth of half an inch or\\nFig. 353. Schroder s intraperitoneal suture of pedicle S, deep suture, passed at once under the whole\\nbleeding surface; C, continuous suture of catgut in different terraces, bringing together the whole wounded\\nsurface, whose lower portion is marked by the heavy line a a, formed by the cauterized uterine cavity\\nP, peritoneal investment.\\nmore, is either cauterized or excised, after which the wound is sewed\\ntransversely with several rows of catgut, as shown in Figure 355.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0557.jp2"}, "546": {"fulltext": "5i6\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nFig. 354. Vaginal drainage with a cross tube after\\nabdominal hysterectomy (after Martin).\\nThe last row of sutures brings the serous surfaces over the wound\\nin accurate contact (Fig. 354). After a careful toilet the pedicle\\nis dropped and the external in-\\ncision is closed. The two great\\ndangers which attend this opera-\\ntion are hemorrhage and sepsis.\\nMartin aimed to reduce these\\ndangers to a minimum by estab-\\nlishing drainage from the cul-de-\\nsac into the vagina. The danger\\nof infection is always greater when\\nthe uterine cavity is opened.\\nSchroder s operation is an ideal\\none, and it is to be hoped that the\\ntechnique will become so perfect\\nthat it will yield as good results\\nas when the pedicle is treated by\\nthe extraperitoneal method.\\nLaparo-liysterectomy with Ex-\\ntraperitoneal Treatment of the Ped-\\nicle. The extraperitoneal treatment of the pedicle aims to eliminate\\nor to minimize the danger from hemorrhage and sepsis. G. Kimball\\nfirst proposed abdominal hysterectomy for interstitial myofibroma,\\nand his patient recovered. He was followed by Koeberle and Pean in\\nrapid succession. The uterus is liberated in the manner described\\nabove. Elastic constriction as a prophylactic hemostatic agent is also\\nemployed. Koeberle secured the pedicle with an instrument of his\\nown device, the serre noend, which is still quite extensively used. It is\\na miniature wire ecraseur, with which he constricted the pedicle, tight-\\nening the wire loop from time to time until it cut its way through the\\ntissues this result was generally accomplished in from twenty to\\ntwenty-five days. Hegar modified the operation in so far that he\\nexcluded the peritoneal cavity from the mortifying stump by suturing\\nthe pedicle below the constricting elastic ligature to the parietal perito-\\nneum of the margin of the wound this modification marked a decided\\nadvance in the extraperitoneal treatment of the pedicle. Koeberle s\\nwire loop and the elastic ligature used by most surgeons in the extra-\\nperitoneal treatment of the pedicle to control hemorrhage and to effect\\ngradual division of the pedicle are objectionable, as they invariably give\\nrise to necrosis or sloughing of the stump a condition which has been\\na frequent remote source of infection and of ventral hernia, and which\\nprevents rapid healing of the wound.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0558.jp2"}, "547": {"fulltext": "MYOMA.\\n517\\nIf the amputation has to be done close to the cervix in cases in\\nwhich the uterus is not much elongated, harmful and painful tension\\nhas been one of the drawbacks of Hegar s operation. The writer\\naimed to overcome this difficulty by making, below the level of the\\nrectum, through the broad ligaments, a peritoneal cuff long enough to\\npermit the balance of the pedicle to recede, and at the same time to\\nshut out completely the peritoneal cavity. A circular incision is made\\nthrough the peritoneum, at a point corresponding with that at which the\\nbroad ligaments have been divided. The peritoneum is then, with the\\nfingers and by means of blunt instruments, peeled off from the pedicle\\nto the point at which it is desired to apply the elastic constrictor that\\nis, beyond the limits of the part to be removed. If the incision is not\\nextended into the muscular tissues, this part of the operation is attended\\nby very little hemorrhage. The peritoneal cuff is now sutured with\\ncatgut to the parietal peritoneum all around in the lower angle of the\\nincision, and the balance of the incision is closed (Fig. 355). A solid!\\nFig. 355.\u00e2\u0080\u0094 Extraperitoneal abdominal hyster-\\nectomy elastic constrictor in place; balance of\\nwound sutured.\\nFig. 356. Extraperitoneal abdominal hysterectomy\\noperation completed.\\nrubber cord is now tied firmly around the denuded pedicle, and the\\nuterus is amputated about an inch above it. Thorough cauteriza-\\ntion of the stump and of the uterine cavity as far as the elastic ligature\\nis advisable. Gauze is now packed around the pedicle as far as the\\nbottom of the peritoneal cuff, after which the usual external dressing is\\napplied (Fig. 356). As the pedicle is not fixed with pins or needles, it\\nsinks back and all tension is avoided. The writer made nineteen con-\\nsecutive operations by this method, and not only did all the patients\\nrecover, but they never complained of a single untoward symptom.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0559.jp2"}, "548": {"fulltext": "5i8\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe ligature with the stump usually came away about the twenty-fifth\\nday, after which the wound rapidly healed. This peritoneal cuff is\\ntransformed into a solid string which makes no traction on the scar, and\\nwhich so far has not given rise to ventral hernia.\\nThe only drawback of this method of operating is the inevitable\\nnecrosis or sloughing of the stump, something in common with Hegar s\\nand Koeberle s operations. The writer has recently abandoned the\\nelastic ligature, and instead has resorted to ligation of the uterine\\narteries and suturing of the cut surface the results have been very\\nsatisfactory. The operation is performed in the manner just described\\nuntil after the amputation of the uterus. The elastic constrictor may be\\nFig. 357.\u00e2\u0080\u0094 Extraperitoneal abdominal hysterectomy without the use of the elastic constrictor or the wire\\nloop operation completed.\\ndispensed with if both uterine arteries are tied immediately after they\\nare divided, and parenchymatous oozing is arrested by suturing the cut\\nsurface with several rows of catgut sutures. A small strip of mucous\\nmembrane is then excised, after which the cut surfaces are brought\\ntogether with several rows of catgut sutures (Fig. 357). The pedicle\\nis accessible at all times in case of hemorrhage. By abandoning the\\nelastic ligature sloughing of the stump is avoided and the wound heals\\nby primary intention. The space around the sutured pedicle is packed\\nwith iodoform gauze. Secondary sutures are in place, and are pro-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0560.jp2"}, "549": {"fulltext": "MYOMA.\\n5 J 9\\nvisionally tied in a loop over the gauze packing. On the second day\\nthe gauze is removed and the sutures are tied.\\nA little oozing has been observed in several cases operated upon by\\nthis method. In some of the cases the external gauze dressing had\\nto be changed at the end of the first twenty-four hours. All the\\npatients operated upon by this method recovered without any compli-\\ncations whatever. Until the intraperitoneal treatment of the pedicle\\nhas been made safer, the writer regards this method of disposing of\\nthe pedicle preferable, as it gives the surgeon access to it should any\\ncomplications set in.\\nBroad Ligament. Myofibroma of the uterus not infrequently\\nextends between the folds of the broad ligaments, and the tumor\\nbecomes in part intraligamentous, greatly complicating the operations\\nfor its removal. As the connective tissue of the broad ligament con-\\ntains unstriped muscular fibres, it is not surprising that occasionally\\nthere is met with in this locality a myoma which has developed inde-\\npendently of the uterus. Tumors in the broad ligament seldom attain\\ngreat size and usually give rise to but little disturbance, but occasion-\\nally they rapidly increase in size and produce pressure-symptoms which\\nmay require operative interference. The tumors occurred in women\\npast thirty-five years of age in the eleven cases so far reported. In one\\ninstance the tumor weighed sixteen pounds usually the tumors did\\nnot exceed the size of a fist.\\nFig. 358.\u00e2\u0080\u0094 Myofibroma in the broad ligament decortication and suture of the cavity and drainage by the\\nvagina (after Martin).\\nIt would be next to impossible to diagnosticate a myoma of the\\nbroad ligament without an exploratory laparotomy. If such a tumor", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0561.jp2"}, "550": {"fulltext": "520\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nis revealed by an exploratory laparotomy and its removal is deemed\\nnecessary, this should be done by enucleation. Large vessels should\\nbe avoided so far as possible in cutting down upon the tumor. The\\nenucleation is to be done exclusively with the fingers and with blunt\\ninstruments. If the cavity is not large, the wound can be sutured after\\nthe hemorrhage has been arrested completely. If parenchymatous\\noozing is troublesome or if the cavity is large, drainage into the vagina\\nby means of a cross-tube, as advised by Martin and Kaltenbach, should\\nbe resorted to (Fig. 358). The wound is sutured throughout with special\\nreference to bringing the serous surfaces in accurate apposition. Infec-\\ntion from the vagina is prevented by iodoform-gauze packing, which\\nshould also embrace the distal end of the tube. The drain may be\\nremoved as soon as all discharge from it has ceased.\\nFig. 359. Subserous myofibroma of Fallopian tube (after Winckel).\\nFallopian Tube. Myofibroma of the Fallopian tube is exceedingly\\nrare. Winckel describes such a specimen (Fig. 359). In this instance\\nFig. 360. Myofibroma of the round ligament (after Heydemann).\\nthe tumor was small, oblong, and immediately underneath the peri-\\ntoneum. Sutton saw only one specimen, and in this case the myoma\\nwas associated with dermoid cyst of one of the ovaries. The tumor,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0562.jp2"}, "551": {"fulltext": "MYOMA. 521\\nwhich was of the size and shape of a Tangerine orange, involved the\\nwhole thickness of the tube.\\nRound Ligament. The first operation for myofibroma of the round\\nligament was performed by Sir Spencer Wells in 1865. In the year\\n1882 Sanger collected 12 cases, and classified tumors of the round\\nligament according to their anatomical location into (1) intraperitoneal,\\n(2) intracanalicular, (3) extraperitoneal. In the 12 cases reported by\\nSanger the tumor was intraperitoneal in only 3, on the left side twice,\\nand on both sides once. If the tumor occupies the inguinal canal, it\\nsimulates very closely an irreducible inguinal hernia. Such cases have\\nbeen reported by Polaillon, Heydemann, and others. The differential\\ndiagnosis of intraperitoneal tumors of the round ligament and myo-\\nfibroma of the uterus can only be made by a direct examination through\\nan abdominal incision.\\nAlimentary Canal. Myomatous tumors of the alimentary canal\\nare rare.\\nPharynx. Myomata of the posterior wall of the pharynx have\\nbeen described by Middeldorpf. They are either sessile or pedunculated.\\nThe sessile tumors cause pressure-symptoms of various kinds accord-\\ning to their size and location. Polypoid growths, from their mobility,\\noften produce acute attacks of dyspnea, and even death, when they\\nbecome displaced into the entrance of the pharynx. They should be\\nremoved with the galvano-caustic wire, as their point of attachment is\\nusually so low down that arrest of hemorrhage by other measures\\nusually proves inefficient. The tumor is made accessible by exciting\\nvomiting the tumor is then seized and drawn out at one angle of the\\nmouth, when the wire loop is pushed over it and adjusted.\\n(Esophagus. Hilton Fagge reports the cure of a myomatous tumor\\nof the oesophagus in a man thirty-eight years of age. The tumor was\\nsituated in the anterior wall just below the level of the bifurcation of\\nthe trachea. Virchow refers to a specimen which he found at the\\ncardiac end of the oesophagus. In neither of these cases -was the\\ntumor pedunculated.\\nStomach. Virchow makes the statement that myomata are more\\nfrequent in the stomach than in any other part of the digestive tract.\\nWe have already referred to a myoma of the stomach that was con-\\nverted into a sarcoma. If the tumor should occupy the pyloric\\nextremity and produce obstruction, a gastro-enterostomy should be\\nperformed in preference to making an attempt to remove the tumor\\nby enucleation or by excision.\\nSmall Intestines. Myoma of the small intestines has been described\\nby Flenier, Aufrecht, Wesener, and Bottcher. In Flenier s case the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0563.jp2"}, "552": {"fulltext": "522 PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor produced invagination, and enterectomy was performed success-\\nfully by Czerny. In nearly all cases which have so far been reported\\nthe tumors were located in the upper part of the intestinal canal.\\nRectum. The rectum is more frequently the seat of myoma than\\nany other part of the intestinal canal. On the mucous surface the\\ntumors appear either as sessile tumors or as polypoid growths.\\nKonig removed a pedunculated tumor in the region of the prostate\\ngland in a man in a girl eighteen years of age he removed a myoma-\\ntous tumor with a long pedicle. A few years ago the writer removed\\nby laparotomy a subserous myoma from the rectum of a woman\\nforty-five years old. The probable diagnosis was either a peduncu-\\nlated myofibroma of the uterus or a dermoid cyst of the ovary. The\\ntumor, which had been growing for ten years, was movable. From\\nits size it produced distressing pressure-symptoms. On opening the\\nabdominal cavity a smooth, hard, movable tumor was found, covered\\nby peritoneum. In seeking for its attachment a broad pedicle was\\nfound behind the uterus and extending in the direction of the pelvis.\\nUterus, ovaries, and tubes were normal. The peritoneum was incised\\nwhere the pedicle appeared to be narrowest, and the tumor was enucle-\\nated. As soon as the tumor was removed gas escaped, and an exam-\\nination revealed, in the anterior wall of the rectum, an opening large\\nenough to admit two fingers. With a moist compress the intestines\\nwere protected, and after cleansing the wound an attempt was made to\\nclose the opening by suturing. Owing to the depth of the rectal open-\\ning the suturing was unsatisfactory. A large drain was placed vis-a-vis\\nwith the sutured place and was brought out at the lower angle of the\\nwound. Iodoform gauze was packed around the tube. The remain-\\ning part of the external incision was sutured. On the second day gas\\nand feces escaped otherwise there were no untoward symptoms. The\\nintestinal fistula swelled in the course of a few weeks, after which the\\npatient recovered quickly and perfectly, and remains well at the present\\ntime. Microscopical examination of sections of the tumor showed the\\ntypical structure of myofibroma.\\nBladder. According to Virchow, myoma of the bladder can\\ndevelop only in the prostatic portion of the urethra and the base of the\\nbladder. Belfield s investigations have shown that myomata of the\\nbladder not only occur as tumors projecting into the bladder, but that\\nthey also may grow in the direction of the perivesical tissues. Myo-\\nmata of the bladder are comparatively rare. Terrier and Hartmann\\nhave recently gathered the particulars of 16 cases from different\\nsources. Of 15 cases in which the clinical history was given with\\nsufficient detail, there were 7 women and 8 men. The age varied from", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0564.jp2"}, "553": {"fulltext": "MYOMA. 523\\ntwelve to seventy-four years. In structure the tumors are in many\\nrespects analogous to uterine myofibromata. The tumor originates in\\nthe muscular layers of the bladder. Projection takes place most fre-\\nquently in the direction of the bladder. In the 16 cases reported this\\nwas the case in 10 instances; in 4 the growth was external; in 1\\ncase, a diffuse infiltration in 1 case growth occurred in both direc-\\ntions. The part of the bladder which the tumors occupy is most vari-\\nable six times they were in the region of the trigone three times in\\nthe anterior wall two were at the summit one in the posterior wall\\nand trigone one case included nearly the entire bladder-wall except\\nthe right side one was a multiple tumor, and invaded both the anterior\\nand the posterior walls. In size they varied from a walnut to that of\\na child s head. They appear either as rounded or lobulated tumors.\\nThey are likely to be pedunculated, but may be sessile or even infil-\\ntrative in the first instance they are easily removed. The presence of\\nthe tumor sooner or later causes cystitis, ureteritis, and obstructive\\nlesions of the kidney Pressure-symptoms are frequently present.\\nWhen the tumor projects into the bladder hematuria is one of the\\nmost frequent symptoms. Intravesical exploration does not always give\\nmuch assistance to reach a correct diagnosis. Hypogastric, vaginal,\\nand rectal palpation, and especially bimanual examination under the\\ninfluence of an anaesthetic, are much more satisfactory, and in most\\ninstances the site and size of the tumor can thus be determined. The\\ntreatment necessarily must vary according as the growth is external or\\ninternal. In the subperitoneal variety the usual rules of abdominal sur-\\ngery will apply. Removal by enucleation through an abdominal incis-\\nion and suturing of the visceral wound will usually lead to a satisfactory\\nresult. In the intravesical form removal by perineal section, vaginal\\nsection, and hypogastric section, or combinations of these, have each\\ntheir advocates. At the present time, however, the advantages of hypo-\\ngastric section, as shown by Guyon, are especially marked in the re-\\nmoval of this form of tumor. Knox and Gussenbauer observed cystic\\ndegeneration in vesical myomata, and Volkmann observed partial necro-\\nsis. Konig removed through a perineal incision a tumor the size of a\\npigeon s egg from the caput gallinaginis in a boy twelve years old.\\nVolkmann removed a similar tumor by suprapubic cystotomy.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0565.jp2"}, "554": {"fulltext": "XXVII. NEUROMA.\\nDefinition. A neuroma is a tumor composed of nerve-tissue pro-\\nduced from a matrix of neuroblasts or fibroblasts, according to the\\nanatomical structure of the tumor. Virchow made a distinction between\\nbenign nerve-tumors according as the tumor is composed of medul-\\nlated or of non-medullated nerve-fibres, designating the former neur-\\noma myelinicum, and the latter neuroma amyelinicum. This anatomical\\ndistinction is retained at the present time. By far the greatest number\\nof benign tumors of the nerves belong to the amyelinic variety, as\\nthey do not contain a numerical increase of medullated nerve-fibres.\\nSome of these tumors have already been discussed in the section on\\nFibroma. The nerve-sheaths not infrequently contain matrices of fibro-\\nblasts from which true fibromata develop, the pre-existing nerve-fibres\\nbeing simply an accidental anatomical constituent of the tumor. In\\nother cases the fibrous tissue is more intimately intermingled with\\nterminal nerve-fibres, as in cases of amputation-neuroma.\\nEmbryology. In the embryo the neural canal consists at first of\\na solid cylinder of epithelial cells developed from the epiblast. During\\nthe differentiation of these cells there forms a supporting frame-\\nwork of which the neuroblasts constitute the essential element. They\\nare the germinal cells of His, and they multiply by karyokinesis.\\nFurther differentiation of the neuroblasts results in the formation of\\nganglion-cells and conducting cells. The conducting cells, which are\\nconnected with nerve-fibres and acquire sheaths of greater or lesser\\nthickness, are known as the medullated and the non-medullated fibres.\\nIn the central nervous system the connective tissue is represented\\nby neuroglia. Ranvier asserts that the processes of the pia mater and\\nthe vessels are surrounded by a sheath of neuroglia. It is, however,\\ndifficult to determine just where the connective tissue ends and the\\nneuroglia begins. In the brain and the spinal cord the connective-\\ntissue tumors, benign and malignant, develop from the neuroglia.\\nBiirgner and Klebs regard the nuclei and the protoplasm of the sheath\\nof Schwann as neuroblasts. From these neuroblasts new nerve-fibres\\nare produced in the case of myelinic neuroma, and the proliferation\\nfrom them is concerned in the repair of nerves after injury or disease.\\nHistology and Histogenesis. The structure and origin of a neur-\\n524", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0566.jp2"}, "555": {"fulltext": "NEUROMA.\\n525\\noma depend upon the nerve-trunk or the part of the central nervous\\nsystem from which the tumor springs. A tumor produced from nerve-\\ncells or neuroblasts is composed very largely of nerve-tissue, whereas\\na tumor produced by proliferation of neuroglia or from fibroblasts\\ncontained in the nerve-sheath is more akin to a fibroma than to\\na neuroma. Virchow classifies neuromata as follows\\n1. Hyperplastic fascicular neuroma:\\na. White, containing medullated\\nnerve-fibres\\nj b. Gray, containing non-medul-\\nv. lated nerve-fibres.\\n2,\\nHyperplastic medullary neuroma, usually occurring in the brain or\\nas a congenital tumor.\\n3. Heteroplastic medullary neuroma, found in the ovary by Virchow\\nand Gray, found in the testicle by Verneuil.\\nThe majority of neuromata are simply fibrous tumors lying along\\nthe course of a nerve or attached to the nerve-terminations in a stump.\\nTrue nerve-tumors are most common on\\nthe ears, the eyelids, and the side of the\\nface. They usually have a plexiform ap-\\npearance, and these ramifications can be\\nfelt under the skin (Fig. 361). The tumor\\nconsists of a fibrous framework through\\nwhich run bundles of nerve-fibres, some\\nof them completely medullated, others\\nonly partially so (Fig. 362). Large gan-\\nglion-cells with characteristic nuclei and\\nnucleoli are also sometimes found im-\\nbedded in the tumor-mass. Waldenstrom,\\nwho doubts the correctness of Virchow s\\nidea that a neuroma is composed largely\\nof nerve-fibres without medullary sheath,\\nregards them as fibromata originating from\\nthe interstitial connective tissue.\\nWestphal has traced neuromata of the\\nskin to the endoneurium. The nerve-fibres\\nin neurofibromata undergo a change which\\nis conceded by nearly all observers, in that the medullary sheath under-\\ngoes atrophy, and that the nerve-sheaths become the seat of hyaline\\ndegeneration, which was first noticed and described by Schuster. The\\nenlargement of a nerve-end in amputation-neuroma is due to an abun-\\ndant formation of small myelinic fibres produced from the neuroblasts\\nFig.\\n61. Portion of a neuroma from\\nthe right ear (after Bruns).", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0567.jp2"}, "556": {"fulltext": "526\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwhich have been exposed for a long time to irritation caused by cica-\\ntricial tissue. It is well known that an amputation-neuroma will only\\ndevelop in connection with scar-tissue and the irritation incident to the\\nk\\nw\\nFig. 362. Transverse section of a painful subcutaneous tubercle (Surgical Clinic. Rush Medical Col-\\nlege, Chicago) a, fine connective-tissue reticulum b, axis-cylinders c, nerve-bundle cut transversely\\nd. neurilemma, somewhat thickened.\\nconditions producing it. Witzel has recently shown that in many cases\\nthe neuroma is found attached to the end of the bone in the stump.\\nThe tumor presents itself in the form of a bulbous enlargement of the\\nend of the nerve, which closely resembles a spring onion in outline\\n(Fig. 363). Cross-sections of such tumors show the numerical increase\\nof myelinic nerve-fibres (PL 13, Fig. 1). Under the same influence the\\nfibroblasts proliferate and greatly increase the amount of connective\\ntissue, producing thus a true neurofibroma. In the majority of cases\\nthe tumor is limited and forms the bulbous extremity of the nerve\\nin some instances, as in the case reported by Hayem and Gilbert, the\\nnerve is at this time enlarged for a very considerable distance, the\\nenlargement being due to an abundant formation of small myelinic\\nfibres and to hyperplasia of the pre-existing interstitial connective\\ntissue.\\nEvery surgeon of large experience knows that an amputation-", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0568.jp2"}, "557": {"fulltext": "NEUROMA.\\nPlate 13.\\nOMR.\\nSimple neuroma after amputation (after Boyce) a and nerve-bundles c, connective tissue. (Obj. I inch\\nosmic acid.) 2. Neuroma of the fourth ventricle (after Klebs). (Nigrosin and hematoxylin Zeiss.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0569.jp2"}, "558": {"fulltext": "", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0570.jp2"}, "559": {"fulltext": "NEUROMA.\\n527\\nneuroma in some cases is exceedingly prone to return after excision,\\nand these cases are undoubtedly those in which the nerve is enlarged\\nfar beyond the bulbous extremity. The writer has known instances in\\nb\u00e2\u0080\u0094~\\nFig. 363.\u00e2\u0080\u0094 Amputation-neuroma (after Karg and Schmorl). Upon the crural nerve (a) is seen the bulbous\\ntumor (b), which has been produced by proliferation of the bundles of nerve-fibres. The tumor is composed\\nof interlacing myelinic nerve-fibres at c is seen a bundle of nerve-fibres which is divided into numerous\\nfilaments in a downward direction.\\nwhich such neuromata were excised four and five times, and an early\\nrecurrence of the pain, with return of the tumor, followed each opera-\\ntion. In one case a cure was finally effected by excising four inches of\\nthe sciatic nerve, far beyond the apparent limits of the tumor.\\nKlebs is of the opinion that neuromata of the central nervous\\nsystem are not composed, as is usually asserted, of cells derived exclu-\\nsively from neuroglia, but that the nerve-cells take an active part in\\ntheir development (PL 13, Fig. 2). He consequently regards them not\\nas histioid but as organoid tumors. He proposes the name neuro-", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0571.jp2"}, "560": {"fulltext": "528 PATHOLOGY AND TREATMENT OF TUMORS.\\nglioma in place of glioma. With due deference to the weight of\\nopinion of this author, it must be maintained that in glioma the\\nneuroglia-proliferation furnishes the bulk of the tumor, and that the\\nnerve-cells constitute an accidental product incident to the increased\\nvascularity caused by the tumor-formation.\\nThe mesenteric nerves are occasionally the seat of diffuse miliary\\nfibromyxomatous neuromata (Fig. 364).\\nFig. 364. Miliary fibromyxomatous neuromata of the mesenteric nerves; X 50 (after Perls). In the\\nnodule (a) the nerve passes unchanged through the centre of the swelling; in b it is separated by myxomatous\\ndegeneration of the perineurium into two bundles in c its fibrillar are separated.\\nNeurofibroma is occasionally diffuse, following different nerve-trunks,\\nwhen it is called a plexiform neurofibroma. The tumors often attain", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0572.jp2"}, "561": {"fulltext": "NEUROMA.\\n529\\noreat size, imbedding the nerve-trunks in large masses of fibrous tissue\\n(Fig. 365). Marchand, who reports two cases of this affection, regards\\nthe tumor as a cylindrical fibroma of the nerve-sheaths. In one case,\\nFig. 365. Plexiform neurofibroma of the plexus pudendus and ischiadicus, one-fourth natural size (after O\\nWeber). The whole mass forms a tumor weighing several pounds.\\na boy twelve years old, the tumor involved the upper lid of the left eye\\nand the adjacent part of the temporal region at the same time it pene-\\ntrated deeply into the orbital cavity. It was first noticed when the child\\nwas six months old. The second case was a boy eight years old. The\\ntumor was soft, extended from a point behind the right ear in the direc-\\ntion of the temporal region and beyond the parietal eminence, and\\nprojected an inch beyond the surrounding skin. The tumor in each\\ncase was composed of convoluted cords which contained remnants of\\n34", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0573.jp2"}, "562": {"fulltext": "530 PATHOLOGY AND TREATMENT OF TUMORS.\\nnerve-fibres. Schwann s sheath was intact, consequently the tumor\\nmust have developed from the perineurium, with participation of the\\nwalls of the blood-vessels. In the only case of plexiform neurofibroma\\nthat has come under the writer s observation, the tumor, which occu-\\npied the palmar side of the hand and extended along the branches of\\nthe median nerve which supply the thumb and the index finger, was\\nseveral inches in length, quite hard, and presented the characteristic\\nconvoluted appearance. The tumor was extirpated, and did not return\\nafter the operation.\\nRegressive Metamorphoses. With the exception of plexiform\\nneurofibroma, benign tumors of nerves do not attain large size. After\\nthey reach the size of a hemp-seed or that of a walnut they remain\\nstationary. They are not much disposed to\\nregressive metamorphosis. Besides hyaline\\nand myxomatous degeneration, no other\\nretrograde pathological changes have been\\nobserved. The liability of a neuroma to\\nbecome transformed into a sarcoma is\\nperhaps a little greater than that of a sim-\\nple fibroma, more especially in cases in\\nwhich the tumor has undergone myxoma-\\ntous degeneration.\\nEtiology. In many instances neuroma\\nappears as a congenital tumor, particularly\\nthe heterotopic variety and plexiform neur-\\noma. Plexiform neuroma has usually been\\nmet with in young persons, and the growth\\nof the tumor was in most instances referred\\nto infancy or early childhood. The heredity of neuroma, like that of\\nmany other forms of benign tumors, is unquestionable. The heredity\\nof multiple neurofibromata is particularly well marked. Chronic\\ninflammatory affections of the nerve-sheaths or of tissues in close\\nproximity to nerve-trunks is a potent exciting cause. The trau-\\nmatic influence in the etiology of neuroma is well shown in the\\ncase of amputation-neuroma. Wounds and contusions may exert a\\nsimilar influence in exciting a latent tumor-matrix to active tissue-\\nproliferation.\\nSymptoms and Diagnosis. The symptoms produced by a neur-\\noma consist in varying degrees of functional disturbance of the nerves\\nwhich are the seat of the tumor. With the exception of amputation-\\nneuroma and the subcutaneous painful tubercle, pain and tenderness\\nare not conspicuous symptoms unless the tumor causes nerve-compres-\\nFig. 366. Fibromyxomatous tis-\\nsue from specimen shown in Figure\\n372 X 250.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0574.jp2"}, "563": {"fulltext": "NEUROMA. 531\\nsion, as when the tumor is located in a bony channel through which\\nthe nerve passes. In multiple neurofibromata of the skin pain and ten-\\nderness are usually absent. In some cases in which pain is absent it\\ncan be produced by pressure. With the exception of plexiform neur-\\noma, the tumor is circumscribed, encapsulated, and movable it is\\nsmooth, and often is spindle-shaped. In multiple neurofibromata the\\ndiagnosis is not difficult, as tumors can be felt in the course of different\\nnerves. A plexiform neuroma can be distinguished from an arterial\\nangioma by the size of the tumor, by its undergoing no changes under\\npressure, by placing the part in different positions, and by the absence\\nof pulsations and bruit.\\nPrognosis. The prognosis in neuroma is favorable, aside from\\nthe liability of the tumor to undergo transformation into sarcoma.\\nThe tumor does not involve adjacent tissues, and metastasis has never\\nbeen observed. In the painful varieties the general health of the\\npatient is often undermined by the loss of sleep and by inadequate\\nout-door exercise. The rapid growth of a neuroma that has been sta-\\ntionary for a long time is a probable indication that malignant trans-\\nformation has occurred.\\nTreatment. Operative treatment in multiple neurofibromata is con-\\ntraindicated unless some of the tumors should cause pain by pressure,\\nwhen, if accessible, such nodules are to be removed by excision.\\nAmputation-neuroma must be excised with the surrounding scar-tissue,\\nand the section of the nerve must be made beyond the limits of the\\ndisease. If the nerve above the bulbous tumor is enlarged, it must be\\nfollowed sufficiently far and excised with the tumor in order to guard\\nagainst a- recurrence of the neuroma. A plexiform neuroma must be\\nexcised if all parts of the tumor can be reached, as eventually the\\ntumor may attain great size, and the nerves imbedded in the fibrous\\nmass are destroyed in the course of time. Painful subcutaneous\\ntubercles should be excised. The removal of circumscribed tumors\\nof nerve-trunks must be effected without destroying the continuity of\\nthe nerve. This can be done without difficulty by enucleation. After\\nthe affected nerve has been exposed the capsule of the tumor is\\nincised in the direction of the nerve-fibres and the tumor is enucleated.\\nThe writer recently removed from the median nerve above the wrist-\\njoint a tumor the size of a hickory-nut. The patient was a girl twenty\\nyears of age, and the tumor had been growing for five years. It was\\ncentrally located. On the surface of the tumor could be seen bundles\\nof nerve-fibres. The capsule of the tumor was incised between the\\nvisible nerve-fibres, after which the tumor was enucleated without diffi-\\nculty. The nerve-sheath was sewed with fine catgut. The wound.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0575.jp2"}, "564": {"fulltext": "532 PATHOLOGY AND TREATMENT OF TUMORS.\\nwhich was sutured throughout and was then sealed with aseptic cotton\\nand iodoform collodion, healed by primary intention. The pain and\\nthe prickling sensations which the tumor had produced disappeared\\nslowly after the operation.\\nTopography.\\nMultiple Neurofibromata. Superficial multiple neurofibromata of\\nthe skin have been described in the section on Fibroma. The relation\\nof these tumors to the nerve-sheath was first pointed out by Reckling-\\nhausen. The deeper nerves are occasionally the seat of multiple neuro-\\nfibromata in which nearly all the nerves of the body may become\\ninvolved. The tumors are due to multiple matrices of fibroblasts or\\nof fibroblasts and neuroblasts.\\nSorzka does not believe that the development of multiple neuro-\\nfibromata is caused by metastasis, as has been claimed by some authors\\nhe attributes them to a congenital disposition of the nerves, so that the\\ntumors may appear simultaneously or in rapid succession at different\\npoints independently of the primary tumor. In nearly all cases the\\npatients were children or young adults.\\nHeusinger records the case of a sailor twenty-three years old in\\nwhom all the nerves were affected by numerous nodular enlargements.\\nNot a nerve in the entire body was found normal. The enlargements\\nwere caused by increase in the connective tissue. The axis-cylinders\\nwere normal. There was neither pain nor tenderness.\\nPrudden reports the case of a girl twenty-five years of age who\\nduring convalescence from variola became paraplegic, and during this\\ntime multiple neuromata appeared. At the post-mortem more than\\na thousand tumors were found, affecting not only the peripheral\\nbranches and the sympathetic, but also the cranial nerves and the\\npneumogastric. Under the microscope these tumors showed an enor-\\nmous increase of the intrafascicular as well as the perivascular con-\\nnective-tissue fibres. The nerve-fibres were not increased in size or in\\nnumber. Only one tumor, in connection with a branch of the lumbar\\nplexus, contained within its capsule cells resembling ganglion-cells of\\nthe sympathetic nerve.\\nVirchow collected thirty cases of multiple neurofibromata, which he\\ncalls general neuromatosis. In one case he found five hundred, in\\nothers from eight hundred to a thousand, tumors.\\nIn multiple neurofibromata operative treatment is contraindicated\\nunless one or more of the tumors, occupying localities in which pain\\nfrom pressure is produced, are accessible, in which case the tumors\\nshould be excised.", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0576.jp2"}, "565": {"fulltext": "NEUROMA. 533\\nCranial Nerves. The cranial nerves are frequently the seat\\nof neuromata. If the tumor occupies that part of a nerve which\\npasses through a bony canal, intense pain, usually diagnosticated and\\ntreated as neuralgia, is the result. Sensory nerves are more fre-\\nquently affected than motor nerves. According to Virchow, among the\\nnerves of special sense the acoustic nerve is the most frequent seat of\\nneuroma. Neuroma of the facial nerve is exceedingly rare. Jocqs col-\\nlected sixty-two cases of neuroma of the optic nerve. Myxofibroma is\\nthe kind of tumor most frequently found in this locality. Myofibromata\\ndo not extend to the globe, but are apt to involve the intracranial por-\\ntion of the nerve. They are painless tumors, but affect and destroy\\nvision at an early stage. Perls has described a true neuroma of the\\noptic nerve the size of a hen s egg. The new nerve-fibres were not\\nsupplied, like the normal fibres of the optic nerve, with a nucleated\\nsheath. The specimen showed also that the new nerve-fibres were\\nformed, not by coalescence of spindle-cells, but by prolongations of\\nthe individual cells. Toynbee reported several cases of neurofibroma\\nof the acoustic nerve, and in every case the tumor produced progres-\\nsive deafness.\\nSpinal Nerves. The roots of the spinal nerves are frequently the\\nseat of neuroma. Owing to the depth of the location of the tumor,\\nit is seldom recognized during life. Chavasse reports a case in which\\nthe tumor, occupying the cervical region, was removed with a fatal\\nresult, the patient dying of septic spinal meningitis.\\nUpper Extremity. Neuroma of the axillary plexus has been\\nobserved and has successfully been removed. The operation in this\\nlocality is difficult, owing to the proximity of the large vessels and to\\nthe number of large nerve-trunks. The ulnar, radial, and median\\nnerves are more favorably situated for the successful removal of neur-\\nomata. The writer has referred to a case that came under his observ-\\nation, in which the tumor, which involved the median nerve just above\\nthe wrist, simulated ganglion almost to perfection. A case of plexi-\\nform neuroma of two digital branches of the same nerve has also been\\nalluded to by the writer.\\nLower Extremity. The sciatic nerve below its exit from the pelvis\\nis occasionally the seat of a neuroma, but is more frequently the seat\\nof neuro-sarcoma. Benign tumors may occur in any part of its course,\\nand are occasionally multiple (Fig. 367).\\nThe removal of tumors of a benign character from larsre nerve-\\ntrunks calls for special care. Nerve-resection is unjustifiable. The con-\\ntinuity of the nerve must be preserved. The tumor is exposed by an\\nincision parallel with the nerve if the tumor is centrally located, the", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0577.jp2"}, "566": {"fulltext": "534\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nmantle of overlying nerve-tissue is incised between the visible bundles\\nof nerve-fibres, after which the tumor is enucleated. In central neuro-\\nFig. 367. Lower extremity from a case of multiple neurofibromata one-third natural size (after Perls)\\na, superficial peroneal b, sural nerve c, superficial branches of saphenous major nerve d, tumor upon\\ndeep peroneal.\\nfibromata that are accessible to operation removal should be advised, as\\nthe pressure-atrophy caused by the tumor will ultimately destroy the\\nfunction of the nerve.\\nPlexiform Neuroma. Plexiform neuroma is always congenital.\\nThe tumor may not be detected at the time of birth, but it is always\\nfound in children and young adults, and the clinical history frequently\\ndates back to early infancy. In most of the cases that have been ex-\\namined carefully the mass of the tumor was composed of fibrous tissue\\nin which the nerves were found imbedded. Bruns found in some speci-\\nmens a marked increase of nerve-fibres. The tumors are found most\\nfrequently in the temporal region, the neck, and the side of the face,\\nbut they may affect almost any part of the body. Christot reports\\ntwo cases in which the tumors were located upon the cheek and the\\nneck. Czerny observed a case in which the tumor involved the lumbar", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0578.jp2"}, "567": {"fulltext": "NEUROMA. 535\\nplexus. In this case the patient was also the subject of a very large\\ncongenital fibroma of the skin. He found in the tumor, besides fibrous\\nFlG. 368. Arm in which the musculo-spiral nerve was neuromatous (after Campbell de Morgan).\\ntissue, new non-medul.lated nerve-fibres. Campbell de Morgan met\\nwith a plexiform neuroma of the musculo-spiral nerve and its branches\\n(Fig. 368). The patient was a young lady. The tumor, which was not\\npainful, had undergone myxomatous degeneration.\\nPlexiform neuromata are painless tumors which grow slowly, but\\nwhich may attain large size. The affected nerves become tortuous,\\nbecause they increase in length as well as in circumference. The rami-\\nfications correspond with the directions of the branches of the nerves\\nthat become successively involved. Thorough excision of the tumor\\nis the only proper surgical treatment.\\nVulva. Neuroma of the vulva is a pathological curiosity. In one\\ncase reported by Simpson the tumor appeared as a painful nodule near\\nthe urinary meatus. Another case is reported by Kennedy. In this\\ncase the tumor appeared as multiple subcutaneous tubercles exquisitely\\ntender to touch.\\nPrepuce. A number of authors have described a very painful\\nrecurring herpes of the prepuce, which they regarded as being of a\\nnature similar to herpes zoster (Hebra, Mauriac, Verneuil, Kaufmann).\\nThe attacks occur every four or five weeks, are preceded by pain in the\\nback and along the thighs, and subside in the course of a few days.\\nIn i860, Verneuil resorted to circumcision in the treatment of this\\nobstinate affection, and effected a permanent cure. He found in the\\nspecimen removed a peculiar form of neuroma {neurome cylindrique\\nplexiforme), which in its distribution and structure resembled plexiform\\nneuroma.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0579.jp2"}, "568": {"fulltext": "XXVIII. SARCOMA.\\nIt is less than fifty years since all malignant tumors were included\\nunder the one term carcinoma. Johannes Mueller found and de-\\nscribed in some malignant tumors spindle-shaped cells, but he regarded\\nthem as a variety of carcinoma-cells. A description of similar cells\\nwas later given by Valentin. Lebert in 1845 made these cells the basis\\nfor his fibroplastic tumor. In 1847, Virchow introduced the term\\nsarcoma, and upon a histological basis separated from carcinoma\\na large group of malignant tumors. He asserted that the spindle-cells\\nwere not characteristic of sarcoma, and he called attention to the dif-\\nferent forms of sarcoma-cells. He relied upon the relation of cells to\\nthe reticulum in making a differential diagnosis between carcinoma and\\nsarcoma. He placed special stress upon the absence of a well-marked\\nstroma and alveolar grouping of the cells. Follin called sarcoma\\nplasmome. Rindfleisch called attention to the histological resemblance\\nof sarcoma to granuloma. By degrees pathologists were brought to\\nadmit that under the term sc sarcoma must be included all malignant\\ntumors originating from tissue of mesoblastic origin. Carcinoma repre-\\nsents the malignant tumors of the tissues of epiblastic and hypoblastic\\norigin. Sarcoma represents the malignajit tumors of the tissues of meso-\\nblastic origin. As the typical tumor-element of the former the embry-\\nonal epithelial cell is recognized of the latter, the embryonal con-\\nnective-tissue cell is the prototype.\\nDefinition. Sarcoma is an atypical proliferation of connective-tissue\\ncells from a matrix of fibroblasts of congenital or post-natal origin.\\nThis definition acknowledges the connective tissue as the sole origin\\nof sarcoma. Histological investigations have shown that sarcoma\\noriginating in the different parts and organs always begins in the\\nconnective tissue primarily, and that the other tissues are involved\\nsecondarily that is, by extension. Sarcoma springs from the subcu-\\ntaneous or intermuscular connective tissue, fascia, submucous and\\nsubserous connective tissue, the neuroglia of the central nervous sys-\\ntem, the lymphoid tissue, the periosteum, the marrow of bone, and the\\nstroma of other tumors. Only the cartilage is exempt as a primary\\nstarting-point of sarcoma. The atypical proliferation of the connective-\\ntissue cells is evidenced from the fact that the sarcoma-cells do not\\n536", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0580.jp2"}, "569": {"fulltext": "SARCOMA. 537\\nreach maturity, and that they invade the adjacent tissues and very\\nfrequently give rise to metastasis. We have already shown, in connec-\\ntion with carcinoma, that mature normal cells never take an active part\\nin the formation of a malignant tumor. The same remarks apply to\\nthe essential cause of sarcoma. The mature connective tissue is acted\\nupon by microbic causes, and if these causes are not sufficiently intense\\nin their action to destroy the tissue, it proliferates and forms granula-\\ntion-tissue, of which the different infective swellings, the granulomata,\\nare composed.\\nIt is impossible to explain satisfactorily the origin of a tumor from\\npre-existing normal connective tissue without assuming the presence\\nof a localized specific microbic cause. It is true that the different forms\\nof sarcoma resemble more closely chronic inflammatory processes than\\ndoes carcinoma, but we are not yet, and probably never will be, in\\npossession of demonstrative proof of the microbic origin of sarcoma.\\nWe are therefore forced to conclude that sarcoma-tissue is produced\\nfrom a matrix of embryonic connective-tissue cells of congenital or\\npost-natal origin.\\nOf all tumors, sarcoma probably develops more frequently from a\\nmatrix of embryonic connective-tissue cells or fibroblasts than any\\nother tumor. The matrix is composed of the same kind of cells as\\nthe matrix of fibroma, except that the cell-development was arrested\\nat an earlier stage. The cells of a sarcoma as compared with those\\nof a fibroma possess greater reproductive power, but do not reach the\\nsame degree of development, owing to a more imperfect specialization\\nof the cells of which the matrix is composed. Every surgeon knows\\nthat trauma plays a more important role in the etiology of sarcoma\\nthan in that of carcinoma. The trauma in sarcoma not only acts as\\nan exciting cause in stimulating a latent matrix to active proliferation,\\nbut it frequently produces at the same time the essential cause, a post-\\nnatal matrix of granulation-tissue. It would be difficult to explain satis-\\nfactorily in any other manner the frequent origin of sarcoma in inflam-\\nmatory products and at the seat of a fracture. As the endothelial cells\\nare only a modified form of connective-tissue cells, malignant endothe-\\nlial tumors will be included among the sarcomata.\\nHistology and Histogenesis. The presence of a reticulum in\\nsarcoma was formerly denied. Ackermann and others have shown that\\na reticulum is always present. In some specimens the stroma is well\\nmarked in others it is so fine that it is almost hidden by the tumor-\\ncells. Teasing preparations of hardened specimens shows the fibril-\\nlated structure best. Ackermann claims that the reticulum of sarcoma\\nis the product of sarcoma-cells. Schwann asserted that embryonal", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0581.jp2"}, "570": {"fulltext": "538 PATHOLOGY AND TREATMENT OF TUMORS.\\nconnective-tissue cells elongate and break up into fibrillae until the cells\\nare lost. His views were supported by Virchow, Danders, and K61-\\nliker. Virchow denied that fibrillae are produced by the breaking up\\nof cells. Liicke and Rindfleisch were of the same opinion. The\\norigin of normal connective tissue from a blastema was asserted by\\nBizzozero, Kollmann, Valentin, M. Schulze, and Bruecke. Ackermann\\nstudied fibrillation in spindle-celled sarcoma, and observed that fibrillae\\nwere produced by splitting up of the protoplasm of the cells. The\\nfibrillae in sarcoma resemble the same structures in connective tissue.\\nThe reticular arrangement of the fibrillae has been explained by union\\noccurring between projections of different cells. The meshes of this\\nreticulum become apparent when filled with fluid or cells. If the\\nmeshes are empty, they collapse. A jelly-like substance is always\\npresent in embryonal connective tissue, and is always found in the\\nconnective-tissue spaces. This substance, which is a mucin-serum, can\\nbe seen best around transverse sections of fibrillae. In old portions\\nof the tumor this material is scanty, as the fibrillae become more com-\\npact by contraction. Cicatricial contraction does not occur from loss\\nof substance, but from the disappearance of the intercellular substance.\\nMany authors consider this substance, with the fibrillae, as one body\\nwhich constitutes the cement-substance. Bizzozero says the stroma of\\na sarcoma is either soft, amorphous, mucoid, or jelly-like, at times more\\ncompact and fibrillated.\\nThe intercellular substance holds a relation to the question of the\\norigin of fibrillae. If the fibrillae originate from the blastema, they\\nform a part of the cement-substance if they are a product of cells,\\nthey are derivatives of these structures, which would leave the mucin-\\nserum only as the proper cement-substance.\\nIn sarcoma cell-proliferation takes place in the immediate vicinity\\nof blood-vessels, and is controlled and influenced by them. Spindle-\\ncells are formed in the adventitia these cells either cannot be distin-\\nguished from the cells of this part of the vessel-wall or they differ only\\nin size. The cells either come in direct contact with the vessel-wall or\\nare separated from it only by a gelatinous layer. The latter contains\\nthe sarcoma-cells, few in number, imbedded in a fine net-like ground-\\nsubstance, the wide meshes of which contain the mucin-serum. There\\ngrow into the tumor young buds of capillary vessels which have imper-\\nfect walls the cells arrange themselves into minute cylinders, the cen-\\ntres of which correspond with new blood-vessels.\\nThe intimate relations of the walls of nezv blood-vessels with the paren-\\nchyma of the tumor is the characteristic feature of sarcoma. As sarcoma,\\nstarting from a central point, extends almost equally in all directions,", "height": "4423", "width": "2769", "jp2-path": "pathologysurgic00senn_0582.jp2"}, "571": {"fulltext": "SARCOMA. 539\\nthe resulting tumor usually approaches a globular shape, unless at\\nsome points obstacles to its growth are presented. In organs where\\nthe structure is uniform throughout, as in the brain, tumors grow in\\na globular shape, while in organs presenting parallel arrangement of\\n.C., r\\nFig. 369. Sarcoma of skull, showing capillary vessels, the walls of which are composed in part of sar-\\ncoma-cells (Surgical Clinic, Rush Medical College, Chicago): a, delicate stroma of connective tissue; b,\\ngroups of small round cells; c, new capillary vessels.\\nthe structures the tumor assumes an oblong shape, as is the case in\\nmuscles and long bones. In bone the tumor either destroys the bone-\\ntissue or pushes the compact layer before it. All these properties of\\nthe tumor indicate the presence of great tension, which can be referred\\nto increased blood-pressure. This increased pressure can be explained\\nreadily in the case of sarcoma from the presence of numerous and\\ndilated blood-vessels. In many cases the tumor is composed largely\\nof new blood-vessels with the characteristic cells interposed between\\nthem. In the vascular variety of sarcoma the tumor differs from an\\nangioma in the greater amount of tissue which exists between the\\nvessels and in the greater firmness of this tissue. In fibro-sarcoma the\\nvessels are scanty, but are gradually increased in size. The vessels in\\nsarcoma remain patent in the cut surface, as in cases of papilloma.", "height": "4409", "width": "2806", "jp2-path": "pathologysurgic00senn_0583.jp2"}, "572": {"fulltext": "54o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe spindle-cells with a scanty intercellular substance constitute the\\nwalls of the new capillary blood-vessels, as was first shown by\\nWaldeyer. In all capillary vessels the endothelial cells are preserved.\\nIn a new sarcomatous growth the vessels increase in size and are later\\npushed apart by the cellular elements. The walls are thin and remain\\nthin, so that finally the lumina of the vessels appear to be surrounded\\nby only a single layer of endothelial cells (Fig. 369, c). The circula-\\ntion in the capillaries is active and the blood-pressure is considerable,\\nand, as the walls are weak, the blood-pressure is communicated to the\\ntissues of the tumor, in which event the tumor pulsates.\\nIn all histological varieties of sarcoma the cells are characterized\\nby the existence of a large nucleus, which in young tumors almost\\nobscures the cell-protoplasm. In the spindle-cells the nucleus is\\ncentrally located (Fig. 370). The giant-cells are multinuclear (Fig.\\nFig. 370. Spindle-cells from sarcoma (after Liicke).\\n371). The cells vary greatly in size and shape, but a certain uniformity\\nis observed in each tumor. The shape of the cell is not only greatly\\ninfluenced by the structure of the mesoblastic tissue in which the tumor\\noriginates, but also by the cell-environments. The cells are often\\nmoulded into different shapes by pressure. The shape of the nucleus\\nis determined by the shape of the cell. The nucleus is always clear,\\nwell-defined, and surrounded by a proper nuclear membrane. The con-\\ntents of the nucleus vary according to the age of the cell. In young\\nand rapid-growing sarcoma the contents are rich in chromatin later\\nthe chromatin is diminished and there appears a beautiful network of\\nchromatin threads that do not readily absorb staining material. One or\\ntwo nucleoli which are deeply stained are always present. In young", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0584.jp2"}, "573": {"fulltext": "SARCOMA.\\nPlate 14.\\nFibrosarcoma of the base of the tongue, recurrent seven times X 5\u00c2\u00b0\u00c2\u00b0; a longitudinal fibres of vessel\\nb, circular fibres of vessel; c, vessel cut transversely; d, endothelial layer of vessel.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0585.jp2"}, "574": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0586.jp2"}, "575": {"fulltext": "SARCOMA.\\n541\\ntumors, besides cells, leucocytes are always present, but their number\\nis usually limited. They are most numerous along the course of blood-\\nvessels. Although the imperfect condition of the capillary walls would\\nappear to favor emigration of leuco-\\ncytes, the escape of leucocytes is limited.\\nLeucocytes are found in abundance only\\nin young and rapid-growing tumors. In\\na specimen examined by Klebs he found\\nthe large vessels of the tumor partly\\nclosed by normal white thrombi. The\\nexistence of the leucocytes in the tumor\\nis of short duration.\\nSarcoma-cells reproduce themselves\\nby karyokinesis, as was first observed\\nand described by Van Henkelem. The\\nsame method of cell-reproduction in\\nsarcoma has been studied by Aryama\\nand Klebs. Distinct alveolation of the\\nstroma of sarcoma is observed only in\\nexceptional cases.\\nBillroth in 1869 introduced the term alveolar sarcoma, and included\\nin this variety of sarcoma all tumors in which the connective-tissue\\nstroma showed a reticulated structure, in the meshes of which the\\nsarcoma-cells are arranged in groups (Fig. 372). He insists that such\\ntumors are often wrongly considered as carcinomatous from the size\\nof the cells and the alveolated structure of the reticulum. As such\\ntumors are found in localities devoid of epithelial cells, they must be\\nclassified with the sarcomata. In these cases the reticulum is composed\\nof the pre-existing connective tissue of the part in which the tumor\\ngrows. A good illustration is furnished by the malignant primary\\ntumors of the lymphatic glands. Although the alveolated structure\\nof the reticulum of some sarcomatous tumors is undisputed, the\\narrangement of the cells in the alveoli is different from that in carci-\\nnoma, in that the cells are not arranged in concentric compact layers.\\nAlveolation is observed most frequently in sarcoma of endothelial\\nFig. 371. Giant-cells from sarcoma (after\\nLiicke).\\nPacinotti demonstrated the existence of lymphatics in sarcoma by\\ninjections of asphalt dissolved in chloroform. Lymphatics were found\\nboth in the parenchyma and in the capsule of such tumors.\\nMorphology of Sarcoma-cells. The morphology of sarcoma-cells\\nis less uniform than that of carcinoma-cells. Many pathologists, but\\nmore especially Rindfleisch, have considered different forms of cells as", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0587.jp2"}, "576": {"fulltext": "542\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nbelonging to the same kind, differing only in reference to the degree\\nof development. Rindfleisch believed that round-cells are converted\\ninto spindle-cells, and vice versa. Ackermann and Klebs have seen no\\nsuch transition. No intermediate forms have been found.\\nHistological Varieties. Round-celled Sarcoma. It is not neces-\\nsary to make a histological or clinical distinction between large and\\nsmall round-celled sarcoma. Some tumors are composed exclusively\\nof round cells, and as these cells, according to Ackermann, lack the\\npower of fibrillation, the tumors possess a minimum amount of inter-\\nFig. 37 2\\n-Alveolar sarcoma; X i\u00c2\u00b0o (Surgical Clinic, St. Joseph s Hospital, Chicago).\\ncellular substance, are soft, and grow rapidly. The appearance of\\nsections of round-celled sarcoma under the microscope bears a strong\\nresemblance to granulation-tissue, from which, without the aid of a\\nclinical history, it is difficult to distinguish it (Fig. 373). In some\\ntumors the round cells are scattered between the spindle-cells and the\\ngiant-cells (Fig. 374). In the genuine round-celled sarcoma starting\\nin tissues other than lymphatic glands, the separate phases of develop-\\nment occur in the same order as in spindle-celled sarcoma, and are\\nmore accurately defined than in the latter. In the first place, the ves-\\nsels are dilated and new ones are formed, which show the same character\\nas in spindle-celled sarcoma. According to Ehrlich, the round cells\\nalways appear in close proximity to the vessel-wall. The vessel-lumina\\nare more patent, and the walls of the vessels are lined with well-devel-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0590.jp2"}, "577": {"fulltext": "SARCOMA.\\n543\\n-n- g\\nusa\\n.2 o\\n.5 S\\nS F\\n5 -5!\\n2Br", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0591.jp2"}, "578": {"fulltext": "544 PATHOLOGY AND TREATMENT OF TUMORS.\\noped endothelia. The round cells which compose the principal mass\\nof the new tissue are distinguished by their large nuclei containing an\\nabundant supply of chromatin. A superficial examination reveals the\\npicture of an inflammatory process. A careful examination, however,\\nshows that the cells are arranged in rows along the course of blood-\\nvessels, which peculiar arrangement constitutes one of the most reliable\\ndiagnostic evidences of the character and variety of the tumor. If\\nthese rows of cells are examined more carefully, it becomes evident\\nthat they are the product of connective-tissue proliferation. Very\\nfrequently short rows of four or five quadrangular cells are met with,\\ndensely packed, which are joined on the sides by triangular cells.\\nThe cells in such circumstances lose their round shape from mutual\\npressure. Round cells differ from spindle-cells in that the cell-seg-\\nmentation by indirect division more speedily extends from the nucleus\\nto the cell-proliferation. Mitotic figures are never present. Between\\nthe round cells are found leucocytes, which are recognized by their\\nsmall and intensely stained nuclei.\\nSpindle-celled Sarcoma. This is the fibro-plastic tumor of Lebert,\\nthe fasciculated sarcoma of Cornil and Ranvier, the recurrent\\nfibroid of Paget. The subdivision into small and large spindle-celled\\nsarcoma is superfluous the difference is simply one regarding the size\\nof the cells, the structure of the tumors representing these varieties\\nbeing the same. Spindle-celled sarcomata are the commonest of this\\ngroup of tumors, and are found most frequently in dense fibrous tissues,\\nFig. 375. Small spindle-celled sarcoma X 300 (after D. J. Hamilton): a, the spindles exposed entire; b,\\nthe same cut across.\\nsuch as the skin, the periosteum, and the sheaths of muscles. The inter-\\ncellular substance is very variable in some cases the tumor is com-\\nposed almost exclusively of cells in others the stroma is so copious\\nas to justify the name fibrosarcoma or fasciculated sarcoma terms\\nwhich are frequently used in the designation of hard sarcomatous", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0592.jp2"}, "579": {"fulltext": "SARCOMA.\\n545\\ntumors. The cells are frequently arranged in fascicles which surround\\nthe blood-vessels. The spindle shape of the cells can be shown best\\nin separating the cells from hardened specimens by teasing. In sec-\\nFig. 376. Large spindle -celled sarcoma X 400 (after D. J. Hamilton) a, ordinary spindle; b, branched flat\\ncell; c, flat endothelium-like cell.\\ntions the shape of the cells will depend on the direction of the section.\\nCells that are cut transversely appear as round or oblong nucleated\\nFig. 377.\u00e2\u0080\u0094 Oat-seed-like spindle-celled sarcoma X 300 (after D. J. Hamilton).\\ncells if the section is made oblique, the cells appear ovoid, and the\\nspindle shape is preserved only if the cut falls parallel with the cells (Fig.\\n375). The spindles interlace in bundles at somewhat obtuse angles.\\n35", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0593.jp2"}, "580": {"fulltext": "546\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe large spindle-cell is three or four times larger than the small cells,\\nand some of the cells frequently show a number of terminal prolonga-\\ntions (Fig. 376).\\nAnother variety of sarcoma-cell, differing from spindle-celled sar-\\ncoma only in that the terminations of the spindles are more obtuse, has\\nbeen described by D. J. Hamilton under the name of oat-seed-like\\nspindle-celled sarcoma (Fig. 377). The reticulum is composed of\\nconnective-tissue fibrils and the fibrillated prolongations of the spindles.\\nThe spindle-cells possess the maximum power of fibrillation. In sec-\\ntions in which the cells have been brushed out the reticular spaces are\\nnot empty, as in carcinoma, but contain a network of the finest fibrils.\\nThe large spindle-celled sarcoma is usually softer than tumors com-\\nposed of small spindle-cells. Spindle-celled sarcoma grows less\\nrapidly than tumors composed of other histological varieties of cells.\\nThe degree of malignancy is determined by the abundance of the\\nstroma. If the connective-tissue stroma is well developed, the tumor\\nis hard and grows slowly if the stroma is scanty, the tumor is corre-\\nspondingly soft and more malignant.\\nGiant-celled Sarcouta. This tumor consists of various forms of cells,\\nof which the large, many-nucleated cell, resembling the myeloplaques\\nor osteoclasts in the bone, is the prototype. Giant-celled sarcoma\\narises pre-eminently from bone (Fig. 378), but similar tumors are also\\nFig\\nGiant-celled sarcoma from upper jaw X 230 (after Perls).\\nfound in other tissues. In bone, giant-cells, the myeloplaques of\\nRobin, are found in a normal condition. According to Kolliker, these\\ncells act the part of osteoclasts, or bone-destroyers. In connection\\nwith bone giant-celled sarcomata occur as tumors which are clinically\\nvery different from one another. The periosteal form is most frequently\\nfound in the alveolar sockets of the teeth (epulis), where the tumors", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0594.jp2"}, "581": {"fulltext": "SARCOMA. 547\\nmanifest the lowest degree of malignancy. The myelogenous form is\\nproductive of early metastasis an occurrence which often takes place\\nbefore the primary tumor is detected. The so-called malignant epulis\\nis composed mostly of spindle-cells (and between them, here and there,\\na giant-cell with multiple nuclei in the centre of the cells) and round-\\ncells (Fig. 379). If such a tumor is carefully examined, it will be seen\\n$*1\\ny\\nFig. 379. Sarcomatous epulis; X 480 (Surgical Clinic, Rush Medical College, Chicago) a, small round cells\\nb, spindle-cells c, c, giant-cells d, d, blood-vessels.\\nthat the giant-cells are derived from the bone hence it is easily under-\\nstood that a local recurrence can be prevented only by removing with\\nthe diseased gingiva the superficial portion of the bone where the\\ntumor is attached. Another diagnostic sign may be mentioned, the\\nbrownish color of the tumor-tissue an appearance which charac-\\nterizes all giant-celled sarcomata. The greater danger which attaches\\nto the central or myelogenous form consists in the greater vascularity\\nof the tumors, as within them the vessels undergo an astonishing\\ndegree of development and dilatation. The arteries are frequently so\\nnumerous and so large, and their walls are so thin, that the pulsations\\nare imparted to the tumor-tissue. Other tumors of the same kind have\\nundergone angiomatous degeneration to such an extent that the} are", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0595.jp2"}, "582": {"fulltext": "548 PATHOLOGY AND TREATMENT OF TUMORS.\\noften mistaken for blood-cysts, and their true nature can often be ascer-\\ntained only by the aid of the microscope. The great vascularity of\\nthese tumors makes a diagnosis between aneuiysm of bone and sar-\\ncoma difficult. Distinguished surgeons have ligated large arteries on\\nthe proximal side on the supposition that the pulsating tumor was\\nan aneurysm, when the subsequent clinical history revealed the sar-\\ncomatous nature of the tumor.\\nDuring the earliest stage of the tumor no swelling of the bone can\\nbe detected, the pain is slight, and tenderness is frequently wanting.\\nIf the bone is opened at this stage, its interior presents the appearances\\nof a hemorrhagic focus. The blood in some parts is fluid, in others\\ncoagulated. More important from a diagnostic standpoint is the absorp-\\ntion of bone, if such has already taken place. If considerable of the\\nbone has been removed by absorption, or if perforation has already\\ntaken place, the diagnosis no longer remains doubtful. The earliest\\nstages of the development of myeloid sarcoma consist of dilatation of\\nthe medullary vessels in the immediate vicinity of the tumor-matrix,\\nfollowed by active cell-proliferation. Sections of the tumor show a\\nvariety of color some parts of the cut surface are dark red, brownish,\\nor yellow others are of a pearly whiteness. The brownish-red spots\\nwhich appear isolated and scattered through the substance of the tumor\\nare most characteristic. Some tumors contain cysts with clear con-\\ntents. The white parts of the tumor are frequently dotted with small\\npigmented points. All these different parts of the tumor correspond\\nwith definite histological changes. In the red patches the blood-vessels\\nhave undergone the greatest degree of dilatation. In the brown spots\\nthe cells are pigmented with the coloring material of the blood. In\\nthe white portions of the tumor the blood-vessels are scanty and the\\ntumor-tissue is composed largely of spindle-cells.\\nThe nuclei of giant-cells, like those in other forms of sarcoma, have\\na granular structure. They are surrounded by a nuclear membrane,\\nand they contain often large nucleoli of a homogeneous structure;\\nothers can be considered as compound or giant-nuclei.\\nFrom a histological point of view two kinds of giant-cells are found\\nin sarcoma. In one kind the cells appear as aggregations of nuclei, in\\nthe interior of which a well-defined nuclear space may be seen occupied\\nby nucleoli which lie free in the space or are imbedded in a somewhat\\nclearer granular ground-substance in the other form proliferating\\nnuclei are found within the nuclear membrane. The giant-cells cannot\\nbe considered as a further development of the normal giant-cells, as\\nthey are found in localities where the latter are absent. In a case of\\nprimary sarcoma of the epistropheus and secondary aneurysm of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0596.jp2"}, "583": {"fulltext": "SARCOMA. 549\\nvertebral artery, quoted elsewhere in detail, Klebs was able to trace\\nthe origin of giant-cells to osteoblasts in the decalcified bone\\nspecimen.\\nVan Henkelem claims that sarcoma-cells cannot produce mature\\ntissue, and that in this respect they differ from ordinary embryonal\\nconnective-tissue cells. This function, however, is not entirely wanting,\\nbut is greatly diminished. In epulis this tissue-transformation is seen\\nto a certain extent, as most of the sarcoma-cells are converted into\\ntissue of a higher physiological type, and in periosteal sarcoma new\\nbone is frequently found as one of the constituents of the tumor. The\\ngiant-cells are endowed with fibrillating power, in this respect being\\nclosely allied to the fibroplastic cells this function explains the more\\nbenignant character of giant-celled as compared with round-celled sar-\\ncoma. Arnold found in tumors giant-cells surrounded by small\\nspindle-cells.\\nDestruction of giant-cells by fibrillation may be seen in the oldest\\nportions of tumors. In giant-celled sarcoma there may always be\\nfound spindle-cells in greater or lesser abundance.\\nMixed-cell Sarcoma. In mixed-cell sarcoma none of the cells which\\nhave been described are found as the exclusive tumor-elements. Pure\\nround-celled and spindle-celled sarcomata are not infrequent. In the\\nremaining sarcomatous tumors there is a mingling of spindle-cells,\\nround cells, and giant-cells in varying proportions. Such a tumor is\\nshown in Figure 379.\\nMixed-cell sarcoma is found most frequently in myeloid and peri-\\nosteal sarcomata. The degree of malignancy of such tumors depends\\non the preponderance of non-fibrillating tumor-elements. In the most\\nbenign forms the fibrillating cells are present in abundance, the tumor\\nis hard and of slow growth, while the reverse histological structure\\nresults in opposite conditions which determine greater malignancy.\\nMelano-sarcoma. Pigmented sarcomata, which form a distinct and\\nseparate group of tumors, surpass any other histological form of\\nsarcoma in malignancy. These tumors are characterized by early\\nregional and general dissemination. The primary tumor is always\\nfound in tissues which, in a normal state, contain pigment hence the\\ntumors occur most frequently in the skin and the eye. Melano-sarco-\\nmata are particularly prone to develop in pigmented warts and moles.\\nIf the primary tumor occurs in tissues in which, in a normal condition,\\npigment material is absent, we must assume the presence of pigmented\\ncells deposited in the tissues by errors of development that is, the\\nexistence of a matrix of pigmented cells. The pigment is not derived\\nfrom the coloring material of the blood, as was formerly supposed, as", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0597.jp2"}, "584": {"fulltext": "550 PATHOLOGY AND TREATMENT OF TUMORS.\\nNenski has shown the presence in the pigment material of sulphur,\\nwhich is a constituent of some of the mesoblastic tissues. It is possible\\nthat iron may take a part in the pigmentation, but this supposition is\\nimprobable. Dressier found iron in the coloring material melanin.\\nRindfleisch was quite positive that the melanin is derived from the\\nhematin of the red blood-corpuscles. Kolaczek, who made a careful\\nstudy of eight cases of melanotic tumors with a view of ascertaining\\nthe source of melanin, maintains that it is not produced by metabolic\\nactivity of cells, but is derived from the coloring material of the blood.\\nGussenbauer claimed that thrombosis is the cause of pigmentation in\\ntumors, but this position is no longer tenable. Virchow was the first\\nto show that the pigmented cells are first stained diffusely a yellow\\ncolor, and that the pigment-granules form later. Eiselt found that the\\nirT\\n^3\\nx\\ni\\nm\\nI W-\\n4\\nrM\\nFig. 380.\u00e2\u0080\u0094 Cells from melano-sarcoma of skin X 720 (after Karg and Schmorl). The protoplasm of the\\nlarge tumor-cells is filled with fine granules of pigment material, so that the cells appear as though they were\\ncovered with a thin film of coal-dust.\\npigment material which is eliminated through the urine in persons\\nsuffering from melano-sarcoma is identical with the coloring material\\nof the blood.\\nIn Oppenheimer s case, studied by Nenski, the epithelial cells in the\\nkidneys and alveoli of the lungs were stained yellow. The pigmented\\ncells receive their material from the tissue-juices. A few years ago\\nLanz injected an emulsion of fragments of melanotic tumors of the\\nskin, brain, liver, and spleen of a man into the spleen of a guinea-pig.\\nThe health of the animal was not at once affected, but it died six\\nweeks later with an accumulation of pigment in almost every part of\\nits body, so that Lanz felt assured there was a new formation of pig-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0598.jp2"}, "585": {"fulltext": "SARCOMA.\\nPlate 15.\\nMelano-sarcoma of the skin, showing irregular distribution of pigment material with tumor- tissue a, pigmented\\npart of tissue; b, tumor-tissue without pigment (Surgical Clinic, Rush Medical College, Chicago).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0599.jp2"}, "586": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0600.jp2"}, "587": {"fulltext": "SARCOMA. 55 1\\nment. The presence of pigmented cells of normal or abnormal origin\\nis essential for the occurrence of melano-sarcoma. The tumor-growth\\ntakes place by proliferation of pigmented cells. Pigmentation of the\\ntumor-cells follows the course of blood-vessels, but is irregularly dis-\\ntributed through the tumor-tissue (Fig. 380).\\nThe unequal distribution of the pigment is particularly well marked\\nin the metastatic tumors. The pigmented cells are the carriers of the\\ncoloring material. The cut surface of melanotic tumors presents often\\nalmost a black appearance, and shows certain parts of the tumor more\\ndeeply stained than others. The metastatic tumors closely resemble\\nthe primary tumor so far as the pigmentation is concerned. Pigmented\\nsarcoma-cells do not fibrillate, which fact explains the great malignancy\\nof melanotic sarcoma. The fibroplastic part of such tumors is always\\ncomposed of spindle-cells which are not pigmented.\\nAlveolar Sarcoma. In alveolar sarcoma, as has been stated pre-\\nviously, the reticulum of the tumor is composed of a meshwork of\\nl 1 \u00e2\u0080\u0094*T\\nm\\nI\\nC\\nFig. 381.\u00e2\u0080\u0094 Alveolar sarcoma of skin X 85 (Surgical Clinic, Rush Medical College, Chicago): a, alve-\\nolated connective-tissue stroma; b, group of round sarcoma-cells somewhat shrunken from hardening c, a\\nspace, surrounded by connective-tissue recticulum, from which the cell-contents have been lost during prepa-\\nration of specimen.\\ndelicate fibres of connective tissue, in the spaces of which are found", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0601.jp2"}, "588": {"fulltext": "55 2\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ngroups of round sarcoma-cells not arranged in compact concentric\\nlayers as in carcinoma (Fig. 381).\\nAlveolar sarcoma grows very rapidly, and the tumor-tissue is sub-\\nject to early degenerative changes. The blood-vessels follow the\\nconnective-tissue stroma, but do not traverse the alveoli, the cell-\\ncontents of which, owing to an inadequate blood-supply, undergo early\\nregressive metamorphosis. This form of tumor, which in some cases\\nat least is determined by the new formation and the peculiar arrange-\\nment of the blood-vessels, is found most frequently in the skin, the\\nlymphatic glands, the bones, and the pia mater.\\nAngiosarcoma. Kolaczek described this variety of sarcoma, known\\nalso as siphonoma, cylindroma, etc. These tumors are usually of a more\\nor less tuberous structure their consistence varies from a jelly-like\\nFig. 382. Angiosarcoma of the orbit; X 75 (Surgical Clinic, Rush Medical College, Chicago) a, con-\\nnective-tissue capsule or stroma; b,b, cells lining the spaces; c, c, c, lumina of dilated new capillary vessel;\\nd, a tear in the specimen caused by handling\\nmass to the density of cartilage. On section the surface presents an\\nalveolar structure, but seldom regular, to which, in addition to great vas-\\ncularity, occasionally blood-cysts and hemorrhages impart a variegated\\nappearance. Under the microscope angio-sarcomata present usually\\na reticulated, seldom an alveolar, structure (Fig. 382). The cells are", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0602.jp2"}, "589": {"fulltext": "SARCOMA. 553\\narranged in the form of strands corresponding with the blood-vessels\\nlocated in their centre if the vessels do not contain blood, the tumor\\nsimulates carcinoma. The cells, which are epithelioid in shape and are\\nnormally multinuclear, often show prolongations, and their margins are\\nnot so sharply defined from the ground-substance as in carcinoma.\\nThe ground-substance is composed of all possible forms of con-\\nnective tissue homogeneous, granular, myxomatous, cellular, and\\nfibrillary. The vessels are numerous, large, and always capillary, and\\nthe intercellular tissue is scanty, imparting to the structure an angioma-\\ntous appearance. In many forms the cells are closely grouped around\\nthe vessels, as if they were developed in their wall and had closed\\nsheaths around them. The masses of cells thus formed, with a blood-\\nvessel for a centre, may be packed closely together in long strings with\\nmore or less frequent anastomoses, or they may be arranged in rounded\\ngroups, giving the tumor an alveolar appearance. Sometimes the walls\\nof the blood-vessels and the adjacent tissues, in these as in other forms\\nof tumors, undergo hyaline degeneration, giving to the whole or to\\nparts of the tumor a more or less gelatinous appearance.\\nv h\\nFig. 383.\u00e2\u0080\u0094 Endotheliomatous sarcoma of the pleura; X 35\u00c2\u00b0 (Surgical Clinic, Rush Medical College. Chi\\ncago): a, round cells; l\\\\b, oblong cells; c. delicate reticulum.\\nAngio-sarcomata are quite rare, and are most frequently found", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0603.jp2"}, "590": {"fulltext": "554 PATHOLOGY AND TREATMENT OF TUMORS.\\nabout the head. In 46 out of 60 cases this part of the body was affected.\\nIn the only case which came under the writer s observation the tumor\\ninvolved the skin over the frontal bone, at a point near the hairy scalp.\\nAckermann saw a case of angio-sarcoma of the corpora cavernosa of\\nthe penis. The growth of the tumor is slow. Recurrence after excis-\\nion is rapid. Only in five cases did the tumor give rise to metastasis.\\nEndotheliomatous Sarcoma. It is very probable that in angio-\\nsarcoma the angioblasts take an active part in the production of the\\ntumor, in which event this tumor should be classified with the sar-\\ncomata of endothelial origin. Malignant tumors which spring from\\nmatrices of embryonal endothelial cells are sarcomata. The structure\\nand vascularization of endotheliomatous sarcoma (Fig. 383), as seen in\\nprimary malignant tumors of the serous membranes, are almost identical\\nwith sarcoma of connective-tissue origin. The cells are round, oval,\\nand sometimes cylindrical or cuboidal, the latter modifications in shape\\noccurring in consequence of pressure. The connective-tissue stroma\\nis more abundant than in round-celled sarcoma, and is packed more\\ndensely in the stroma-spaces.\\nR. Volkmann, on the basis of 54 cases of endothelioma, believes that\\nthese tumors are of mesoblastic origin, and that although they resemble\\nin many respects sarcoma they should be classified separately.\\nEndotheliomatous sarcoma not infrequently contains cholesterin-\\ncrystals. The tumor, which may be nodular and of considerable size,\\nor multiple, is found most frequently in the pleura, the peritoneum, the\\npia mater, the ovary, the testicle, the lymphatic glands, and the brain.\\nNepvue describes an endothelial sarcoma of the pleura in a child\\nseven years of age, the tumor simulating pyothorax. The tumor was\\nthe size of an adult s head, and displaced the lung. Exploratory punc-\\nture made the diagnosis of a solid tumor possible, and no operation\\nwas undertaken.\\nGlioma. Sarcoma of the connective tissue of the central nervous\\nsystem, the neuroglia, is called glioma. It is the most frequent of all\\nbrain-tumors. The tumor is composed\\nof small round or oval cells in a mesh-\\nwork of exceedingly delicate fibrillar\\n(Fig. 384). In some cases the tumor-\\ncells are spider-like (Fig. 385). The\\nquantitative relation of cells to the fibril-\\nlated reticulum varies greatly, and, as\\nfig. 384\u00e2\u0080\u0094GiioiTia of the corpora quadrigem- Mj ura pointed out, the cells may be\\nina; X 250 (after Perls). r J\\nmore abundant at the margin of the\\ntumor. In exceptional cases the cells assume a spindle shape.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0604.jp2"}, "591": {"fulltext": "SARCOMA.\\n555\\nOwing to the delicate structure of the reticulum and its great vas-\\ncularity, glioma is a soft tumor, and when centrally located in the brain\\nis globular in shape. Gliomata sometimes have a well-defined border,\\nbut more frequently it is impossible to determine where the tumor\\nends and the healthy tissue begins. They are found most frequently\\nin the posterior segment of the lateral ventricles, but they may occur in\\nany part of the brain and spinal cord, and not infrequently they attain\\nFig. 3 8 5 .-Gliomatous tumor of the brain, from a boy; X 35 (after D. J. Hamilton): a, blood-vessels-,\\nb, spider-cell with double nucleus c, small round cell.\\nthe size of a fist or a child s head before death ensues. The tumor is\\ngrayish-white in color, with reddish-pink lines indicating the location\\nof the blood-vessels. Klebs and Bertheau insist that the nerve-cells", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0605.jp2"}, "592": {"fulltext": "556\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ntake part in the production of the tumor, as they found nerve-cells as\\none of its component parts. This opinion is not generally endorsed.\\nThe growth of a glioma is slow, and in other ways it pursues a\\nmore benign course than the connective-tissue or the myeloid sarcoma.\\nMetastasis in the pia mater of the brain and the spinal cord was\\nobserved in one case by Lemcke. The liability to hemorrhage con-\\nstitutes one of the immediate sources of danger. Gliomata have also\\nFig. 386. Microscopical appearance of a typical psammoma.\\nbeen found in the spinal cord by different observers, and in the acoustic\\nnerve by Virchow. Glioma of the retina is an affection of childhood.\\nIn the cases reported the ages of the children varied from two to four\\nyears. The tumors often extend along the optic nerve and form large\\nretrobulbar tumors. Recurrence after enucleation of the eyeball is\\nfrequent. From the orbit the tumor frequently extends to the cranial\\ncavity, either along the optic nerve or through the orbital fissure. As\\na heterotopic tumor glioma has been found in exceptional cases in the\\nkidney, the ovary, and the testicle. Knapp reported the first case in\\nwhich the tumor gave rise to metastasis. Similar cases have since been\\nreported by Schiess-Gemuseus, Hofmann, Rusconi, Bizzozero, Dresch-\\nfeld, Nellessen, and Heymann and Fiedler.\\nHelfreich reported a case of congenital glioma of both retinae.\\nEisenlohr believes that glioma of the retina develops from nests of\\nmesoblastic cells from the vitreous body that fail to undergo complete\\ndevelopment, and from which the tumor subsequently takes its origin.\\nPsammoma. Psammoma is an endothelial growth of the envelopes\\nof the brain that was first described by Virchow as a separate tumor.\\nAlthough this tumor lacks the clinical features of sarcoma, Virchow", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0606.jp2"}, "593": {"fulltext": "SARCOMA.\\n557\\nincluded it with the sarcomata. Sutton refers it to an epithelial matrix\\nin the villous processes of the choroid plexus but as it is found more fre-\\nquently in localities where there are normally no epithelial cells, it is\\nadvisable to include it among the connective-tissue type of tumors.\\nThe tumor is composed of onion-like cell-masses separated by a stroma\\nof connective tissue. These concentric bodies consist of endothelium-\\nlike cell-nests arranged around blood-vessels, which in the course of\\ntime become infiltrated with calcareous salts. The relation of the\\ntumor-tissue to blood-vessels is well shown in Figure 387.\\nFig. 387.\u00e2\u0080\u0094 Psammoma from choroid plexus X 300 (after D. J. Hamilton) a, branching vessels with the\\ncell-nest-like bodies upon them b, cell-nests calcined.\\nIt was first believed that the dura mater was the favorite seat of\\npsammoma, but more extended observations have shown that it occurs\\nmost frequently in the choroid plexus and in the ventricles of the\\nbrain. Progressive growth of the tumor is arrested by fatty degen-\\neration of the tumor-cells and by calcification. The tumors, which\\nusually vary in size from a pea to that of a walnut, are often sym-\\nmetrical, occupying in the brain the same location on both sides.\\nIn the lateral ventricles a tumor of fair size may not give rise to\\nany symptoms in other cases it has caused cerebral disturbances\\nof different kinds, and focal symptoms which pointed to the loca-\\ntion of the tumor. If the tumor does not undergo calcification, its\\ngrowth is progressive, and it eventually destroys the life of the\\npatient.\\nPsammoma of the spinal membranes is very rare. The clinical his-\\ntory of all such cases has been one of slow progressive paralysis and\\ndeath.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0607.jp2"}, "594": {"fulltext": "558\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nRegressive Metamorphoses. The absence of a well-developed\\nreticulum, the great proliferating activity of the cells, and the atypical\\nvascularization of sarcoma render the tumor liable to early and exten-\\nsive degenerative changes. Fatty degeneration is common, but calci-\\nfication is only observed in psammoma. The granular detritus in fatty\\ndegeneration is either absorbed or, by the addition of serum, remains\\nas a turbid fluid which occupies spaces surrounded by tumor-tissue,\\nforming cysts without a proper cyst-wall.\\nThe imperfect development of the walls of blood-vessels is the\\ncause of frequent hemorrhages into the substance of the tumor, where\\nthe blood either coagulates, is absorbed, or remains in a fluid state.\\nh\\nFig. 388. Myxomatous degeneration in sarcoma X 75 (Surgical Clinic, Rush Medical College, Chicago)\\na, connective-tissue stroma; b, b, sarcoma-cells c, c, c, myxomatous tissue.\\nThe staining of the tissues of the tumor in the vicinity of ruptured\\ncapillaries is one of the characteristic features of most of the sarcoma-\\ntous growths. The liability to hemorrhage is increased by the exten-\\nsion of fatty degeneration to the capillary walls. If the hemorrhage is\\ncopious, the tumor-tissue is compressed by the extravasated blood, and\\na blood-cyst forms, which frequently adds to the difficulty in diagnosis.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0608.jp2"}, "595": {"fulltext": "SARCOMA. 559\\nThe sudden increase in the size and tension of the tumor should lead\\nto the suspicion that a free hemorrhage has taken place into the sub-\\nstance of the tumor. In subcutaneous sarcomata this accident is often\\nannounced a day or two later by discoloration of the skin. Hyaline\\ndegeneration is not as frequently observed in sarcoma as in carcinoma.\\nMyxomatous degeneration is of frequent occurrence in sarcoma.\\nThe myxomatous degeneration, as seen in Figure 388, begins at dif-\\nferent points at the same time, usually in the oldest parts of the tumor,\\nwhen, by confluence of the spaces, a large territory of myxomatous\\ntissue is formed. Both stroma and cells undergo this change, but the\\nblood-vessels remain intact for a long time (Fig. 389). In myxo-sar-\\n7$ ft. v^fcfe^\\ne:,,\\nf* mM^ -M^\\nmwKz-miz\\n:f^, :.,/7.v.\u00c2\u00b0-^^7 :77. V 7J8#^^\\ns*^\\nFig. 389.\u00e2\u0080\u0094 Myxomatous cavity in the centre of a sarcomatous tumor; X 40 (after D. J. Hamilton):\\na, substance of the tumor as yet unaffected with the degeneration b, the clear myxomatous part c, a vein\\nd, an artery in the midst of the mucoid.\\ncoma the cells become macerated in the sero-mucin several delicate\\nprocesses which form a network in the meshes of which the myxoma-\\ntous material is deposited\u00e2\u0080\u0094 and the tissues assume the appearance of\\nwhat was formerly called net-cell sarcoma. With the myxomatous\\ndegeneration the tumor becomes softer, and a sense of fluctuation is felt\\non palpation if the degeneration has become extensive.\\nCaseation has been observed in sarcoma as another form of regres-\\nsive metamorphosis. It begins in different parts of the tumor at the\\nsame time, and by the coalescence of different foci large cavities filled\\nwith cheesy material are formed. It is questionable if such a regres-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0609.jp2"}, "596": {"fulltext": "5 6\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nsive metamorphosis is possible without infection of the tumor with\\ntubercle bacilli. The structure of the vessels in the tumor is such that\\nlocalization of floating microbes easily occurs, and it is more than prob-\\nFig. 390. Portion of the edge of the myxomatous space shown in Figure 400; X 450 (after D. J.Hamil-\\nton): a, the edge of the tumor; b, the branching cells lying in the clear mucoid.\\nable that future investigations will show that caseation in sarcoma\\nfollows in consequence of infection with tubercle bacilli.\\nUlceration and sloughing take place as soon as the tumor, by\\ninvasion and pressure, reaches a free surface. The sloughing is often\\nvery extensive, attended by a foul-smelling discharge caused by infec-\\ntion with putrefactive microbes. Sloughing of the skin relieves the\\ntension, and the tumor-tissue projects beyond the surface defect in the\\nform of fungous masses, furnishing a good representation of what was\\ncalled by the old authors the fungus hcematodes. Infection of the\\ntumor may occur without ulceration by localization of floating pus-\\nmicrobes in the defective capillary vessels by mural implantation.\\nWith the occurrence of this complication the symptoms of an acute\\nphlegmonous inflammation are superadded to the symptoms caused by\\nthe tumor. When extensive sloughing is the result of such an acute\\ninflammation, although the inflammatory process may destroy appar-\\nently the entire tumor, a spontaneous cure is never effected in this way.\\nThe transformation of sarcoma-tissue into tissue of a higher physio-\\nlogical type is observed most frequently in connection with sarcoma-\\ntous epulis and periosteal sarcoma, and in rare instances in glandular\\nsarcoma. In periosteal sarcoma new bone is almost constantly pro-\\nduced. Frequently, if not always, the new bone is produced through", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0610.jp2"}, "597": {"fulltext": "SARCOMA. 561\\nthe medium of cartilage-cells, as cartilage-cells and bone-cells are often\\nfound side by side in the same specimen (Fig. 391). In some cases the\\nprocess of development is arrested with the formation of cartilage.\\nEspecially is this the case in glandular sarcoma (Fig. 392).\\nDurham observed two cases of ossifying sarcoma. One of the\\npatients was a man seventy-three years of age, who, when a boy twelve\\nyears of age, sustained a severe burn in the iliac region, extending\\nto the median line. The tumor originated in the scar, and contained,\\nbesides the usual sarcoma-cells, cartilage-cells and well-developed bone.\\nd^t\\nV ^^k-^^M$-\\nFig. 391.\u00e2\u0080\u0094 Ossifying periosteal sarcoma of the humerus; X 75 (Surgical Clinic, Rush Medical College,\\nChicago): a, connective-tissue stroma b, round sarcoma-cells c, cartilage-cell d, d, d, bone-cells.\\nThe other case was a sarcoma of the breast in a woman twenty-seven\\nyears old. Ossification of a sarcoma tends to retard tumor-growth,\\nand it must be regarded as an indication that the tumor will pursue\\na chronic course.\\nLocal and General Infection.\u00e2\u0080\u0094 The growth of a sarcoma takes\\nplace exclusively by proliferation of the cells composing the embry-\\nonal matrix. The type of the cells is determined by the location and\\nthe stage of arrest of development of the cells of the matrix. A\\nmatrix representing lymphoid tissue will produce, as a rule, round cells\\n36", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0611.jp2"}, "598": {"fulltext": "562\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nand giant-cells, while a connective-tissue matrix produces more fre-\\nquently spindle-cells. If the cells of a connective-tissue matrix are\\narrested at an early stage in their development, the probability is strong\\nthat the tumor produced from the matrix will be a round-celled\\nm\\nJW\\nFig. 392. Myxo-chondro-sarcoma of parotid X 38 (after Karg and Schmorl). The upper half of\\nthe picture consists of the subcutaneous tissue, in which hair-follicles and sweat-glands may be seen. From\\nthis tissue the tumor can be distinguished sharply by its peculiar structure. In the ground-substance, which\\nis composed partly of connective tissue (a), partly of myxomatous tissue and partly of cartilage (c), are\\nimbedded strings of cells (d). These are made up of small endothelial cells.\\nsarcoma. The rapidity of the growth of the tumor is largely influenced\\nby the stroma. An abundant stroma retards tumor-growth, whereas a\\ntumor composed almost exclusively of cells will grow rapidly. The\\nstroma acts like a filter the denser it is, the greater will be the diffi-\\nculties met with by the cells in leaving the primary tumor and reaching\\nthe surrounding tissues.\\nA great deal has been written concerning the capsule of a sarcoma.\\nTo the naked eye many sarcomata appear to be encapsulated. Micro-\\nscopical examination of the capsule and of the tissues immediately outside", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0612.jp2"}, "599": {"fulltext": "SARCOMA.\\n563\\nof it shows that what appears to be a capsule is the connective tissue\\naround the periphery of the tumor, which tissue has become condensed by\\npressure, but which holds in its meshes young sarcoma-cells, which are\\nalso found in a zone of lesser or greater width in the adjacent tissues.\\nThe enucleation of a sarcoma is invariably followed by a speedy local\\nrecurrence the best possible proof that the capsule does not i?idicate the\\nlimits of the tumor, and is in reality a pathological delusion.\\nThe growth of a sarcoma is rapid in proportion to the activity of\\ncell-migration. The young sarcoma-cells leave the primary or mother-\\ntumor and migrate into the surrounding connective-tissue spaces, estab-\\nlishing wherever they become located independent centres of tumor-\\ngrowth. The pre-existing connective tissue serves the purpose of a\\ntemporary framework or stroma, which is later removed and replaced\\ni\\nr\\nFig. 393.\u00e2\u0080\u0094 Small round sarcoma-cells infiltrating muscular fibre at some distance from the tumor X 450\\n(after D. J. Hamilton).\\nby the product of fibrillation of the sarcoma-cells. Sarcoma displaces\\ntissue to a greater extent than carcinoma, but it eventually invades and\\ndestroys adjacent tissues regardless of their anatomical structure. The\\ntumor grows in the direction offering the least resistance, in this respect\\nresembling benign tumors, but no tissue, no matter how dense it may", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0613.jp2"}, "600": {"fulltext": "564 PATHOLOGY AND TREATMENT OF TUMORS.\\nbe, offers an impermeable barrier to its local extension. Of all the tis-\\nsues, cartilage offers the greatest resistance to progressive local exten-\\nsion of sarcoma. In sarcoma of the epiphyseal region of the long\\nbones the articular cartilage is often found completely detached, show-\\ning but slight traces of the destructive action of the tumor but ulti-\\nmately even this structure gives way and the joint becomes involved.\\nIn sarcoma of the intermuscular connective tissue the muscle-fibres are\\ndestroyed some distance from the tumor by cell-infiltration (Fig. 393).\\nSokolow made some very interesting investigations concerning the\\nbehavior of muscle-fibres in sarcomatous tumors. He came to the\\nconclusion that the muscle -fibres take no active part in the growth of\\nsarcoma, but are removed by the infiltrating cells.\\nWhile the central part of a sarcoma is undergoing regressive meta-\\nmorphoses the peripheral growth adds to the size of the tumor. It is\\nin the periphery that the most active tissue-changes are observed. If\\nthe tumor is located in parts that offer equal resistance to the extension\\nof the tumor, it always assumes a globular shape. Surface sarcomata\\nare flat tumors. The tumor also becomes flattened beneath firm fascise.\\nIf the tumor perforates a dense structure at a point corresponding with\\nthe centre of a tumor, the tumor grows with great rapidity on the sur-\\nface upon which the perforation opens. It is in this manner that a\\nsarcoma of the dura mater, after perforation of the cranium, assumes\\nthe shape of a sleeve-button, the contracted portion corresponding with\\nthe perforation in the bone, and the flattened masses with the primary\\ntumor of the dura and its external pericranial portion.\\nRegional extension of a sarcoma takes place along the sheaths of\\nblood-vessels and nerves, seldom through the lymphatics except in cases\\nof lympho-sarcoma. As lymphatics have been demonstrated in sarcoma,\\nit is somewhat singular that regional infection so seldom takes place\\nthrough the lymphatic vessels. That local and regional extension takes\\nplace by migration of sarcoma-cells is well shown in cases of central\\nsarcoma of bone. In these cases minute sarcomatous tumors are often\\nfound in the medullary tissue at a distance from the primary tumor,\\nwith perfectly healthy tissue between them. We can only assume that\\ncells have wandered away from the mother-tumor into the myeloid\\ntissue, and that the young daughter-tumors are the product of tissue-\\nproliferation of these cells, which have reproduced the tumor in the\\nsame tissue in the neighborhood of the primary tumor. Barth ascer-\\ntained that in local recurrence of spindle-celled sarcoma the disease\\nis rendered much more malignant by an increase of the round cells\\nand a decrease of the spindle-cells.\\nMetastasis. General dissemination in sarcoma takes place much", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0614.jp2"}, "601": {"fulltext": "SARCOMA.\\n565\\nmore frequently and at an earlier stage than in carcinoma. In this\\nregard sarcoma is much more malignant than carcinoma. Small\\nround-celled sarcoma gives rise to metastasis much more frequently\\nthan do spindle-celled and giant-celled sarcoma. The smaller the cells,\\nthe greater the liability to early and extensive general dissemination.\\nThe intimate relations which exist between the blood-vessels and the\\ntumor-tissue in sarcoma serve to explain the frequency of metastasis.\\nIsolated cells can permeate the vessel-wall, and are then carried with\\nthe blood-current to distant parts or organs, where, after the cells have\\nFig. 394-\u00e2\u0080\u0094 Metastasis of a round-celled sarcoma in the liver; X 40 (after Karg and Schmorl). Both\\ntumor-nodules are composed of round cells, and can be distinguished clearly from the adjacent liver-tissue.\\nIn the vicinity of the sarcomatous nodules the liver-cells are flattened. Several capillary vessels in the\\nvicinity of the tumors are blocked by tumor-cells.\\nbecome implanted upon a vessel-wall, there are produced secondary or\\nmetastatic tumors which resemble the primary tumor in every respect.\\nIn round-celled sarcoma the metastatic tumor is composed of round\\ncells; in spindle-celled sarcoma the metastatic tumor is composed of\\nspindle-cells and in melano-sarcoma the metastatic tumor is composed\\nof pigmented cells. In the very rare cases of myosarcoma the meta-\\nstatic tumors contain muscular fibres which answer in their structure to", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0615.jp2"}, "602": {"fulltext": "566 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe fibres of the primary tumor. Brodowsky recorded a case of myo-\\nsarcoma of the stomach with metastases, and found in the secondary\\nmetastatic tumors small unstriped muscular fibres. Birch-Hirschfeld\\nexamined a case of myosarcoma of the uterus which contained, besides\\nflat muscular fibres, many small muscular fibres and cells which appeared\\nto be a transition into spindle-cells. The metastatic tumors which were\\nfound in the liver and the bronchial glands showed a similar structure\\n(Fig. 394).\\nVery frequently the tumor grows into the lumen of the vessel,\\nwhich then becomes closed by a sarcomatous thrombus from which\\nfragments may become detached these fragments may form emboli\\nand become arrested in the distal branches of the pulmonary artery,\\nwhere new centres of tumor-growth are established.\\nMelano-sarcoma has the reputation of giving rise frequently to early\\nand diffuse metastasis. The whole surface of the body is at times\\nstudded with innumerable pigmented nodules, and many of the internal\\norgans may be affected similarly. Mr. Holden reports the case of a\\nboy ten years old upon whom two operations were performed for\\nsarcoma of the parotid. After the second operation both testicles\\nbecame sarcomatous almost simultaneously. At the post-mortem very\\ndiffuse metastasis was found involving the subcutaneous and internal\\nlymphatic glands.\\nThe extent to which various organs become implicated in some\\ncases of general dissemination of sarcoma is well illustrated by a case\\nminutely reported by Forster. The patient was a man thirty-seven\\nyears of age. The primary tumor was a small round-celled sarcoma\\nof the thigh. A year later the post-mortem showed metastatic tumors\\nin the right and left submaxillary regions, the scalp, the axillae, the skin\\ncovering the breast, the thyroid gland, the pleurae, the large bronchi,\\nthe pericardium, the peritoneum, the mesenteiy, the omentum, the pan-\\ncreas, the duodenum, the ascending colon, the stomach, the dura mater,\\nand the pituitary body. In the brain there were six nodules. Strange\\nas it may appear, the liver and the spleen were free.\\nEtiology. An hereditary predisposition to sarcoma must be recog-\\nnized. In a few instances sarcoma occurred as a congenital tumor.\\nAlthough no age is exempt, sarcoma is. met with most frequently in\\nchildren and in young adults. Sarcoma of bone is rare in the aged.\\nGlandular sarcoma is more frequent during old age. At the age of\\npuberty the genital organs are more frequently the seat of sarcoma\\nthan at any other period of life. That sarcoma not infrequently starts\\nin chronic inflammatory products is well known. Chronic irritation is\\noften an exciting cause. The inflammatory tissue produced under", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0616.jp2"}, "603": {"fulltext": "SARCOMA. 5 6 7\\nsuch circumstances undoubtedly furnishes frequently the essential\\ntumor-matrix. Sarcoma occurs at times in scar-tissue in which there\\nare buried unspecialized connective-tissue cells which only await the\\ninfluence of conditions, local or general, which will enable them to\\nassume active tissue-proliferation. The subcutaneous and the deep\\nconnective tissues are frequently the starting-points of sarcoma. The\\nserous membranes are more commonly affected than the submucous\\nconnective tissue. The lymphatic glands, the periosteum, and the\\nmarrow of bone are favorite localities for the development of the\\nprimary tumor. Of the glandular organs, the thyroid, the testicle, the\\novary, and the mammary gland are most frequently affected. Sar-\\ncoma of the central nervous system and its envelopes is of common\\noccurrence.\\nThe influence of trauma is more pronounced in the etiology of\\nsarcoma than in that of carcinoma. Not infrequently a bruise or a\\ncontusion acts as the exciting cause. The development of a sarcoma\\nat the seat of a fracture has repeatedly been observed. The writer has\\nreferred to such a case that came under his observation. Mr. Griffith\\nrecords a very similar case. The patient was a man twenty-one years\\nof age who sustained a fracture of the femur at the junction of the\\nmiddle and lower thirds. The usual treatment by rest and fixation\\nof the fragments was carried out for five weeks, when the limb was\\nimmobilized in a plaster-of-Paris bandage. Ten weeks after the acci-\\ndent a swelling was observed where the bone had been fractured. The\\npatient refused an amputation at this time. Five months after the acci-\\ndent the thigh was enormously enlarged, the skin was tightly stretched,\\nthe superficial veins were coursing in the form of dark broad bands,\\nand the whole surface was intersected with silvery streaks. The patient\\ndied less than eight months after the injury. The post-mortem revealed\\nthat the shaft of the femur had disappeared, except two small pieces\\nof detached bone about an inch in length, forming the anterior wall\\nat the lower end, and a piece about four inches long and one inch\\nin width at the upper end. The articular cartilages were intact.\\nThe tumor was a spindle-celled sarcoma that weighed twenty-five\\npounds.\\nThe influence of trauma in the production of sarcoma should be\\nremembered in the examination of remote swellings appearing at the\\nsite of an injury. The immature callus in fractures, failing to undergo\\ntransformation into tissue of a higher physiological type, in rare cases\\nbecomes the sarcoma-matrix. In injuries of the soft tissues there may\\nbe produced a similar matrix, which becomes the starting-point for the\\nsarcoma. The influence of trauma and of chronic irritation in the pro-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0617.jp2"}, "604": {"fulltext": "568 PATHOLOGY AND TREATMENT OF TUMORS.\\nduction of sarcoma is shown most conclusively in connection with the\\norigin of sarcoma in warts and pigmented moles. A wart which is the\\nseat of chronic irritation not infrequently becomes the starting-point of\\na sarcoma. The subepithelial connective tissue in a state of chronic\\ninflammation reverts to its embryonal condition and furnishes the essen-\\ntial tumor-matrix (Fig. 395). A pigmented mole may remain harmless\\nFig. 395. Sarcoma which originated in a wart of the scalp (after Liicke) a, granulating ulcer of the surface;\\nb, sarcoma-tissue c, level of the skin d, cutis.\\nthroughout a lifetime, but when it is exposed to chronic irritation or\\nbecomes the seat of an injury it is exceedingly prone to undergo trans-\\nformation into a melano-sarcoma.\\nSymptoms and Diagnosis. The diagnosis of sarcoma must be\\nbased upon a careful study of the clinical history of the case and a\\nminute examination, which, if need be, should be supplemented by\\nexploratory puncture and by microscopical examination of sections of\\nfragments of tissue removed with the harpoon-trocar. A failure to\\nelicit from the patient and his friends a clear clinical history has led to\\nmany serious mistakes in diagnosis and treatment. The most import-\\nant points to be brought out in the clinical history are the length of\\ntime the tumor has existed and its primary anatomical starting-point.\\nThe statements made by patients are often vague and unreliable. For\\ninstance, a tumor may have existed for several months, when from the\\npatient s statements it often appears that it has developed suddenly; or\\nthe tumor is often discovered accidentally after it has existed for some\\ntime and has attained considerable size. This fact should be borne in\\nmind, as otherwise the tumor might be mistaken for an infective\\nswelling.\\nAs inflammation always affects vascular connective tissue, and thus\\nshares with sarcoma the same anatomical location, an accurate know-\\nledge of the primary anatomical starting-point of a sarcoma is of special\\nvalue in the differential diagnosis between sarcoma and carcinoma and\\nbenign mesoblastic tumors. Let us take, for the purpose of illustration,\\na malignant tumor involving the bones of the cranial vault. In differ-\\nentiating between a sarcoma and a carcinoma it is important to ascer-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0618.jp2"}, "605": {"fulltext": "SARCOMA. 569\\ntain from the patient whether the growth began in the skin as an\\nulcer, or whether the tumor made its appearance first under the\\nintact skin, as it is plain that in the former instance the tumor would\\nbe a carcinoma with secondary implication of the bone, whereas in the\\nlatter case there could be no further doubt of the sarcomatous nature\\nof the tumor. It would be immaterial, so far as the nature of the\\ntumor is concerned, whether it originated in the dura mater, the bone,\\nthe periosteum, or the subcutaneous connective tissue. The subcu-\\ntaneous origin of the tumor would exclude the possibility of its being\\na carcinoma, unless the tumor developed from a displaced tumor-\\nmatrix composed of epithelial cells a very rare occurrence indeed in\\nthis locality. In the differential diagnosis it is exceedingly important to\\nascertain whether the tumor originated in epiblastic, hypoblastic, or meso-\\nblastic tissues. With few exceptions malignant tumors originating in\\nmesoblastic tissues are sarcomata, whereas all malignant tumors of\\nepiblastic or hypoblastic origin are carcinomata. In the examination of\\nulcerating malignant tumors the surgeon is often unable to make\\nthis distinction, and must rely upon the patient s statement regarding\\nthe early history of the tumor. With veiy rare exceptions primary\\nmalignant tumors of the lymphatic glands, the bone, and the connec-\\ntive tissue are sarcomatous. In malignant tumors of the glands it is,\\nof course, impossible to decide whether the tumor started in the paren-\\nchyma or in the connective tissue in other words, whether it had an\\nepithelial or a connective-tissue matrix. In such cases we must rely\\nupon the shape of the tumor and its relations to the adjacent tissue in\\ndistinguishing between a sarcoma and a carcinoma.\\nAs a rule, sarcoma grows more rapidly than carcinoma. There are,\\nhowever, exceptions to this rule. Malignant epulis and psammoma\\ngrow slowly, and in the latter tumor limitation of growth is often\\nbrought about by fatty degeneration and calcification. Billroth relates\\na case of sarcoma in the occipital region in which, during twenty years,\\nfifty operations were performed.\\nSarcoma is usually not attended by much pain unless a nerve is\\ninvolved directly or by pressure. In a case of neuro-sarcoma of the\\nmedian nerve reported by Volkmann the pain was severe in the region\\nof the distribution of the nerve. Muscular atrophy was also a marked\\nfeature. Even in central sarcoma of bone the pain is usually not\\nsevere.\\nA sarcomatous tumor is usually globular, oblong, flat, or spindle-\\nshaped, according to the location of the tumor and the anatomical\\narrangement of the tissues in which it is located. Its surface is\\nsmooth its consistency is variable. In the soft tissues the tumor", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0619.jp2"}, "606": {"fulltext": "57\u00c2\u00b0 PATHOLOGY AND TREATMENT OF TUMORS.\\nis movable, in this respect differing greatly from carcinoma, in which\\nfixation of the tumor is present almost from the beginning of the\\ngrowth. Sarcoma attains greater size before ulceration occurs. The\\nprincipal reason for this difference in the clinical behavior of sarcoma\\nand carcinoma undoubtedly is to be found in the fact that sarcoma is\\nalways covered by intact skin or mucous membrane, while carci-\\nnoma begins as a surface affection. In large sarcomata the superficial\\nveins are always enlarged. In soft tumors a sense of fluctuation is\\nimparted to the palpating fingers. The margins of the tumor are more\\ndefined in sarcoma than in carcinoma. In carcinoma of the breast the\\ntumor can be moved without moving the surrounding gland-tissue.\\nIn myelogenous sarcoma pulsations and bruit are often present. True\\naneurysm of bone is very rare. Klebs has never seen such a case.\\nThe differential diagnosis between an infective swelling and a sarcoma\\ncan often be made only by resorting to an exploratory puncture. If\\nthe diagnosis between a gumma and a sarcoma is not clear, the patient\\nshould be given the benefit of the doubt and should be placed on a\\nvigorous antisyphilitic treatment for several weeks.\\nBillroth was the first to point out that regional glandular infection\\nis very rare in sarcoma, while it is the rule in carcinoma. The regional\\ninfection is in the direction of intermuscular septa and along the sheaths\\nof blood-vessels and nerves. Metastasis occurs earlier and more fre-\\nquently in sarcoma than in carcinoma. The general health is usually\\nlittle impaired until ulceration or general dissemination takes place.\\nIn sarcoma of the serous surfaces the primary tumor gives rise\\nto multiple growths by cells becoming detached, displaced, and im-\\nplanted at different points. In sarcoma of the internal organs the\\npresence of the tumor is usually not suspected until symptoms are\\nproduced from pressure. Mr. Barclay reports a case of sarcoma of\\nthe anterior mediastinum in which the only subjective symptom was\\ndyspnea. The sternum was slightly elevated, and the tumor extended\\nabove it into the tissues of the neck.\\nIt has been ascertained by Ebstein, Pel, Renvers, Erb, Volkers, and\\nKast that the temperature rises in irregular curves in sarcoma of the\\ninternal organs. Priestly recently reported a case of sarcoma of the\\nliver in which this phenomenon was regularly observed. In a case\\nof sarcoma of the pancreas, mentioned to the writer by Drs. Vande-\\nventer and Northrop of Marquette, Michigan, the evening rise in the\\ntemperature was so constant and persistent that the case was diagnosed\\nas typhoid fever by a most competent practitioner. The thermometer\\nshould be employed as a diagnostic resource in cases of suspected\\nsarcoma of internal organs.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0620.jp2"}, "607": {"fulltext": "SARCOMA. 571\\nPathological fracture is frequently caused by myelogenous sarcoma\\nand by metastatic carcinoma. In melano-sarcoma the color of the\\ntumor and its origin in pigmented tissue render the diagnosis suf-\\nficiently positive. In glioma and psammoma of the central nervous\\nsystem a probable diagnosis can often be made from the focal symp-\\ntoms that are sometimes, but not always, present.\\nPrognosis. The most malignant forms of sarcoma are soft and\\nsmall-celled, and they are attended by rapid regional extension and\\nearly generalization. The degree of malignancy is determined by the\\nrapidity of growth. In some cases the growth is so rapid that clin-\\nically the sarcoma resembles more closely an inflammatory process\\nthan a tumor. In one of Billroth s cases the tumor grew so rapidly\\nthat a diagnosis of furuncle was made. The patient died of pulmonary\\nsarcoma in less than three months.\\nMistakes in diagnosis are oftenest made in the most malignant forms\\nof sarcoma. Slow growth indicates a more benign tendency of the\\ntumor. Sometimes the primary tumor grows slowly, the secondary\\ntumors very rapidly. Sarcoma leads to a fatal termination sooner than\\ncarcinoma. Melano-sarcoma is the most malignant of all tumors and\\nthe least amenable to successful treatment by operation. Local recur-\\nrence after operation is more frequent and takes place sooner in sar-\\ncoma than in carcinoma. Billroth maintained that a local recurrence\\nmay take place twenty years after the removal of the tumor. The\\nsame author was of the opinion that in may cases the recurrence after\\na thorough operation was due to inoculation of the margins of the\\nwound with sarcoma-cells deposited there by the knife used in the\\noperation.\\nGiant-celled and spindle-celled sarcomata offer the most favorable\\nprognosis. The prognosis is, of course, greatly modified by the loca-\\ntion of the tumor, the physiological importance of the adjacent tissues\\nor organs, the degree of accessibility of the tumor, and the presence\\nor absence of metastasis, but, on the whole, it is much graver in sarcoma\\nthan in carcinoma. The most favorable cases for successful operative\\ntreatment are sarcomatous epulis and myeloid sarcoma of bone.\\nTreatment. If we have found it necessary to urge the necessity of\\nearly and thorough removal of carcinoma, this advice applies with\\ndouble force to the necessity of early and thorough operations in the\\ntreatment of sarcoma. Sarcoma gives rise to local, regional, and\\ngeneral infection at an earlier stage than carcinoma hence the disease\\npasses sooner beyond the limits of a successful operation. In sarcoma\\nthe lymphatic glands do not stand guard between the primary tumor\\nand the general circulation as in carcinoma, and metastasis follows", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0621.jp2"}, "608": {"fulltext": "57 2 PATHOLOGY AND TREATMENT OF TUMORS.\\nmore frequently by the direct route through the blood-vessels of the\\ntumor. Not infrequently a sarcomatous thrombus which does not quite\\nblock the blood-vessel forms in one of the vessels of the tumor and\\nextends far beyond the limits of a radical operation. Billroth relates\\nan instance in which such a thrombus formed in the spermatic vein in\\nconnection with a sarcoma of the testicle. The thrombus by proximal\\ngrowth finally reached the right side of the heart, where it became\\nattached to the septum between the ventricles, and the septum was\\nfinally perforated by the tumor. It is not difficult to conceive that the\\nexistence of such an intravascular extension of the tumor would pre-\\nclude all possibility of a successful operation. Operative treatment\\nslwnld be resorted to before regional and general dissemination of the\\ntumor has taken place.\\nThe employment of efficient caustics in the treatment of incipient\\nsurface carcinomata is sometimes excusable, but in the treatment of\\nsarcoma caustics should invariably be avoided. As soon as a diagnosis\\ncan be made the tumor should be removed by excision or by amputa-\\ntion. A radical operation by excision offers the only reasonable pros-\\npect of success. Local recurrences should be dealt with in the same\\nmanner as soon as their existence is discovered.\\nIn the excision of a sarcoma a zone of apparently healthy tissue at\\nleast an inch in width should be removed with the tumor, if this can\\nbe done without coming in conflict with tissues and organs that do not\\nadmit of such a radical procedure. The skin overlying a sarcoma\\nshould invariably be removed with the tumor. In sarcoma of glands\\nand of the uterus the whole organ must be removed. The incisions\\nshould be made in the direction of the large vessels of the part affected,\\nnot only for the purpose of exposing the vessels well with a view of\\nguarding against unintentional injury, but also with the object of\\nremoving as much as possible of the connective tissue between the\\ntumor and the vessels. In the radical operation for carcinoma the\\nsurgeon has in view the removal of the lymphatics in the region of the\\ntumor; in operations for sarcoma he seeks to remove not only the\\nproximal lymphatics a possible route for regional infection but he\\naims to remove as much as possible of the connective tissue in the\\nregion of the tumor, through which tissue local and regional infection\\ntakes place. In extensive sarcoma of the extremities amputation at\\nsome distance from the tumor is indicated in the majority of cases;\\nAvhether the tumor has started in soft parts or in bone is immaterial.\\nFascial sarcoma of the limbs so often involves important vessels and\\nnerves that amputation is the only alternative. Resection in the con-\\ntinuity of a long bone is applicable in the case of the radius, the ulna,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0622.jp2"}, "609": {"fulltext": "SARCOMA. 573\\nand the fibula if the disease has not extended beyond the periosteum.\\nRemoval of central myeloid tumors by scraping has in a few cases\\nrecently been practised with success, but the cases are few for which\\nthis procedure is adapted, and it is always attended by great risks of\\na speedy recurrence, which, after it has manifested itself, calls for an\\namputation without delay. Operations for glioma of the brain have\\nyielded a number of brilliant immediate results, but with few exceptions\\nthe operations were followed, as would be expected, by an early local\\nrecurrence. Sarcoma of large nerve-trunks usually requires amputa-\\ntion, as excision of an extensive section of a nerve would be followed\\nby permanent paralysis and an early local recurrence. Operative\\ntreatment is contraindicated in the presence of metastasis and if the\\ntumor cannot be removed completely, either on account of its size, its\\ninsufficient accessibility, or its implication of structures the removal of\\nwhich with the tumor is not feasible or justifiable.\\nThe administration of drugs has very generally been abandoned,\\nas ample experience has demonstrated that we are not in possession\\nof any remedy that exerts a curative effect upon sarcoma. Arsenic,\\nso strongly advised by Billroth and others, has yielded negative results.\\nIt was urged that Fowler s solution should be given in gradually\\nincreasing doses both by the mouth and by parenchymatous injections\\nuntil symptoms of intoxication are produced, when the use of the drug\\nshould not be suspended, but the doses should be diminished. The\\nwriter has resorted to this treatment in a number of instances, but has\\nnever witnessed even a retarding effect.\\nThe beneficial effects of an intercurrent attack of erysipelas in cases\\nof sarcoma have been noticed by different surgeons for a long time.\\nBush was the first to intentionally inoculate with erysipelas patients\\nsuffering from sarcoma, but his expectations were not realized. After\\nthe discovery of the streptococcus of erysipelas by Fehleisen numerous\\ninoculations with pure cultures of this microbe were made in cases of\\ninoperable carcinoma and sarcoma. A few cases appear to have been\\ncured permanently some were benefited, others were not improved,\\nand in some death was caused by the erysipelas. These inoculations\\nhave been deprived of the risk to life by using sterile cultures of the\\nstreptococcus erysipelatis in place of active cultures. Coley and Bull\\nreport a series of cases in which this method of treatment appears to\\nhave been followed by encouraging results. It seems that the toxines\\nof the micrococcus prodigiosus increase the curative effect of the tox-\\nines of the microbe of erysipelas. The treatment of inoperable cases\\nof sarcoma by this method should be encouraged and persistently\\ncarried out. The directions for this treatment are laid down in the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0623.jp2"}, "610": {"fulltext": "574 PATHOLOGY AND TREATMENT OF TUMORS.\\nsection on the Treatment of Tumors. The writer has recently treated\\nsix cases of inoperable sarcoma with the combined sterilized cultures\\nwithout any appreciable effect. It would be advisable to treat cases of\\nsarcoma by this method after all operations, with the expectation that\\nthe treatment would prove useful in preventing a local recurrence.\\nThe palliative treatment of inoperable cases of sarcoma is the same\\nas in carcinoma.\\nTopography.\\nSkin. With the exception of the pigmented variety, sarcoma of\\nthe skin is rare. It occurs most frequently in scars, or by the trans-\\nformation of the connective tissue of a wart or the stroma of a papil-\\nloma or a fibroma into a sarcoma. Independently of such pre-existing\\n**r s\u00c2\u00bb\\n9 Ifc\\nFig. 396.\u00e2\u0080\u0094 Large round-celled sarcoma of skin X 250 (after Karg and Schmorl). The tumor is composed\\nof large round cells, which in some places, by crowding together, have been somewhat flattened. Most of\\nthe cells contain one nucleus some of them are multinuclear. The intercellular granular substance is scanty,\\nand can be seen only in certain parts of the field.\\npathological conditions, its starting-point is in the subcutaneous con-\\nnective tissue. That sarcoma is often caused by chronic irritation there\\nis no doubt. In a case of sarcoma over the scapula the writer found\\nthat the location of the tumor corresponded exactly with a point where\\nthe suspender had produced the greatest amount of pressure and fric-\\ntion. Sarcoma may be composed either of round cells or of spindle-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0624.jp2"}, "611": {"fulltext": "SARCOMA. 575\\ncells, or these two kinds of cells may be present in varying proportions\\nin the same tumor (Figs. 396, 397).\\nThe most frequent form of sarcoma of the skin is the melano-sar-\\ncoma. This tumor originates either in a pigmented nevus, a wart, or\\nthe bed of a finger-nail. In either locality the tumor is so near the\\nsurface of the skin that ulceration is an early occurrence (Fig. 398).\\nA melano-sarcoma seldom attains great size, because, as a rule, the\\ntumor at an early stage reaches the surface of the skin and ulcerates.\\nMuch of the pigment produced in melanotic tumors is eliminated\\nthrough the urine. It not infrequently happens that the secondary\\nA\\nyg* v\\nFig. 397.\u00e2\u0080\u0094 Small spindle-celled sarcoma of the skin; X 250 (after Karg and Schmorl). The tumor con-\\nsists of numerous bundles of spindle-cells, which have been cut longitudinally in the centre of the field,\\ntransversely in the periphery. A kw cells contain fine granules of pigment, which appear in the picture as\\nminute black dots.\\nlymphatic tumors grow very rapidly, while the primary tumor grows\\nslowly or remains stationary. In melano-sarcoma regional infection is\\nfollowed soon by general dissemination, although there are exceptions\\nto this rule. Melano-sarcoma occurring in the matrix or the neighbor-\\nhood of the nail presents itself at first as a black nodule which ulcer-\\nates early, and local, regional, and general dissemination follows rapidly.\\nThe great toe is most frequently thus affected. In a case which came\\nunder the writer s notice the matrix of the nail of the right index finger\\nwas the starting-point of the tumor. The patient, a tailor thirty-five", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0625.jp2"}, "612": {"fulltext": "576 PATHOLOGY AND TREATMENT OF TUMORS.\\nyears of age, attributed the tumor to the prick of a needle. In this\\ncase the whole chain of glands from the primary tumor to the apex\\nof the axilla became infected in less than three months, and death\\nresulted from general dissemination within a year from the time the\\ntumor was discovered. The case was treated repeatedly with caustics,\\nwhich greatly aggravated the local conditions and hastened the fatal\\ntermination.\\nMelano-sarcoma of the skin is characterized by the pigmentation\\nFig. 398 Melano-sarcoma of the skin; X 9 (after Karg and Schmorl) vertical section through a\\nmelano-sarcoma of the skin of the arm. The tumor (a), which projects mushroom-like beyond the level of\\nthe surrounding skin (6) and penetrates into the underlying cutis (c), is composed of dense streaks of large\\nround cells, which, with the magnification used here, cannot be seen. On the surface the tumor is ulcerated\\nand covered with crusts which appear as dark homogeneous masses at the margins the tumor is covered by\\nepithelium (d) which has proliferated irregularly at the border of the tumor, under the cutis, masses of pig-\\nment material are deposited (e).\\nof the primary and secondaiy tumors and by the rapidity with which\\nlocal, regional, and general dissemination occurs.\\nThe only proper treatment for melano-sarcoma of the skin is early\\nexcision of the primary tumor. If the tumor starts in the neighbor-\\nhood of a finger-nail or a toe-nail, amputation is preferable to excis-\\nion. In sarcoma of the skin occurring in other parts of the body,\\nwhether pigmented or not, the incisions should be made at least an\\ninch distant from the visible and palpable margins of the tumor. It\\nis very doubtful whether anything can be gained from an operation\\nafter extensive regional infection has occurred. Such cases should be\\ntreated by sterilized cultures of the streptococcus of erysipelas admin-\\nistered subcutaneously.\\nSubmucous Connective Tissue. As a primary tumor of the sub-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0626.jp2"}, "613": {"fulltext": "SARCOMA. 577\\nmucous connective tissue sarcoma is an exceedingly rare tumor. The\\nFig. 399. Melanotic sarcoma.\\ntumor in this locality does not become pedunculated it remains ses-\\nFig. 400. Sarcoma of the skin of the back.\\nsile 4 and ulceration sets in early and progresses with the growth of the\\n37", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0627.jp2"}, "614": {"fulltext": "578\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ntumor. The oedema of the tumor-tissue that is almost a constant con-\\ndition in submucous sarcoma imparts to the tumor under the micro-\\nFig. 401. Fascial sarcoma of axillary space involving scapula, requiring amputation of the entire upper\\nextremity.\\nscope a myxomatous appearance at an early stage and hastens the\\nactual myxomatous degeneration. Sarcomata of the uterus and of the\\nintestinal canal usually begin as submucous tumors.\\nFascial Sarcoma. Fascial sarcoma may appear anywhere in the\\ndeep connective tissue it occurs most frequently, however, between\\nthe planes of large muscles, presenting itself as a smooth, globular,\\npainless tumor which displaces and infiltrates the adjacent tissues.\\nUnless bound down by resisting structures, the tumor is quite movable,\\nand when it is soft pseudo-fluctuation is present. The tumor is com-\\nposed of spindle-cells or of round cells, or these two kinds of cells may", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0628.jp2"}, "615": {"fulltext": "SARCOMA.\\nPlate 16.\\ni. Sarcoma of breast. 2. Enormous fascial sarcoma between scapula", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0629.jp2"}, "616": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0630.jp2"}, "617": {"fulltext": "SARCOMA. 579\\noccur in the same tumor. In some of the soft tumors the round cells\\nare unusually large and multinuclear. The tumor, which develops\\nwithin a few weeks after a contusion, follows the intermuscular septa\\nand the sheaths of vessels and nerves it differs from a myxoma and\\na lipoma by its rapid growth, and from inflammatory swellings by the\\nabsence of pain and tenderness. In large tumors central necrosis occa-\\nsionally takes place. Hemorrhages into the substance of the tumor\\nand myxomatous degeneration are of frequent occurrence. Regional\\ninfection takes place along connective-tissue routes, seldom through the\\ndeep lymphatics.\\nSarcoma is met with most frequently in the deep connective tissue\\nof the neck, the thigh, the leg, the arm, the abdomen, and the scapular\\nregion. During the college session of 1894 the writer removed from\\nthe interscapular region such a tumor, the circumference of which\\nequalled that of a large soup-plate. Portions of the scapular muscles\\nwere removed with the tumor on both sides. The enormous wound was\\ngreatly diminished in size by the use of tension-sutures. About a week\\nafter the operation the patient contracted erysipelas, which commenced\\nat the borders of the wound and spread over the entire surface of the\\nchest, abdomen, neck, and upper extremities. The entire wound healed\\nby granulation in two months, leaving a circular pale scar the size of the\\npalm of the hand. No recurrence had taken place six months after the\\noperation.\\nIn fascial sarcoma of the trunk and neck the tumor should be\\nremoved as early as possible by a thorough excision, including with\\nthe tumor a wide zone of apparently healthy tissue. In fascial sar-\\ncoma of the limbs involving the principal vessels and nerves, ampu-\\ntation is indicated, and the operation should be performed at a safe\\ndistance from the tumor. If the tumor is located some distance from\\nimportant structures and is limited in extent, excision may be tried.\\nIt has been the experience of the writer that such tumors deeply\\nlocated return almost without exception after excision this cannot be\\nsaid of sarcoma of the superficial fascia. In the deep sarcomata the\\nadjacent muscular fibres become infiltrated at an early stage, and the\\ndisease creeps along the connective-tissue spaces far beyond the pro-\\nposed line of incision long before the operation is performed.\\nFascial sarcoma in children is an exceedingly malignant tumor. In\\nthe winter of 1893-94 the writer had under his care, at the clinic of\\nRush Medical College, a girl eight years of age, who was otherwise\\nin good health. Within two months a tumor the size of a child s fist\\nhad formed among the deep muscles of the calf of the leg, about three\\ninches below the knee-joint. There was no pulsation neither pain nor", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0631.jp2"}, "618": {"fulltext": "580 PATHOLOGY AND TREATMENT OF TUMORS.\\ntenderness existed. The skin over the tumor was normal. An explor-\\natory puncture yielded blood. A diagnosis of fascial sarcoma was\\nmade, and the limb was amputated by the Gritti-Stoke supracondyloid\\noperation. Primary healing of the wound took place. Two months\\nafter the operation a soft tumor appeared among the deep muscles over\\nthe posterior aspect of the stump, and unconnected with the scar. As\\nsoon as the parents consent could be obtained amputation through the\\nhip-joint was made; from this operation the little patient recovered\\nwithout any untoward symptoms.\\nFrom his own experience the writer has come to regard amputation\\nas preferable to excision in cases of deep fascial sarcoma of the limbs.\\nIt is possible that with the aid of sterilized injections of the microbe\\nof erysipelas we will be able more frequently to dispense with muti-\\nlating operations.\\nLymphatic Glands. Primary sarcoma of the lymphatic glands,\\nlympho-sarcoma, is a comparatively rare affection. The primary tumor\\nFig. 402.\u00e2\u0080\u0094 Lympho-sarcoma; X 2 7\u00c2\u00b0 (after Karg and Schmorl). The cells of which the tumor is com-\\nposed show the character of lymphoid corpuscles. Besides these small round cells there are seen larger cells\\nwith pale nuclei.\\ninfects adjacent glands of the same region. The tumors, as a rule,\\npresent to the palpating finger a sense of elastic resistance. They are\\nsmooth and movable before the tumor perforates the capsule of the\\ngland. The pre-existing glandular tissue takes no part in the growth\\nof the tumor, and is gradually displaced by the tumor-tissue. The\\ncells of which the tumor is composed are small round cells which are\\nimbedded in an exceedingly delicate reticulum, the meshes of which\\nfrequently are occupied by a single cell (Fig. 402). The regional", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0632.jp2"}, "619": {"fulltext": "SARCOMA. 5 81\\ninfection is usually followed sooner or later by general infection, which\\nin these cases is more frequently the result of migration of sarcoma-\\ncells in the lymph-stream than of direct infection through a vessel-\\nwall. The metastatic tumors present the same lymphoid appearance\\nas the primary tumor. As soon as the capsule of the tumor is per-\\nforated by the tumor, the sarcoma involves the surrounding connective\\ntissue and when the disease in neighboring glands has reached the\\nsame stage, the glandular tumors are incorporated with the perigland-\\nular tumor-tissue in one mass, in which the separate glands can no\\nlonger be identified. At this stage the common tumor-mass frequently\\nimplicates the overlying skin, when ulceration and sloughing take place.\\nBefore dissemination and ulceration occur the health of the patient\\nis but little impaired. When the glands occupy the region of the\\nneck or the mediastinum, the tumors may cause great suffering and\\ndeath from pressure.\\nThe characteristic features of lympho-sarcoma are the successive\\nenlargement of the glands of the region occupied by the primary\\ntumor, followed by metastasis without leucocythemia. In leukemia\\nother blood-producing organs become successively affected, and the\\nblood under the microscope shows the characteristic textural changes.\\nIn pseudo-leukemia the glands in different parts of the body become\\nenlarged. In tuberculosis the glands never attain such large size as in\\nlympho-sarcoma without the occurrence of extensive regressive meta-\\nmorphoses. In primary syphilis the enlargement of the glands can be\\ntraced to the proper source of infection and in secondary and tertiary\\nsyphilis the glandular hyperplasia is universal and the swellings seldom\\nexceed an almond in size.\\nThe prognosis in glandular sarcoma is very grave, as recurrence\\nafter extirpation is the rule. An operation holds out encouragement\\nif it be performed before the capsules of the affected glands have become\\nperforated. As the deep glands are more frequently affected by sarcoma\\nthan the superficial glands, the operation is often very difficult on\\naccount of the close proximity to the tumors of important vessels and\\nnerves. Sarcomatous glands should never be enucleated. Even if the\\ncapsides of the glands are not perforated, young sarcoma-cells have passed\\nthrough them into the periglandular connective-tissue spaces. The opera-\\ntive treatment of lympho-sarcoma consists in a clean and thorough excision\\nof the glands with the surrounding connective tissue.\\nAn operation is justifiable only if there is reasonable hope, from the\\nnumber and location of the glands, that all diseased tissue can be\\nremoved. Incomplete operations increase the malignancy of the tumor\\nand hasten the fatal termination. The only exception to this rule arises", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0633.jp2"}, "620": {"fulltext": "582 PATHOLOGY AND TREATMENT OF TUMORS.\\nwhen the glandular masses threaten life from compression of an import-\\nant organ, when the largest glands may be removed to meet urgent\\nsymptoms. In attempting to remove sarcomatous glands by a radical\\noperation the region affected should be exposed freely by a large incis-\\nion in a direction parallel with the chain of glands. If necessary, the\\noverlying skin is included in two elliptical incisions. No blunt instru-\\nments should be used, and no attempt should be made to remove the\\nglands by enucleation. The whole chain of glands, with the connecting\\nlymphatic channels and the connective tissue surrounding the glands,\\nshould be removed by a clean dissection with scalpel and dissecting\\nforceps. In the region of the neck, when the deep glands are the seat\\nof sarcoma, it is often necessary to include also in the part to be\\nremoved several inches of the internal jugular vein, and sometimes it is\\nnecessary to include also the carotid artery and the pneumogastric\\nnerve. Any or all of these structures should be saved if possible, but\\nwhen they are implicated in the tumor they must be sacrificed fear-\\nlessly. The vessels are to be resected between two ligatures. Resec-\\ntion of the pneumogastric nerve has been performed by Kocher, Kap-\\npeler, the writer, and other surgeons without any immediate disastrous\\nresults the operation is invariably followed, however, by permanent\\nparalysis of the vocal cords on the affected side. Healing of the\\nwound by primary intention should be aimed at in all operations for\\nsarcoma, as healing by granulation cannot but favor a local recur-\\nrence.\\nBones. Sarcoma of bone is met with clinically more frequently\\nthan sarcoma of any other organ or tissue.\\nMuller assigned the name osteoid tumor or ossifying fungus\\ngrowth to what we now recognize as sarcoma. Stanley called the\\nsame kind of tumor of bone malignant osseous tumor. Muller was\\ninclined to classify it with carcinoma. Similar tumors are occasionally\\nmet with independently of bone. Pott described such a tumor which\\nlay loose between the sartorius and vastus internus muscles. In the\\nmuseum of St. Thomas s Hospital, London, there is a tumor like an\\nosteoid carcinoma that was removed from near a humerus, and another\\nfrom a popliteal space. In all these cases the removal of the tumor\\nwas followed by the growth of an ordinary sarcoma devoid of osteoid\\nmaterial.\\nThe osseous part of the tumor is always attached to the bone from\\nwhich the growth had its origin. The microscopic characters of the\\nossified part are those of true bone, but rarely of well-formed bone.\\nAmong 19 cases collected by Paget, 5 of the patients were between\\nten and twenty years old, 9 between twenty and thirty, 4 between thirty", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0634.jp2"}, "621": {"fulltext": "SARCOMA. 5 8 3\\nand forty, and I between forty and fifty. In more than one-half the\\ncases the immediate cause of the tumor was attributed to an injury.\\nAlthough no age is exempt, sarcoma of bone occurs more fre-\\nquently in children and young adults. The active physiological changes\\nwhich take place during the development of the skeleton constitute\\na potent exciting cause. Sarcoma is found most frequently in that\\npart of the bone where the circulation is most active that is, in the\\nepiphyseal extremities of the long bones and in the inner layer of the\\nperiosteum, the cambium. The most malignant form is the periosteal,\\nand the most benign form is sarcomatous epulis.\\nHistological Varieties. Giant-celled or Myeloid Sarcoma. A sar-\\ncoma should be called myeloid or giant-celled if the tumor\\nFig. 403. Giant-celled sarcoma of upper jaw; X 250 (after Karg and Schmorl). Between the densely\\npacked spindle-cells and round cells of the tumor are numerous multinuclear giant-cells variously shaped.\\nThe nuclei, which contain distinct nucleoli, are distributed equally through the protoplasm of the cells, in\\ncontrast to the giant-cells in tubercular products, in which the nuclei occupy the peripheral zone of the cells.\\nis composed in at least one-half of giant-cells. Many sarcomata\\ncontain giant-cells, but when these cells do not predominate the\\ntumor is designated according to the cell-elements which form the\\ngreater bulk. A pure giant-celled sarcoma does not exist we find\\nat the same time between the giant-cells round cells, spindle-cells, or\\nboth (Fig. 403). The intercellular substance is scanty, amorphous,\\nor in the shape of fibrillar The prototypes in normal tissue of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0635.jp2"}, "622": {"fulltext": "5\u00c2\u00a74\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ngiant-cells are the myeloplaques in the marrow of bone. Giant-celled\\nsarcoma is rare in children and in the aged, and is found most fre-\\nquently in the lower jaw, the femur, and the tibia. The tumor, which is\\nnot encapsulated, but is circumscribed, is of slow growth, of a red or\\nbrownish color, and is not prone to ossify or degenerate.\\nCysts are produced by hemorrhage or by degenerative changes in\\ntumors of large size. The vascular supply of these tumors is so great\\nthat pulsation and bruit are frequently present (Fig. 404).\\nFig. 404. Myeloid cystic giant-celled sarcoma of the lower epiphysis of the femur, from a girl twenty-two\\nyears old longitudinal section, one-half natural size (after Ziesing). The lower end of the tumor is round\\nand is covered by the articular cartilage (d) e, patella. The dark streak (a) indicates thickness and direc-\\ntion of the secondary shell of bone, which can be traced a certain distance along the outer and inner surfaces\\nof the shaft of the bone (a The cyst-walls were smooth; some of the cysts contained serum, others extrav-\\nasated blood (_/\\nThe bone-producing function of myeloid sarcoma is always limited,\\nand in many cases is entirely wanting a circumstance which frequently\\nresults in pathological fracture.\\nRound-celled Sarcoma. In this variety of sarcoma the round cells\\ncompose the entire tumor or the bulk of the tumor, the balance being\\nrepresented by spindle-cells and a few giant-cells. Round-celled is\\nmore malignant than giant-celled sarcoma, more especially if the repre-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0636.jp2"}, "623": {"fulltext": "SARCOMA.\\nPlate 17.\\nOsteosarcoma of the head of the tibia X 200 a, remnants of epiphyseal cartilage b, giant-cells of\\ntumor; c, giant-cells of tumor assuming osteoclastic function; d, vessels; e, tumor-stroma f, large area of\\nabsorbed cartilage with infiltrating tumor-cells.\\nOsteo-sarcoma of the head of the tibia\\ninfiltrating the area of absorbent cartilage\\nMedical College, Chicago.)\\n500 a, remnant of epiphyseal cartilage\\ngiant-cells with osteoclastic function. ^Suv\\nb, sai\\ncal CI\\n:oma-cells", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0637.jp2"}, "624": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0638.jp2"}, "625": {"fulltext": "SARCOMA. 5 8 5\\nsentative cells are small and when the tumor is located near the trunk.\\nThe long bones are most frequently affected, especially their epiphyseal\\nextremities. The tumors are found oftenest in the upper end of the\\nhumerus, the lower end of the radius, the lower end of the femur, and\\nthe upper end of the tibia. The flat bones are also frequently affected.\\nThe round sarcoma-cells possess no fibrillating power; the tumor is\\ntherefore soft, is not encapsulated, and grows more rapidly than giant-\\ncelled sarcoma.\\nIn both giant-celled and round-celled sarcoma the tumors, instead\\nof producing new bone, destroy the pre-existing bone-tissue, thus in\\nthe case of the long bones leading to weakening of the shaft, so that\\noften upon the slightest application of force, as turning in bed, a path-\\nological fracture is produced. If the tumor is located centrally, the\\nresistance being equal on all sides, a spindle-shaped enlargement of\\nthe bone is produced, the centre of the spindle corresponding with the\\nprimary location of the tumor. This enlargement is not caused by\\ntumor-tissue of the bone, but by the expansion of the compact layer\\nof the bone and the periosteum under the greatly increased intra-osse-\\nous tension. The compact layer is weakened by the destruction of\\npre-existing bone-tissue from within outward by the tumor. The\\nsarcoma-cells act in the capacity of osteoblasts. New bone is produced\\nby the periosteum when this is reached by the tumor (Fig. 404, a).\\nIf the tumor is not centrally located, or if it starts in the compact\\nlayer of bone, the tumor occupies one side of the bone, and will\\ngrow in the direction offering the least resistance that is, away from\\nthe bone. In such cases pathological fracture is of less frequent\\noccurrence.\\nRound-celled sarcoma gives rise to regional and general infection\\nmore constantly and at an earlier stage than giant-celled sarcoma.\\nRound-celled sarcoma may originate from the inner layer of the\\nperiosteum, when the resulting tumor soon encircles the bone, and\\nalmost from the beginning implicates the connective tissue outside the\\nperiosteum, where the tumor exhibits more of the phenomena of a\\ndeep connective-tissue sarcoma than sarcoma of bone.\\nSpindle-celled Sarcoma. A spindle-celled sarcoma is very rare in\\nthe interior of bone as a primary tumor. It originates most frequently\\nin the periosteum, where, by continuity of tissue, it soon extends around\\nthe shaft of long bones, appearing as a fusiform tumor. Between the\\nspindle-cells there are often found, in varying proportions, round cells,\\nand sometimes giant-cells.\\nPeriosteal sarcoma very often produces new bone, when we speak\\nof an ossifying sarcoma. Ossification of the tumor takes place fre-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0639.jp2"}, "626": {"fulltext": "586\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nquently in sarcoma of the flat as well as in sarcoma of the long bones.\\nThe tumor is hard if ossification takes place on a large scale or if the\\ntumor is composed almost exclusively of spindle-cells it is soft in non-\\nossifying tumors composed in part at least of round cells and giant-cells.\\nC.T.Wl^iady\\nFig. 405. Periosteal bone producing sarcoma of the leg; starting-point in the tarsus. Vertical section\\nthrough the limb removed by amputation a, tumor-tissue; b, shaft of tibia; c, new bone.\\nIn ossifying periosteal sarcoma the bone left after maceration con-\\nsists of beautiful spiculae, which radiate and branch from the affected\\nbone (Fig. 405). Decalcified specimens show delicate trabecular, usu-\\nally perpendicular to the old bone, and between them a very cellular\\ntissue containing spindle-cells and round cells.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0640.jp2"}, "627": {"fulltext": "SARCOMA.\\n587\\nPathological fracture does not occur in periosteal sarcoma, as the\\naffected bone is not much weakened by the tumor. Clinically, perios-\\nteal sarcoma differs from primary sarcoma of bone by the existence of\\nFig. 406. Periosteal sarcoma of the tibia (Surgical Clinic, Rush Medical College, Chicago).\\ngreater pain and tenderness, by its greater malignancy, manifested by\\nits more rapid growth, and by its tendency to give rise to regional\\nand general dissemination. Sarcomata of some of the bones present\\nsuch peculiar clinical features that a special reference to them is\\nnecessary.\\nCranial Bones. Periosteal sarcoma of the cranial bones forms at\\nfirst an external tumor which attacks the bone beneath, often leading\\nto diffuse secondary sarcoma of the dura mater, and even of the brain\\nitself. Anatomically the tumor is characterized by massive radiating\\nspiculse of bone.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0641.jp2"}, "628": {"fulltext": "5 88\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nMyeloid sarcoma begins in the connective tissue or myeloid tissue\\nof the diploe, and by its growth causes destruction of both tables of the\\nbone, resulting in the formation of large intracranial and extracranial\\ntumor-masses connected by a constricted portion which corresponds\\nwith the primary location of the tumor and the perforation in the\\nskull. New bone is produced when the tumor has reached the peri-\\nosteum, so that the tumor is covered externally by a thin shell of bone,\\nFig. 407. Perforating myeloid sarcoma of the skull (Bruns).\\nwhich, however, yields to the increasing intracranial tension when the\\ntumor pulsates synchronously with the heart s action the tumor also\\npresents other symptoms which point to its partly intracranial location.\\nIn some cases no new bone forms, and pulsation appears as soon\\nas perforation takes place. The tumor gradually becomes softer and\\nsofter, and finally implicates the overlying skin, when ulceration and\\nsloughing hasten the fatal termination. The external tumor has been\\nknown to attain a bulk of half the size of the head. The intracranial\\nextension of the tumor often causes well-marked cerebral symptoms.\\nFormerly, for obvious reasons, myeloid sarcomata of the cranial\\nbones were regarded as absolutely fatal. Bold operation under strict\\nantiseptic precautions has placed them within the reach of successful\\noperations, provided the operative treatment be resorted to in time.\\nThe extension of the tumor to the dura mater does not preclude a\\nsuccessful operation, as during the last ten years large pieces of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0642.jp2"}, "629": {"fulltext": "SARCOMA.\\n589\\ndura mater have been removed with the tumor without any immediate\\nor remote unfavorable complications. During one of these operations\\nVolkmann accidentally injured the superior longitudinal sinus, and the\\npatient died on the table from the immediate effects of the entrance of\\nair. Extirpation of these tumors requires the removal of the cranial\\nwall as far as the limits of the intracranial part of the tumor, when,\\nif the dura mater is affected, it is removed with the tumor. Special\\ncare is necessary to prevent the entrance of air and undue hemorrhage\\nif a part of the superior longitudinal sinus has to be excised with the\\ntumor. Air-embolism can be prevented with certainty by keeping the\\nhead on a level with the body during the operation hemorrhage is\\nguarded against by preliminary compression of the sinus outside the\\nFig. 408. Macerated specimen of periosteal sarcoma of the skull (Bruns).\\nline of incision on both sides, or by excising the sinus between two\\nligatures. Hemorrhage from the sinus in accidental injuries is arrested\\nby ligature, by suture, or by compression-forceps which are allowed to\\nremain and are incorporated in the dressings and removed on the second\\nor third day. The interruption of the circulation in the sinus is a harm-\\nless procedure if the wound remains aseptic should suppuration set in,\\nthe patient is exposed to the dangers of septic sinus-phlebitis and its\\nremote results, sepsis and pyemia. If a large part of the cranial wall\\nhas to be excised, the defect should be filled with an accurately-fitting\\nplate of perforated decalcified bone, which furnishes a temporary pro-\\ntection for the exposed brain and aids the bone-producing tissues in\\ngreatly diminishing the size of the cranial defect. The wound is closed\\nover the bone-plate by sutures except at the most dependent part,\\nwhere tubular or capillary drainage is established. Serious brain-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0643.jp2"}, "630": {"fulltext": "59\u00c2\u00b0 PATHOLOGY AND TREATMENT OF TUMORS.\\nsymptoms usually indicate the extension of the tumor beyond the dura\\nmater, and contraindicate an attempt to perform a radical operation.\\nSarcomatous Epulis. Sarcomatous epulis is a spindle-celled sarcoma\\nof slow growth that usually springs from the alveolar border of the\\njaws, and involves the gum secondarily. Such tumors, although of\\nslow growth, may attain considerable size and cause great deformity.\\nMalignant epulis is found most frequently in persons more than\\ntwenty years of age, and occasionally is seen in children. The tumor\\nis sometimes so much contracted at its base that it appears as a\\npedunculated growth. The teeth are loosened, and are often extracted\\nunder the belief that the swelling is caused by disease of their roots.\\nThe tumor sometimes undergoes in part transformation into cartilage.\\nThe harder the tumor, the slower its growth and the less the liability\\nto regional and general dissemination. If the tumor is allowed to\\npursue its own course, extension to the periosteum, usually over the\\nouter surface of the bone, and destruction of the bone, are sure to\\nfollow. The small-celled variety of epulis is particularly destructive.\\nTumors with intercellular substance are soft and grow rapidly. In\\nsoft tumors the round, non-fibrillating cells predominate. After the\\ntumor has attained considerable size it is subjected to all kinds of\\ninjuries on the part of the teeth and by eating, and inflammation and\\nulceration set in, aggravating the local conditions and increasing the\\nmalignancy of the tumor.\\nFibrous epulis is only attached to the bone sarcomatous epulis grows\\ninto the bone. A careful distinction between the benign and malignant\\nforms of epulis is important from a practical standpoint, as in the former\\ninstance it is not necessary to extend the operation beyond the bone,\\nwhereas in malignant epulis, in order to remove all of the diseased\\ntissue, it is necessary to resort at least to the removal of the alveolar\\nborder of the jaw, and in advanced cases, where the periosteum has\\nbecome extensively involved, nothing short of resection of the jaw in\\nits entirety will fulfil the pathological indications.\\nSarcoma of the Jaws. With few exceptions, tumors of the jaws are\\nsarcomata. Giant-celled, round-celled, and spindle-celled tumors occur\\nin the jaws. In the majority of cases the tumors are mixed-cell sar-\\ncomata. Their degree of malignancy is determined by the abundance\\nof non-fibrillating cells. The round-celled variety is the most malig-\\nnant, giant-celled the most benign, and in mixed-cell tumors the malig-\\nnancy increases with the number of round cells. Myeloid central\\nsarcoma is much less malignant than periosteal sarcoma, sarcomatous\\nepulis excepted. Periosteal sarcoma of the lower jaw is especially a\\nvery malignant tumor. Myeloid central sarcoma of the lower jaw, on", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0644.jp2"}, "631": {"fulltext": "SARCOMA.\\n59 1\\nthe contrary, is a comparatively benign tumor. Sarcomata starting in\\nthe follicles of the teeth are mixed-cell tumors. In the early stages\\nthese tumors are encapsulated, but later they give rise to regional\\nand general infection. Sarcoma of a tooth-follicle only occurs in\\nchildren, and is particularly apt to involve the germ of the first per-\\nmanent molar (Sutton). Myeloid sarcomata are rarely met with\\nafter the twenty-fifth year, whereas the periosteal variety occurs more\\nfrequently in persons advanced in years.\\nNaso-pharynx. Spindle-celled sarcomatous tumors of the naso-\\npharynx usually spring from the under surface of the body of the\\nsphenoid bone. Both nasal cavities are often occluded, and processes\\nof the tumor extend forward into the nostrils and backward into the\\npharynx. These tumors are the source of great distress in preventing\\nnasal breathing and sometimes in-\\nterfering with deglutition they\\nare also attended by excruciating\\nfrontal headache. Hemorrhage\\nis of frequent occurrence.\\nNose. Sarcoma of the nose\\nis seldom seen except in persons\\nbetween the ages of fifteen and\\ntwenty years. Nasal sarcomata\\nfrequently involve one or both\\nantrums. A case of this kind\\nis shown in Figure 409. In this\\ninstance pain was absent, the sense\\nof smell was lost, and the sight\\nof the right eye was impaired.\\nMoore attempted to remove the\\ntumor, but the patient died on\\nthe table in consequence of some interference with the respiration.\\nSubsequent examination showed that the tumor was surrounded by a\\nbony capsule and that its wall was continuous with that portion of the\\nnasal septum formed by the mesethmoid.\\nVertebra. Primary sarcoma of the vertebrae is rare metastatic\\ntumors are of frequent occurrence. The writer has seen two patients\\ndie from the remote effects of metastatic sarcoma of the vertebrae.\\nIn the first case the patient was a girl fourteen years old suffering from\\na round-celled fascial sarcoma in the deltoid region. A few weeks after\\nthe operation she complained of pain in the lower part of the dorsal\\nregion. Kyphosis and complete paraplegia soon appeared, and were\\nfollowed by a very extensive sacral decubitus, from the immediate\\nFig.\\nDeformity produced by a sarcoma of the\\nnasal septum (after Moore).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0645.jp2"}, "632": {"fulltext": "592 PATHOLOGY AND TREATMENT OF TUMORS.\\neffects of which the patient died in less than six months after the opera-\\ntion. The second patient was a man sixty-five years of age, from\\nwhom there was removed a small round-celled sarcoma of the seventh\\nrib on the right side. During the operation the pleural cavity was\\nopened, the lung collapsed, and the patient nearly died on the table\\nfrom the effects of the accident. The wound in the pleural cavity was\\nstuffed with iodoform gauze, and the tumor was rapidly removed with\\na considerable portion of the parietal pleura. The patient rallied and\\nrecovered rapidly from the operation. The wound healed by primary\\nintention, in a few days the air in the pleural cavity was absorbed, and\\nthe lung expanded. Several weeks after the operation, after the patient\\nwas able to leave his bed, intense pain in the middle dorsal region set\\nin. A slight projection of one of the spinous processes of the middle\\ndorsal vertebra was noticeable in a few weeks. Progressive paraplegia,\\nretention of urine, and decubitus followed in rapid succession, from\\nthe combined effects of which the patient died four months after the\\noperation.\\nSarcoma of the vertebra?, whether primary or secondary, in its clinical\\naspects bears a close resemblance to acute spondylitis.\\nDiagnosis. Mistakes in diagnosis are frequently made in cases\\nof sarcoma of the bones. More than this, the diagnosis is often only\\nmade after the clinical history of the tumor has revealed its malignant\\nnature. All histological forms of sarcoma of bone are characterized\\nby progressive growth. The tumor is either soft or hard according to\\nthe histological type of the cells of which it is composed. Encapsula-\\ntion, which may be present at first in some forms of sarcoma, disap-\\npears during the growth of the tumor, when, in degrees of intensity,\\nlocal, regional, and general infection manifests itself. Local exten-\\nsion from tissue to tissue, irrespective of its anatomical structure,\\nconstitutes the distinctive feature between sarcoma and benign tumors\\nof bone. In central sarcoma the extension to other tissues takes place\\nthrough the blood-vessels of the bone, the Haversian canals, and after\\nthe compact layer of the bone has become perforated. Regional infec-\\ntion takes place in preference along the course of blood-vessels, nerves,\\nand intermuscular septa, but in some cases the lymphatics are impli-\\ncated. General dissemination may take place through the lymphatic\\nchannels, but in the majority of cases the tumor-cells enter the blood-\\nvessels, or tae tumor grows into a vein, and the emboli, large or small,\\nare derived from the intravenous, sarcomatous thrombus.\\nRound cells and giant-cells destroy bone. In periosteal sarcoma\\nbone-destruction and the production of new bone take place side by\\nside. Periosteal sarcoma presents itself usually as a firm tumor attached", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0646.jp2"}, "633": {"fulltext": "SARCOMA. 593\\nto or encircling- the bone. Round-cell periosteal sarcoma is the most\\nmalignant of all bone-tumors. In its clinical aspects it more closely re-\\nFig. 410. Sarcoma of the femur invading the knee-joint (Surgical Clinic, Rush Medical College, Chicago).\\nsembles an inflammatory affection than a tumor. Its great malignancy\\nis manifested by rapidity of growth and by early regional and general\\ninfection. Local extension takes place along the periosteum to the\\nunderlying bone and the adjacent tissues. No new bone is produced.\\nIn central sarcoma of the long bones, as long as the tumor is covered\\nby a thin shell of bone, pressure produces a crackling sensation. Pulsa-\\ntions are felt in perforating, non-ossifying sarcoma of the skull and in\\nvascular myeloid central tumors of the long bones. A bruit is often\\nheard in very vascular central sarcomata of the long bones. Glandular\\ninfection occurs most frequently in round-celled sarcoma of the jaws,\\nthe tarsus, the sternum, and the ilium. The signs and symptoms of\\nsarcoma of the vertebrae resemble acute spondylitis. Pathological frac-\\nture is one of the consequences of central sarcoma of the long bones.\\nThe affections most frequently mistaken for sarcoma are infective\\nswellings, cysts, aneurysm, carcinoma, and actinomycosis.\\nInfective Swellings. Subacute and chronic suppurative osteomye-\\nlitis has frequently been mistaken for myeloid and periosteal sarcoma,\\nand vice versa. Primary osteomyelitis is a disease of childhood and\\nyoung adults, the same as myeloid sarcoma. Periosteal sarcoma affects\\nmost frequently persons between twenty and sixty years of age. Cen-\\ntral osteomyelitis is a very painful affection, whereas myeloid sarcoma\\nproduces little or no pain. Inflammatory affections occur more fre-\\nquently in the young than tumors, the proportion being about 3:1.\\nInjury may precede and constitute an etiological factor in both affec-\\ntions. Paget related an instance of a malignant tumor within and\\naround the fibula that attained a large size within eight weeks after\\na strain or perhaps a fracture of the bone. The swelling both in osteo-\\n38", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0647.jp2"}, "634": {"fulltext": "594 PATHOLOGY AND TREATMENT OF TUMORS.\\nmyelitis and in sarcoma of the long bones may be either fusiform or\\none-sided. The consistency of the swelling often offers no clue as to\\nthe nature of the enlargement. An inflammatory swelling may be very\\nhard, and a sarcoma may be soft. A sarcoma may increase in size as\\nrapidly as an inflammatory swelling. In chronic central osteomyelitis\\nno external swelling may appear for months or years. If, however,\\ncareful observation shows that the enlargement is not increasing, this\\ncircumstance would be suggestive of osteomyelitis rather than of a\\nmalignant tumor. The condition of the skin over the swelling affords\\nno trustworthy indication of the nature of the swelling. Enlargement\\nof the subcutaneous veins is found in sarcoma and in deep-seated osteo-\\nmyelitis before the abscess has reached the skin. The soft parts have\\ntheir circulation uninterfered with until the tumor or the inflammatory\\nprocess has implicated the skin by extension of the morbid process.\\nCEdema is more suggestive of the presence of pus than of a tumor.\\nTenderness is always present over an osteomyelitic focus, and is absent\\nor slight in central sarcoma. In periosteal sarcoma pain and tenderness\\nare more conspicuous symptoms. The temperature may be normal in\\nchronic osteomyelitis, and a slight rise of temperature is observed in\\npure cases of sarcoma. In periosteal sarcoma the temperature not infre-\\nquently rises three or four degrees above normal.\\nAn exploratory puncture may prove useful as a diagnostic aid.\\nIn obscure cases an exploratory operation will often be the only means\\nof differentiating a sarcoma from an infective swelling. The exploration\\nin central disease of the bones should be carried not only down to,\\nbut into, the bone by the use of mallet and gouge. If the disease is\\ninflammatory, the bone removed will present the structure of can-\\ncellous bone that is, it will be more or less porous and when the\\nabscess-cavity is reached at least a few drops of pus will be discovered.\\nIf a tumor is exposed by the operation, tumor-tissue and no pus will\\nbe found. At this stage of the operation, in case of doubt the micro-\\nscope may prove of great value in making a positive diagnosis.\\nTuberculosis of the long bones usually affects the epiphyseal ex-\\ntremities, and the adjacent joint is frequently found implicated, while in\\nsarcoma in the same localities joint-complications seldom occur, as the\\narticular cartilage, although not impermeable to sarcoma, protects the\\njoint for a long time. In advanced tuberculosis of the short and flat\\nbones that has terminated in the formation of a tubercular abscess an\\nexploratory puncture will reveal the true nature of the swelling.\\nSyphilitic gummata of bone or of periosteum have frequently been\\nmistaken for sarcoma. Careful inquiry into the history of the case is\\nimportant in cases in which there is any doubt as to the syphilitic nature", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0648.jp2"}, "635": {"fulltext": "SARCOMA. 595\\nof the bone-affection. Gummata often appear as a multiple affection, and\\ncareful examination of the patient will often reveal the presence of marks\\nof antecedent syphilitic lesions or the existence of additional syphilitic affec-\\ntions. The histological structure of gummata under the microscope bears\\nsuch a close resemblance to small round-celled sarcomata that micro-\\nscopical examination should not be relied upon in making a differential\\ndiagnosis between gumma and round-celled sarcoma. In doubtful cases\\nthe patient should be placed upon a vigorous antisyphilitic treatment\\nfor a few weeks, during which time the enlargement should be exam-\\nined frequently in order to observe the effects of the treatment. If the\\nenlargement is a sarcoma, the treatment will make no impression on\\nthe tumor if it is syphilitic, a decided improvement will be noticeable\\nin a few weeks.\\nCysts of bone, parasitic and non-parasitic, grow very slowly, remain\\nlocal, and are not apt to give rise to any subjective symptoms. They\\nare also extremely rare.\\nIn pulsating myeloid tumors of the long bones a careful examination\\nmust be made to distinguish them from true aneurysm. In many\\npulsating sarcomata no bruit can be heard, while in true aneurysm this\\nsymptom is present almost without exception. In aneurysm a more\\ndecided impression is made upon the swelling by compression of the\\nprincipal artery on the proximal side than in pulsating sarcomata. In\\nsarcoma a distinct crackling sensation is produced on making pressure\\nupon the tumor as long as it is covered with a thin shell of bone.\\nThe differential diagnosis between sarcoma and actinomycosis can\\nonly come in question in cases in which the jaws are the seat of the\\naffection. Microscopical examination of fragments of tissue will show\\nthe presence of the essential cause, the actinomyces, if the enlarge-\\nment is an actinomycotic swelling.\\nTreatment. The operative treatment of sarcoma of bone is indicated\\nin all cases in which there is reasonable hope that all diseased tissue\\ncan be removed and in which metastasis has not occurred. The last\\npoint is difficult to determine, as some sarcomata give rise to metastasis\\nat a very early stage, and the metastatic tumors may be very small or\\nmay be located in internal organs, thereby eluding detection. Meta-\\nstatic tumors of the brain are often attended by impairment of vision\\nand by other focal symptoms. Metastatic tumors of the lungs and\\nthe pleurae must be suspected if the patient has a hydrothorax. Ascites\\nis another condition which sometimes develops in consequence of\\nmetastatic tumors of some of the abdominal viscera.\\nIt is superfluous to insist that sarcoma of the bones should be\\noperated upon at the earliest possible moment. Although the chances", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0649.jp2"}, "636": {"fulltext": "596 PATHOLOGY AND TREATMENT OF TUMORS.\\nfor a permanent cure after early operations are not so favorable as in\\ncarcinoma, there can be no doubt that thorough operations in cases\\nof sarcoma, performed before regional and general dissemination has\\noccurred, will in a fair percentage of cases not be followed by recur-\\nrence of the tumor.\\nIn central sarcoma the disease often has become diffused through\\nthe numerous imperfect blood-vessels before such a condition is sus-\\npected and in periosteal sarcoma regional dissemination through the\\nsurrounding connective-tissue spaces often takes place at a very early\\nperiod.\\nLong Bones. In myeloid sarcoma of the long bones a conservative\\noperation is justifiable in small tumors if the disease is limited to the\\nbone. In slow-growing myeloid tumors favorably located removal of\\nthe tumor with the sharp spoon, the chisel, and the hammer has in a\\nfew instances yielded a satisfactory result. The cases adapted for this\\noperation are, however, few and far apart. Resection of the bone in\\nits continuity is another operation adapted for well-selected cases. It\\nis inapplicable if the tumor involves the pancreas or the femur. This\\noperation must be limited to the bones of the forearm, the clavicle,\\nand the ribs. Many years ago the writer excised the inner two-thirds\\nof the clavicle for central sarcoma. The patient was a boy sixteen\\nyears of age. The tumor, which was located near the sternal end, was\\nlarger than a hen s egg, had not extended beyond the periosteum, and\\nwas covered by an imperfect thin shell of bone. The boy recovered\\nalmost perfect use of the arm, and the tumor never returned. In 1876,\\nHenry Morris excised the lower end of the right radius and the lower\\nfourth of the ulnar for sarcoma. No recurrence had taken place six-\\nteen years after the operation (Fig. 411). The patient recovered con-\\nsiderable use of the hand. A few other cases have been reported in\\nwhich excision of a part of the shaft of the long bones yielded satis-\\nFig. 411. Forearm of a woman four years after excision of the lower fourth of the ulnar and the radius for\\na myeloid sarcoma of the radius (after Henry Morris).\\nfactory results. In the majority of cases it is necessary to resort to\\namputation in sarcoma of the long bones.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0650.jp2"}, "637": {"fulltext": "SARCOMA. 597\\nPeriosteal sarcoma invariably necessitates a mutilating operation.\\nAs a rule, the entire bone should be removed. In sarcoma of the\\nbones of the forearm amputation should be performed at or above the\\nelbow-joint if the bones of the leg are the seat of the tumor, Gritti-\\nStokes s supracondyloid amputation will fulfil the pathological indica-\\ntions and will yield the most serviceable stump. In sarcoma of the\\nhumerus amputation through the shoulder-joint, and in sarcoma of\\nthe femur hip-joint amputation, is necessary. If the upper part of the\\nhumerus is affected, removal of the scapula and of part of the clavicle\\nmay become necessary in myeloid sarcoma of the lower end of the\\nfemur amputation at the junction of the upper and middle thirds of\\nthe femur will in all probability remove all the diseased tissue.\\nLower Jaw. In sarcomatous epulis and in central limited myeloid\\ntumors the continuity of the bone can often be preserved. In the\\nformer case the alveolar border and as much of the bone as may be\\ndeemed necessary are removed with the chisel. The tumor is exposed\\nby an incision along the lower border of the jaw, the incision being\\nlarge enough to give free access to the parts to be removed. With the\\nbone a corresponding piece of the periosteum is removed. In central\\nlimited myeloid sarcoma the compact layer of the bone is removed\\nwith chisel and hammer, and the same instruments are employed in\\nremoving the tumor, including with it a zone of bone-tissue adjacent\\nto the tumor. In periosteal sarcoma and in large myeloid tumors one-\\nhalf of the bone must be removed, even if the tumor does not extend\\nto the ascending ramus, as the proximal fragment is rather detrimental\\nthan useful to the patient later, and the severity of the operation is not\\nincreased by disarticulating the bone at the temporo-maxillary joint.\\nThe bone is exposed by an incision shown in Figure 412.\\nIn operating for malignant disease no attempt should be made to\\npreserve the periosteum. After the hemorrhage has been arrested by\\nthe employment of hemostatic forceps the symphysis of the bone\\nis divided. One or two incisor teeth are extracted, when the bone is\\ndivided either with a Butcher saw or a chain-saw, as shown in Figure\\n41 2. If Butcher s saw is used, the section is made from without inward\\nif the chain-saw is employed, a tunnel is made with a narrow-bladed\\nknife behind the symphysis mentis through this tunnel the chain-saw\\nis passed, and the bone is divided from behind forward. After the jaw\\nhas been detached from the soft parts to near the temporo-maxillary\\njoint the disarticulation is effected by twisting the bone forcibly in the\\ndirection shown in Figure 413. The bone is wrenched from the joint\\nfor the purpose of preventing injury to the internal maxillary artery,\\nwhich would be likely to occur if the disarticulation were done bv the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0651.jp2"}, "638": {"fulltext": "598\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nuse of cutting instruments. The mucous membrane should be sutured\\nfrom the side of the mouth by a separate row of catgut sutures, to\\nexclude the cavity of the mouth from the wound. The external wound\\nFig. 412. Excision of one-half of the lower jaw; Fig. 413. Disarticulation of one-half of the lower\\nexternal incision (after Esmarch). jaw by twisting (after Esmarch).\\nis sutured and drained in the usual manner. In some cases it is neces-\\nsary to divide the lower lip in the centre, affording additional room.\\nUpper Jaw. Localized myeloid tumors of the upper jaw and epulis\\nFig. 414. Incisions for resection of the upper jaw (after Esmarch) a, Gensoul s b, Velpeau s c, Syme s\\nd, Malgaigne s e, Nelaton s f, Fergusson s g, Dieffenbach s h, Weber s i, Von Langenbeck s.\\nare treated in the same manner as similar affections of the lower jaw.\\nIn periosteal sarcoma and in tumors involving the antrum excision of the\\nentire jaw is absolutely necessary. The incisions proposed by different", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0652.jp2"}, "639": {"fulltext": "SARCOMA.\\n599\\nsurgeons in exposing the upper jaw are shown in Figure 414. Of all\\nincisions so far proposed, Weber s incision (Fig. 41 5) gives best access to\\nthe bone and leaves the least deformity. The upper lip is divided in the\\nmedian line as far as the septum of the nose, when the incision is\\ncarried below the nostril on the affected side to the base of the nose,\\nand along the side of the nose to a point a little below the level of the\\ninner canthus of the eye, when it is extended outward below the eye-\\nlid as far as the external angle of the eye. The flap is now detached\\nFig.\\n-Weber s incision for excision of\\nthe upper jaw.\\nFig. 416. Bone-section in excision of the upper jaw\\n(after Esmarch).\\nand turned downward and outward. In resecting the upper jaw for\\nmalignant disease the periosteum is removed with the bone. The\\norbital contents are carefully separated from the floor with a periosteal\\nelevator. The malar bone is divided with a chain-saw fastened by a\\nstrong silk thread to a large curved needle. The needle, thus armed,\\nis passed through the orbital fissure, along the posterior surface of the\\nmalar bone, and is brought out at the malar fossa, where the bone is\\ndivided (Fig. 416, a). The nasal process is next divided with cutting\\nforceps (Fig. 416, b). The section through the junction of the maxil-\\nlary bones is made with a chain-saw. The tampon which was inserted\\ninto the nostril before the operation was begun is next removed.\\nA drainage-trocar is now inserted into the nostril, and is pushed into\\nthe mouth at the junction of the hard with the soft palate, and with it\\nthe chain-saw is drawn through the cavity of the mouth and nose\\n(Fig. 417, a). After the extraction of one or two teeth at the point\\nwhere the bone is to be divided, the section is made with the saw. The\\nnext step is to separate with the knife transversely the soft from the\\nhard palate (Fig. 417, b). The bone is now loosened with an elevator\\ninserted into the section made through the malar bone, whereupon the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0653.jp2"}, "640": {"fulltext": "600 PATHOLOGY AND TREATMENT OF TUMORS.\\nbone is seized with Fergusson s lion-jaw forceps and twisted from its\\nFig. 417. Showing line of median bone-sec-\\ntion and method of applying chain-saw (after\\nEsmarch).\\nFig. 418.\u00e2\u0080\u0094 Removal of bone with Fergusson s\\nlion-jaw forceps (after Esmarch).\\nlocation (Fig. 41.\\nThe internal maxillary artery is tied at the bottom\\nof the large wound if it bleeds. After hemor-\\nrhage has been arrested the cavity of the\\nwound (Fig. 419) is packed with iodoform\\ngauze and the external wound is sutured.\\nGreat care is required in the after-treatment.\\nThe patient should be kept in a half-sitting\\nposition for several days. Frequent use of\\nan antiseptic mouth-wash and careful feeding\\nconstitute important features in the after-treat-\\nment. The tampon is removed at the end of\\nthree or four days, and, after carefully cleansing\\nthe wound, is replaced by a smaller one. The\\nwriter has frequently dispensed with the chain-\\nsaw in resection of the upper jaw, and has\\nrelied on the chisel and strong cutting forceps. The operation, by sub-\\nstituting the chisel for the chain-saw, can be performed in half the\\ntime an important matter in performing the operation without a full\\ngeneral anesthetic. The writer has been in the habit of administering\\nsubcutaneously grain of morphia immediately before the anesthetic\\nis administered, and 2 ounces of whiskey by the mouth. As soon as\\nthe patient is unconscious the external incision is made, but the sections\\nthrough the bone are not made until the patient can be roused suf-\\nficiently to spit out the blood which accumulates in the mouth. By\\npursuing this plan there is no danger of the entrance of blood into the\\nbronchial tubes, and, although the patient continues to talk during the\\nFig. 419. Wound-cavity after\\nresection of the upper jaw (after\\nEsmarch).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0654.jp2"}, "641": {"fulltext": "SARCOMA.\\n601\\nbalance of the operation, his recollection of the operation is very\\nimperfect and indefinite the best proof that the pain experienced was\\nnot severe. In some cases of extensive sarcoma of the upper jaw the\\nwriter has been obliged to remove the entire malar bone and the septum\\nof the nose, and in several instances has followed the disease as far as\\nthe frontal sinus. In two cases, at the time of operation the orbital\\ncontents were removed, as the sarcoma had perforated the orbital floor.\\nBy using the chisel these additional operations can be done with ease\\nand without adding much to the gravity of the operation.\\nMammary Gland. As compared with carcinoma, sarcoma of the\\nmammary gland is a rare affection. It is met with most frequently in\\nFig. 420.\u00e2\u0080\u0094 Cysto-sarcoma proliferum (after Konig) a, cysts b, proliferating masses of sarcoma-tissue\\nc, cellular lining of cysts d, stroma.\\nyoung women. It is composed either of round cells, of spindle-cells,\\nor of a mixture of these two kinds of cells in varying proportions.\\nThe tumor begins in the periacinous connective tissue. During the\\ngrowth of the tumor a part of the acini are destroyed by pressure the\\nducts remain open, and as new tumor-tissue is added to their walls\\nthey become greatly distended (Fig. 420). In this way the dilated", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0655.jp2"}, "642": {"fulltext": "602\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nducts, compressed by the tumor-masses, become spaces which contain\\na mucoid material, and which are encroached upon by leaf-like masses\\nof tumor-tissue. Virchow compares the appearance of sections of the\\ntumor to that of a cabbage-head. The cyst-walls project into the\\nspaces in the form of papillomatous dendritic branching formations.\\nAt other times the walls are perforated by the tumor-tissue, which then\\nappears in the spaces as polypoid leaf-like masses. Johannes Mueller\\napplied to this tumor the term cysto-sarcoma proliferum pliyllodes\\n(Fig. 421), and Astley Cooper called it hydatid tumor. The peri-\\ncanalicular proliferation projects into the dilated ducts and constitutes,\\nwith the intracanalicular excrescences, the proliferating masses. Gland-\\ntissue is sometimes found in the tu-mor-substance which has grown\\naround it, but it is soon removed by degeneration and by pressure-\\natrophy. The stroma of the tumor is very apt to undergo myxomatous\\ndegeneration.\\nV\\nFig. 421. Cysto-sarcoma proliferum phyllodes two-thirds natural size (after Haeckel) a, normal gland-\\ntissue; b, myxomatous part c, great proliferation in a cyst.\\nRound-celled sarcoma grows very rapidly the tumor is soft (medul-\\nlary sarcoma), and life is often destroyed in three or four months after\\nthe discovery of the tumor. The rapidity with which such tumors\\ngrow has often led surgeons to mistake them for abscesses, and\\nabscesses have not infrequently been mistaken for sarcomata. A few\\nyears ago a woman forty years of age was sent to the writer by\\nan able practitioner with the diagnosis of sarcoma. The enlargement", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0656.jp2"}, "643": {"fulltext": "SARCOMA. 603\\nof the breast had begun two months before, had increased slowly,\\nand was not attended by any considerable pain. The breast was the\\nsize of a child s head, smooth, and fluctuated on deep palpation. The\\nskin over the swelling was movable and only slightly discolored.\\nAs the swelling came on some time after the patient ceased to nurse\\nher child, the writer was led to resort to an exploratory puncture, and,\\nsomewhat to his astonishment, pus was withdrawn. The case revealed\\nitself as a subacute submammary abscess. The cases are perhaps more\\nfrequent in which a rapid-growing sarcoma is mistaken for an abscess.\\nThe bistoury has often been plunged into such tumors with the inten-\\ntion of opening an abscess, when, to the great chagrin of the operator,\\nonly blood escaped. A puncture made under such circumstances often\\ndoes an incalculable amount of mischief. It becomes the starting-\\npoint of ulceration and sloughing, which convert the subcutaneous sar-\\ncoma into a fungous bleeding mass and initiates the danger incident\\nto suppuration, sepsis, and pyemia.\\nIn spindle-celled sarcoma the tumor is firm, and regional and gen-\\neral dissemination is a later occurrence. Firm tumors are also less\\nsubject to cystic and myxomatous degeneration. Sarcoma of the breast\\nmanifests itself clinically as a rapid-growing tumor with a smooth sur-\\nface, and it is more movable than sarcoma. The rapidity of growth\\ndistinguishes it sufficiently from adenoma, fibroma, and cystoma. The\\nabsence of cicatricial contraction in sarcomata explains why the nipple\\nand the skin over the tumors are not retracted, as is often the case in\\ncarcinoma of the breast. Sarcoma of the breast is not attended by\\npain. The tumor attains greater size before it ulcerates than does\\ncarcinoma. In very rare instances patients suffer from sarcoma and\\ncarcinoma at the same time. Billroth relates an instance in which one\\nbreast was the seat of a carcinoma, and the other of a sarcoma. As\\nyoung round-celled sarcoma-tissue resembles granulation-tissue, the\\nmicroscope cannot be relied upon in making a differential diagnosis\\nbetween sarcoma and chronic infective swellings. Enlargement of the\\naxillary glands, so constantly observed in carcinoma, is seldom seen in\\nsarcoma of the breast. After the tumor has perforated the capsule of\\nthe gland regional infection takes place in the direction of the con-\\nnective-tissue spaces. Chronic suppurative mastitis and submammary\\nabscess can be distinguished from sarcoma by resorting to an explora-\\ntory puncture.\\nThe proper treatment in cases of -sarcoma of the breast is an early\\nand thorough excision. If the disease has not extended beyond\\nthe limits of the gland, the prospects of a radical cure are better in\\nsarcoma than in carcinoma. It is essential not only to remove the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0657.jp2"}, "644": {"fulltext": "604 PATHOLOGY AND TREATMENT OF TUMORS.\\nentire gland, but also to include with it the overlying skin and as much\\nof the periglandular connective tissue as may be deemed necessary.\\nAs regional infection is very prone to extend along the connective\\ntissue accompanying the axillary glands from the margin of the breast,\\nthe writer has been in the habit of laying the axilla freely open and\\nclearing it out much in the same way as in operations for carcinoma,\\nremoving at the same time the fascia of the pectoralis major and the\\nserratus magnus muscles. By undermining the skin for some distance\\non both sides and using tension-sutures the wound can usually be\\nclosed throughout this procedure should be carried out whenever it is\\npracticable in all operations for malignant disease of the breast.\\nIn cases beyond the reach of a radical operation, treatment by sub-\\ncutaneous injections of the sterilized toxines of the streptococcus of\\nerysipelas recommends itself. Partial operations in sarcoma of the\\nbreast are not permissible, as they invariably increase the malignancy\\nof the remaining portion of the tumor. In open fungous tumors the\\nemployment of strong antiseptic solutions will accomplish much in\\ndiminishing the intensity of the fetor and in retarding the sloughing\\nprocess.\\nThymus Gland. Virchow pointed out that sarcomatous tumors\\nof the anterior mediastinum having a regular outline are usually\\nthymic in their origin and recent observers, especially Letulle, have\\nargued for a still more frequent recurrence of this place of origin than\\nVirchow believed. In a paper on The Clinical Study of Intrathoracic\\nTumors, by Pepper and Stengel, allusion is made to three cases of\\nsarcoma of the thymus gland that came under the observation of the\\nauthors. As in the histological structure of this gland the lymphatic\\ntissue is greatly in excess of the epithelial cells, it is to be expected\\nthat it would be more frequently the seat of mesoblastic than epithelial\\ntumors.\\nSarcoma of the thymus gland occurs more frequently in young\\nadults than in persons advanced in years but old age is not exempt,\\nas in one of Pepper s cases the patient was fifty-six years of age. The\\ntumor by its progressive growth gives rise to gradually increasing\\npressure-symptoms, upon which the physician must largely rely in\\nmaking a probable diagnosis, combined with a careful study of the\\nphysical signs.\\nSalivary Glands. The parotid gland is more frequently the seat\\nof sarcoma than the submaxillary gland. The tumor presents itself\\nas a smooth or lobulated, rapid-growing mass, which in a short\\ntime involves the entire gland, and after perforation of its capsule\\nextends in all directions, notably beneath the sterno-mastoid muscle", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0658.jp2"}, "645": {"fulltext": "SARCOMA. 605\\ntoward the pharynx and the external ear, very frequently implicating\\nthe facial nerve as it issues from the stylo-mastoid foramen. The\\nwriter has seen two cases of parotid sarcoma in which the facial nerve\\nwas completely paralyzed at the time of the operation. In each\\ninstance it was found that the tumor had extended to the point of exit\\nof the nerve from the stylo-mastoid foramen. Billroth estimated that\\nthree-fourths of all tumors of the parotid gland are of a sarcomatous\\nnature. The largest number of patients suffering from parotid sarcoma\\nare between thirty and forty years of age. Of the cases which have\\ncome under the writer s observation, the youngest was twenty-five and\\nthe oldest seventy-two years of age. Kaufmann, who has investigated\\nthe histology of sarcomatous tumors of the parotid gland more thor-\\noughly than any other author, classifies these tumors, according to\\ntheir structure, into pure sarcomata, fibro-sarcomata, myxo-sarcomata,\\nand chondro-sarcomata. The pure sarcomata are composed either\\nof round cells or of spindle-cells, and are encapsulated from the\\nbeginning. Fibro-sarcomata appear as hard, smooth, or lobulated\\ntumors composed of spindle-cells. The tumors are also encapsulated,\\nand the results of operation in this as well as in the first variety are\\nfavorable. Myxo-sarcomata often grow to the size of a child s head.\\nThe tumors are round and soft the tissue is of a yellowish or red-\\ndish tint. The tumors contain myxoma-cells, spindle-cells, and round\\ncells.\\nChondro-sarcomata present a nodulated surface. From the capsule\\nbundles of interlacing fibres extend into the substance of the tumor.\\nThe cartilage-tissue appears in islands dispersed throughout the tumor,\\nsome of them being as large as peas.\\nThe great variety in the histological structure of sarcoma of the\\nparotid renders the diagnosis often very difficult. From benign tumors\\nit can be differentiated by the rapidity with which the tumor grows and\\nby the regularity with which it extends ultimately beyond the limits of\\nthe gland. In carcinoma of the parotid lymphatic infection is observed\\nat an early stage in sarcoma regional infection takes place through\\nthe periglandular connective tissue. It is more probable that in chon-\\ndro-sarcoma the islands of cartilage-tissue are formed from chondro-\\nblasts derived from the pinna and deposited in the substance of the\\nparotid gland, than that they result from a development of sarcoma-\\ntissue into tissue of a higher physiological type. In the more benign\\nforms of sarcoma of the parotid extirpation of the tumor should be\\nperformed without division of the facial nerve. If the tumor grows\\nrapidly or if it has involved the entire gland, a radical operation is\\nnecessarily followed by permanent facial paralysis. The technique of", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0659.jp2"}, "646": {"fulltext": "606 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe operation has been described fully in connection with Carcinoma\\nof the Parotid Gland. In sarcoma of the submaxillary gland the\\nwhole gland and the surrounding connective tissue should be removed\\nwith the tumor.\\nTongue. Butlin regards sarcoma of the tongue as an exceedingly\\nrare affection. Mr. Targett reports a case in which, in a patient twenty-\\nfive years of age, a sarcoma developed on the under portion of the\\nleft side of the tongue, involving at the same time the floor of the\\nmouth. The tumor appeared as a hard, painless mass, and the mucous\\nmembrane over it was not ulcerated. It was removed through an\\nincision of the cheek extending in a backward direction from the left\\nangle of the mouth. Examination of sections of the tumor under\\nthe microscope showed it to be a round-celled sarcoma. In fifteen\\nmonths it returned in the left submaxillary region and below the\\nzygoma of the right side. Mr. Targett gives the history of two\\nadditional cases which occurred in Guy s Hospital. Sarcoma of the\\ntongue must be distinguished from carcinoma, tuberculosis, gumma,\\nand actinomycosis.\\nTonsil. Sarcoma of the tonsil is of more frequent occurrence than\\ncarcinoma. It also grows more rapidly and attains larger size before\\nulceration occurs than does carcinoma. Infection of the deep lymphatic\\nglands, of such constant occurrence in carcinoma and primary syphilis,\\nis absent in sarcoma. Excision of the tumor through Cheever s or\\nKocher s incision is the only proper surgical treatment, and should\\nbe done if all the diseased tissue can be removed and no indications of\\nmetastasis are present.\\nIntestinal Canal. Sarcoma of the intestinal canal as compared\\nwith carcinoma is an extremely rare affection. It occurs most fre-\\nquently in the upper part of the small intestines, about the ileo-cecal\\nregion, the colon, and the rectum. Rokitansky described spindle-celled\\nsarcoma of the intestines that projected in a nodulated form into .the\\nlumen of the bowel. Billroth and Esmarch have reported cases of\\nalveolar sarcoma of the rectum. Frerichs and Meyer have seen speci-\\nmens of melano-sarcoma involving the intestinal canal. A sarcoma\\nof the intestines never comes to the attention of the surgeon until\\nthe tumor has given rise to some form of intestinal obstruction.\\nA sarcoma produces intestinal obstruction either by the tumor-mass\\nfilling the lumen of the bowel, by invagination, or by volvulus, and\\nnever by cicatricial contraction, as is so often the case in circular carci-\\nnoma. Sarcoma of the intestines begins in the submucous connective\\ntissue, and is composed either of spindle-cells or of round cells in\\nboth varieties and in mixed-cell sarcoma myxomatous degeneration is", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0660.jp2"}, "647": {"fulltext": "SARCOMA. 607\\na constant and early occurrence. A correct diagnosis is only made\\nin the operating- or the post-mortem room.\\nIf in operating for intestinal obstruction a sarcoma is found as its\\ncause, an enterectomy is indicated if the tumor has not extended\\nbeyond the intestinal wall if this extension has taken place, a radical\\noperation is out of the question, and the surgeon must content himself\\nwith making an artificial anus above the tumor, or, what is better, an\\nintestinal anastomosis.\\nOmentum. The great omentum is occasionally the seat of primary\\nsarcoma, and the tumor in this locality often attains an enormous size.\\nThe writer removed, in a man fifty years of age, the entire omentum\\nfor a tumor that weighed over thirty pounds.\\nKidney. Sarcoma of the kidney is more common than carcinoma.\\nIt is met with most frequently in children and young adults. The\\ngrowth of the tumor is rapid, and the tumor usually reaches an enor-\\nmous size before it destroys life. The mass is smooth, and pseudo-\\nfluctuation is generally present. The tumor is composed usually of\\nround cells. The malignancy of sarcoma of the kidney is very great,\\nand recurrence after extirpation of the kidney is the rule.\\nDiagnosis. The diagnosis of sarcoma of the kidney is usually not\\nvery difficult. The only affections for which it is liable to be mistaken\\nare hydronephrosis, pyonephrosis, and on the right side a distended gall-\\nbladder. Hemorrhage from the kidney in sarcoma occurs frequently,\\nand its occurrence in children is very suggestive of malignant disease\\nof the kidney. The retroperitoneal location of the tumor can be\\ndetermined positively by inflation of the colon. If the tumor is intra-\\nperitoneal, it will be displaced by the distended colon if it is retroperi-\\ntoneal, the tumor can be felt less distinctly in front, and where dulness\\nexisted before the inflation there is resonance due to the location of the\\ndistended colon in front of the kidney. Soft sarcomata of the kidney\\npresent pseudo-fluctuation on palpation, and if a large cyst occupies\\nthe anterior surface of the kidney, true fluctuation can be felt. In some\\ncases tumor-tissue escapes with the urine, and examination under the\\nmicroscope will be of great value in rendering the diagnosis positive.\\nBuhl in his lectures on pathological anatomy used to cite and show\\na specimen in which the sarcoma-tissue extended from the pelvis of\\nthe kidney in a string-like projection to the meatus urinarius. In hydro-\\nnephrosis and pyonephrosis, if any doubt exists between these affec-\\ntions and sarcoma, an exploratory puncture through the lumbar region\\nis harmless, and will enable the surgeon to make a positive diagnosis.\\nIf the tumor is large, it can be felt immediately under the abdominal\\nwall, when it feels like the back of a turtle. Ascites is usually present.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0661.jp2"}, "648": {"fulltext": "6o8\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nExtension to other organs and over the peritoneal surfaces is of com-\\nmon occurrence. If the disease is limited to the omentum, a radical\\noperation is indicated.\\nGirls appear to be more predisposed to primary sarcoma of the\\nkidney than boys. The tumor is composed of spindle-cells and large\\nand small round cells. The origin from a matrix of embryonal cells\\nis well shown in sarcoma of the kidney by the frequency with which\\nstriped muscular fibres are found in the tumor. Sarcoma of the kid-\\nney grows very rapidly and often reaches an enormous size. Tumors\\nweighing ten pounds are not rare. The tumor is usually soft, and\\nUreter.\\n^^H^^**^ Kidney.\\nFig. 422.\u00e2\u0080\u0094 Renal tumor originating in an accessory adrenal (after Henry Morris).\\ncysts, large and small, are common. Hemorrhage into the cysts occurs\\nfrequently. In pyonephrosis an examination of the urine will throw\\nmuch light on the kidney affection, and in case the ureter is completely\\nobstructed, lumbar exploratory puncture will demonstrate the presence\\nof pus in the pelvis of the kidney. In two cases of sarcoma of the\\nkidney the writer found a large renal calculus in the pelvis. In one\\ncase the calculus was a perfect mould of the dilated pelvis and was\\nin direct contact with the tumor-tissue. It is a question whether the\\ncalculus acted as an exciting cause of the tumor or whether it devel-\\noped in consequence of the tumor.\\nTreatment. As sarcoma of the kidney destroys life in such a short\\ntime, an early operation is indicated, provided the opposite kidney is\\nin a healthy condition. This question can be determined by a careful", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0662.jp2"}, "649": {"fulltext": "SARCOMA.\\nPlate i!\\n72v\\nSarcoma of the kidney. Nephrectomy. Recovery, a, Secondary tumors; .polypoid projection of\\nprimary tumor into the pelvis of the kidney c, c, invasion by tumor of the adjacent kidney-substance\\n(St. Joseph s Hospital, Chicago).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0663.jp2"}, "650": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0664.jp2"}, "651": {"fulltext": "SARCOMA. 609\\nanalysis of the urine, and in females by catheterization of the ureter\\nwith Kelly s catheter. The mortality after the operation has been\\ngreat. According to S. W. Gross, of 64 nephrectomies for malignant\\ndisease, 33 died a mortality of 52.45 per cent. A number of the\\ncases died later of metastasis or local recurrence, so that of all the\\ncases, only 5 were alive and well two years after the operation. Not-\\nwithstanding these discouraging results, it is the duty of the surgeon to\\noperate if the patient s strength is such as to warrant the operation,\\nand if no indications are present that the tumor has extended beyond\\nthe organ primarily affected. Age is no contraindication to the opera-\\ntion. Steele of Chicago in 1894 successfully removed an enormous sar-\\ncoma of the kidney from a child only a little more than a year old. The\\nchild not only recovered from the operation, but afterward gained in\\ngeneral health. The mortality of intraperitoneal operation is over 50\\nper cent.; that of lumbar nephrectomy, about 25 per cent. If the\\ntumor is ?iot too large to be removed through a lumbar incision, this\\nmethod of operating should invariably be resorted to. Konig s incision\\nis the one that should be selected, as it affords more room than Simon s\\nand inflicts less traumatism than Bardenheuer s. Tumors too large\\nfor the lumbar operation should be removed by an incision through\\nthe linea semilunaris. A tumor that is too large to be removed by\\nlumbar nephrectomy cannot be removed by an extraperitoneal opera-\\ntion through an anterior incision, as has been claimed by some surgeons.\\nIf an extraperitoneal operation in part is attempted, the peritoneum will\\nsurely be torn during the operation. The external border of the rectus\\nmuscle serves as a guide in making the incision. The incision through\\nthe abdominal wall is made in the usual manner. After the abdominal\\ncavity has been opened to the requisite extent, the kidney, covered by\\nthe parietal peritoneum, will at once come in view. The intestines are\\nkept out of the way by aseptic gauze compresses. The peritoneum\\ncovering the tumor is then carefully incised, and when the capsule of\\nthe kidney has been identified the kidney with the tumor is enucleated.\\nIf the hilum of the kidney cannot easily be reached, and the vessels and\\nthe ureter cannot be tied separately, these structures are grasped with\\na covered compression-forceps, the kidney is removed, and the ureter\\nand the vessels are tied later. After arresting all hemorrhage the\\nperitoneal incision through which the kidney was removed is carefully\\nclosed with fine silk or catgut sutures, and the external wound is closed\\nin the usual manner. As the incision has been made through the\\nabdominal muscles, at least four rows of sutures should be employed\\nin closing the external incision. If for any reason it is deemed neces-\\nsary to drain the retroperitoneal wound, a counter-opening should be\\n39", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0665.jp2"}, "652": {"fulltext": "610 PATHOLOGY AND TREATMENT OF TUMORS.\\nmade in the lumbar region by tunnelling the tissues with a pair of\\nstrong and long hemostatic forceps from within outward, when the\\nskin in the lumbar region over the point of the instrument is cut, and\\nwith the forceps either a tubular drain or a strip of iodoform gauze is\\ndrawn through. After this has been done the peritoneal wound and\\nthe abdominal incision are dealt with in the manner just described.\\nFrom a woman thirty-eight years of age the writer removed a sarcoma\\nof the kidney by laparotomy according to the method described. The\\ntumor weighed eight pounds. No outward symptoms followed the\\noperation, and the patient left the hospital at the expiration of five\\nweeks. For several weeks her general health continued to improve, but\\nfour months after the operation a local recurrence could clearly be\\nmade out. The patient succumbed six months later, ten months after\\nthe operation. The tumor in this case was so large that intestinal\\nobstruction was threatened on several occasions. The intestinal symp-\\ntoms were produced by pressure of the tumor upon the colon. At\\nthe time of operation the colon was found in front of the tumor,\\nstretched and flattened by it.\\nUterus. The first case of sarcoma of the uterus was described in\\ni860 by Mayer. The diagnosis was verified by a microscopical exam-\\nination of the specimen by Virchow. Soon afterward Langenbeck\\nreported a case of inversion of the sarcomatous uterus. In 1867,\\nVeit was able to find only three recorded cases. In 1871, Keegar\\nbased his investigations on sarcoma of the uterus on nine cases which\\nhad been reported up to that time.\\nDiffuse sarcoma of the submucous connective tissue of the endo-\\nmetrium is much more frequent than sarcoma of the muscular wall\\nof the uterus. Of 144 cases collected by Williams, one-third were\\nlimited to the mucous membrane of the cavity of the uterus. The\\ntumor occurs as a diffuse infiltration or as a polypoid growth. In the\\ndiffuse infiltrating form the tumor is composed of round cells and\\nspindle-cells with a very scanty intercellular substance (Fig. 423).\\nKlebs and Abel have found in the uterine mucous membrane a\\ncombination of carcinoma and sarcoma a carcino-sarcoma. Diffuse\\nsarcoma of the uterine mucous membrane grows very rapidly, destroy-\\ning the glands and the mucous membrane and infiltrating the muscular\\nwall of the uterus. Local infection spreads much more rapidly than\\nin carcinoma.\\nThe polypoid variety appears as a firmer tumor and contains more\\nspindle-cells (Fig. 424).\\nIn the more circumscribed form of sarcoma of the uterine mucous", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0666.jp2"}, "653": {"fulltext": "SARCOMA.\\n611\\nmembrane the tumor attains considerable size before it ulcerates and\\ninvades at its base the uterine wall (Fig. 425).\\nFig. 423. Diffuse sarcoma of the uterine mucous membrane (after Wyder). The neoplasm is separated\\nfrom the peritoneum on the left by a well-marked layer of healthy muscular tissue several millimeters thick;\\nthe superficial portions toward the cavity of the uterus, on the right, are beginning to disintegrate. In the\\ndeeper parts are seen the connective-tissue fibres, rich in fusiform cells with long and short processes. Be-\\ntween them is an amorphous basement-substance with a large accumulation of cells, the nuclei of which\\nappear to resemble those of the others. In the superficial portions the bands of the connective and muscular\\ntissues have entirely disappeared, being replaced by round cells. The tumor is rich in vessels about which\\nare foci of hemorrhage. In no part of the tumor can we find any trace of mucous membrane or of glands.\\nFig. 424.\u00e2\u0080\u0094 Cells from a spindle-celled sarcoma of the neck of the uterus (after Pernice). Some of the cells\\npresent a cross-striation.\\nSarcoma of the muscular wall of the uterus is also either circum-\\nscribed or diffuse. The circumscribed form resembles myoma. In\\nthe diffuse variety the whole body of the uterus becomes enlarged.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0667.jp2"}, "654": {"fulltext": "612 PATHOLOGY AND TREATMENT OF TUMORS.\\nCyst-formation by degeneration or dilatation of lymphatics is common\\nin both forms. In a few cases cartilage has been found in uterine\\nsarcomata.\\nSarcoma is most frequently met with in young women. It presents\\nmany of the clinical aspects of carcinoma. The discharge is, however,\\nFig. 425. Sarcoma of the uterine mucous membrane (after Pozzi).\\nless fetid during the early stages, ulceration appears later, and the cer-\\nvix is not so much dilated as in carcinoma. Infection of the retro-\\nuterine glands, so common in advanced cases of uterine carcinoma, is\\nabsent in sarcoma.\\nThe prospects of a permanent cure by operation are not so good in\\nsarcoma as in carcinoma, as recurrence has followed early operations.\\nVaginal hysterectomy is indicated in all cases in which the sarcoma\\nhas not extended beyond the uterus.\\nDeciduoma Malignum. This is a malignant tumor of the chorionic\\nvilli, first described by Sanger in 1888. Since that time it has been\\ndescribed by different authors; and in 1895, when J. W. Williams wrote\\non this subject, he found 25 cases recorded, including his own. Histo-\\nlogically, this tumor differs according to the structure and nature of\\nthe cells of which it is composed. In some cases the tumor presented\\na carcinomatous structure, in others the structure corresponded with\\nsarcoma, and in rare cases a combination of sarcoma and carcinoma.\\nIn the majority of cases, however, the sarcomatous nature of the tumor\\nwas unquestionable. In the sarcomatous form the tumor is composed", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0668.jp2"}, "655": {"fulltext": "SARCOMA.\\n613\\nof spindle-shaped cells, containing large nuclei and polygonal or round\\nmultinuclear cells, with a very scanty or no well-defined reticulum.\\nPregnancy is the most important etiological\\nelement all the cases having followed labor\\nat full term, abortions, or hydatiform moles.\\nSanger divides the cases into two groups,\\naccording as they followed hydatiform moles\\nor pregnancy. The age of the patients varied\\nfrom seventeen to fifty-five years the largest\\nnumber of patients were between twenty and\\nthirty years of age. The most important\\nsymptom is uterine hemorrhage following\\nsome form of pregnancy. The hemorrhage,\\nas a rule, is not continuous, and appears\\neither soon after delivery or some months\\nlater. The uterus is enlarged in proportion\\nto the size of the tumor, and its walls are\\ninfiltrated by the growth. Recurrence after\\nremoval of the mass is the rule. The tumor\\ngives rise to early and diffuse metastases.\\nSecondary vaginal tumors constitute a char-\\nacteristic clinical feature of this disease. The\\nprognosis is very grave, as death usually\\noccurs within six months from the appear-\\nance of the first symptoms. In the diagnosis the clinical history of\\nthe case, uterine hemorrhages, and vaginal metastases are the most\\nimportant evidences to be taken into consideration. As the disease is\\nso rapidly fatal, and, as a rule, the patients do not come under the care\\nof a surgeon before metastasis has taken place, the treatment is of\\nnecessity only of a palliative nature. If the disease could be recog-\\nnized before it has resulted in metastases, complete removal of the\\nuterus would offer a fair chance of permanent recovery. Of eight hys-\\nterectomies performed for this condition, four died from recurrence of\\nthe growth the other four recovered from the operation, but sufficient\\ntime has not elapsed to show that the operation proved curative.\\nOvary. Sarcoma of the ovary is of rare occurrence. Cohn\\nestimates its frequency at about 1 per cent, in relation to cystic disease.\\nIt is usually bilateral, and it gives rise to ascites at an early stage.\\nIt is composed of spindle-cells or of round cells, the former variety\\nbeing more frequent. According to Eckhardt and Pomorski, many\\nsarcomata are of endothelial origin, springing from lymphatics or from\\nblood-vessels (Figs. 426, 427).\\n1,\\na\\nFig. 426. Endothelioma of the\\novary commencing proliferation of\\nendothelium in the lymphatic spaces\\n(after Pomorski) lymphatic\\nspace, with endothelial cells in the\\nmidst of an interstitial substance of\\nthe nature of connective tissue;\\na, alveolar dilatation of lymphatic\\nspace; p, proliferation of cells,\\nwhich arrange themselves like a\\nrow of beads. (Hartnack oc. 3,\\nob. 7.)", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0669.jp2"}, "656": {"fulltext": "614\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nThe symptoms of an ovarian sarcoma are those of rapidly-develop-\\ning malignant tumors. The tumor is found in preference in young\\nwomen. Ascites with hard nodular masses on one or both sides of\\nthe uterus should arouse suspicion regarding the malignant nature of\\nthe pelvic difficulty. The extension of the tumor to the tissues out-\\nside the tumor often renders an operation very difficult and results in\\nearly local recurrence. If the tumor is removed before it has ex-\\ntended to the broad ligament, the uterus, and other adjacent parts,\\na permanent cure is possible. Braun removed a sarcoma of the\\nFig. 427. Endothelioma of the ovary reticular modification of connective tissue under the influence of the\\nendothelial proliferation (after Pomorski) lymphatic space elongated and becoming transformed into an\\nalveolus b, bundles of interstitial connective tissue; r, transformation of fibrous connective tissue in a retic-\\nulum ep, transformation of epithelial cells into epithelioid cells connection of the large cells with the ground-\\nsubstance. (Magnification same as that of Figure 426.)\\novary, and the patient remained in good health eleven years after the\\noperation.\\nOf 36 cases of ovarian sarcoma recently collected by Zangenmeister,\\nand which were subjected to radical treatment, 4 died from the imme-\\ndiate and 3 from the remote effects of the operation, 3 from metastasis,\\n3 from local recurrence in 6 cases the ultimate result could not be\\nascertained 1 1 remained in good health and free from recurrence over\\nfour years, 2 after two years, and 1 died sixteen years after the opera-\\ntion from other causes.\\nVagina. Sarcoma of the vagina is found as a diffuse affection in\\nchildren; in the adult it presents itself as a firm, circumscribed tumor\\nmanifesting little tendency to degeneration. As pathological curiosities", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0670.jp2"}, "657": {"fulltext": "SARCOMA.\\n615\\nin this location there must be mentioned sarcomatous tumors, contain-\\ning striated muscular fibres, and melanotic carcinoma.\\nVulva. Among 10,000 patients Winckel saw only 2 cases of\\nsarcoma of the vulva. In one case the tumor was as large as a\\nman s head, and was attached to the vulva by a pedicle the size of\\na child s arm. The patient was then twenty-five years of age. The\\ntumor, which was first noticed when she was seventeen years old,\\nwas removed, and microscopical examination showed that it was a\\nround-cell sarcoma. In the second case the patient was a multi-\\npara forty-six years of age. The tumor, which was as large as a\\nchild s head, sessile, hard, and lobulated, was removed, and exam-\\nination showed it to be a myxo-sarcoma. Hildebrandt reports two\\nsimilar cases. Other cases have been recorded by Kleeberg and by\\nGustav Simon.\\nTesticle. Sarcoma of the testicle is not of frequent occurrence.\\nVirchow maintains that it is found most frequently in children, boys,\\nand old men. The writer has seen several cases of sarcoma in men\\nfrom twenty to forty years of age. The tumor is composed of spindle-\\ncells or of round cells, or it presents itself as a mixed-cell tumor. The\\nround cells are very large and are often multinuclear. The tumor is\\nquite firm, and on section presents a yellowish- or grayish-red color.\\nIt frequently begins in the epididymis. As the tumor increases in size\\nthe parenchyma of the testicle is displaced and destroyed. If perfora-\\ntion of the tunica albuginea has taken place, the tumor grows very\\nrapidly. Extension along the spermatic cord results in speedy and\\nextensive regional infection. Metastasis fre-\\nquently precedes the fatal termination. Very\\noften the same affection appears in the opposite\\ntesticle.\\nIn the differential diagnosis of sarcoma of the\\ntesticle it is important to exclude carcinoma, tuber-\\nculosis, gumma, and hematocele. Figure 428\\nrepresents a sarcoma of the testicle that occurred\\nin a child three and a half years old, and which\\nwas carefully reported by Neumann.\\nCastration is indicated if the spermatic cord is\\nnot affected or if the diseased part of the cord can\\nbe removed. In all operations for malignant dis-\\nease the cord should be removed as high as pos-\\nsible. For this purpose the inguinal canal should\\nbe laid open, and by gradual traction as much of the cord as practicable\\nshould be brought down and liberated. Enlargement of the retroperi-\\nFig. 428.\u00e2\u0080\u0094 Myosarcoma of\\nthe testis (after Neumann).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0671.jp2"}, "658": {"fulltext": "616 PATHOLOGY AND TREATMENT OF TUMORS.\\ntoneal glands in the inguinal region contraindicates castration. Some\\nof the sarcomatous tumors of the testicle contain striated muscular\\nfibres, and in very rare cases the tumor is pigmented.\\nBrain and its Envelopes. In the brain we have described, as\\npeculiar varieties of sarcoma, psammoma and glioma. The dura mater\\nis not infrequently the starting-point of sarcoma. The tumor destroys\\nthe bone over it, and appears, after perforation has taken place, as\\na pulsating tumor.\\nOperative treatment is contraindicated in psammoma and is of\\ndoubtful propriety in glioma. Bergmann for good reasons opposes\\nintracranial operation for malignant disease. Surgeons, however, will\\ncontinue to operate for glioma, as the tumor frequently produces focal\\nsymptoms which enable them to locate it with precision, and a positive\\ndiagnosis is usually made only after the tumor has been exposed or\\nafter operation, by examination of sections of the tumor under the\\nmicroscope.\\nSarcoma of the dura mater, if it could be diagnosed at an early\\nstage, should be removed by operation. After the tumor has perforated\\nthe skull the intracranial part of the tumor is usually so extensive that\\nan operation would prove of no avail.\\nBye. The optic nerve and its branches are not infrequently the\\nseat of glioma. In the interior of the eye the malignant tumors are\\nrepresented by melano-carcinoma and melano-sarcoma, the latter being\\nmuch the more frequent. Pigmented sarcoma may arise from any part\\nof the uveal tract that is, from the pigmented tissue of the iris, the\\nciliary body, and the choroid. The commonest seat is the choroid.\\nThe intraocular sarcomata are either round-celled, spindle-celled, or\\nmixed-cell sarcoma. Sarcoma of the eye occurs most frequently in per-\\nsons from forty to sixty years of age, but is occasionally seen in children.\\nThe tumor extends along the blood-vessels and the optic nerve. The\\nincreased intraocular tension results in sloughing of the cornea, when\\nthe tumor protrudes in the form of a pigmented fungous mass. Exten-\\nsion of the tumor along the optic nerve into the cranial cavity does\\nnot often take place. Metastasis at quite an early stage is of frequent\\noccurrence, the tumor in this respect resembling melano-sarcoma of\\nthe skin.\\nEarly enucleation is the only surgical resource in all cases of melano-\\nsarcoma of the interior of the eye. This operation should be performed\\nas soon as the tumor can be detected and diagnosed by the aid of the\\nophthalmoscope.\\nBladder. Sarcoma is a very rare affection of the bladder, and\\nmost of the cases so far reported were in young females. Kuster", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0672.jp2"}, "659": {"fulltext": "SARCOMA. 617\\nreported five cases, and one case came under the observation of Konig,\\nwho removed a pedunculated round-celled sarcoma the size of a hen s\\negg from the neck of the bladder by perineal section. Sarcoma in the\\nbladder, in its structure and its manner of local extension, very closely\\nresembles sarcoma of the uterus. It starts most frequently in the\\nsubmucous connective tissue. In the differential diagnosis between\\nsarcoma and carcinoma of the bladder it is important to remember\\nthat sarcoma is much the more rare, that it is found in preference in\\nyoung females, and that ulceration occurs later than in sarcoma. The\\ndifferential diagnosis between sarcoma of the bladder and benign\\ntumors, and the treatment, are the same as in carcinoma.\\nProstate. Malignant tumors of the prostate start primarily in this\\norgan, as the prostate is seldom affected secondarily either by extension\\nof the tumor from an adjacent organ or by metastasis. Wyss collected\\n28 cases of malignant disease of the prostate in young boys less than\\nten years old. In all of the cases the prostate was the primary seat of\\nthe tumor. The symptoms resemble those of carcinoma of the same\\norgan. Thompson has reported 18 cases of primary malignant tumors\\nof the prostate. Kapuste has shown by his investigations that tumors\\nof the prostate in children are usually sarcomatous, while carcinoma\\nof this organ is a disease of advanced age. Besides the functional\\ndisturbances produced by the tumor, spontaneous pain, hemorrhages,\\nand the escape of fragments of the tumor after ulceration has set in\\nare the most conspicuous clinical phenomena.\\nRadical operations for tumors of the prostate have been performed\\nby Billroth, Demarquay, Nussbaum, and others. In Nussbaum s and\\nBillroth s cases a part of the rectum was removed with the prostate\\nand a part of the bladder-wall. If the disease has not extended beyond\\nthe prostate and these are the cases to which radical operations should\\nbe restricted the prostate and as much of the neck of the bladder as\\nis endangered by the tumor should be removed through the perineal\\nincision devised by Zuckerkandl. The efficiency and safety of the\\noperation would be enhanced by a preliminary suprapubic cystotomy.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0673.jp2"}, "660": {"fulltext": "XXIX. TERATOMA.\\nSo far we have considered tumors composed of a single representa-\\ntive histological element. We have studied tumors composed of cells\\nderived from one of the germinal layers the epiblast, the hypoblast,\\nand the mesoblast and have found that the different classes of tumors\\nrepresented the tissues of only one of these embryonal layers. The\\nepiblast and the hypoblast were represented by papilloma, adenoma,\\nand carcinoma the mesoblast, by the different tumors representing the\\nconnective-tissue type of benign tumors and sarcoma. We now come\\nto the last class of tumors that contain tissues and organs derived\\nfrom two or all of the germinal layers.\\nDefinition. A teratoma is a tumor composed of various tissues,\\norgans, or systems of organs which do not normally exist at the place\\nwhere the tumor grows. The highest type of a teratoma is a foetus\\nin foetu. In the simpler varieties the tumor is composed of heterotopic\\ntissues, such as bone, teeth, skin, mucous membrane, etc. All teratoid\\ntumors are congenital that is, the tumor either exists at the time of\\nbirtli or the patient is born with the essential tumor-matrix. A teratoma\\nnever springs from a matrix of post-natal origin.\\nOrigin of Teratoid Tumors. A tumor composed of a single rep-\\nresentative histological element frequently starts from a matrix of post-\\nnatal origin, as the writer has aimed to show in connection with all the\\ntumors so far discussed but the more complicated matrix of a tera-\\ntoma has invariably a congenital origin, and is produced in the embryo\\nby errors of growth and by displacement of tissue by inclusion. Klebs\\nclassifies teratoma according to their origin into endogenous and ecto-\\ngenous, the former arising from a matrix formed in the same individual,\\nthe latter from foetal inclusion. The latter mode of origin is possible,\\nbut certainly very rare. A case of this kind was recently reported\\nfrom Gussenbauer s clinic by Pupovac. The patient was an infant, and\\nthe congenital tumor involved the side of the neck. Examination of\\nthe tumor showed embryonic tissue representing different parts of the\\nbody bone, cartilage, muscle-, gland-, and brain-tissue. One of the\\nstrongest arguments in support of the correctness of Cohnheim s theory\\nconcerning the origin of tumors is furnished by the teratomata. Maas\\nsucceeded in producing dermoid cysts artificially in animals by implan-\\n618", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0674.jp2"}, "661": {"fulltext": "TERATOMA. 619\\ntation of dermoid fetal tissue. He produced dermoid cysts in young rats\\nby introducing into the peritoneal cavity pieces of skin and parts of limbs\\nof new-born rats. After two and a half months he found small cysts\\ncontaining pus, cholesterin, and hair. The lining of these cysts was com-\\nposed of tissues representing all the histological elements of true skin.\\nA great deal of speculation has been rife in reference to the origin\\nof the higher types of teratoma. Rauber pointed out that two embryos\\nmay spring up in union in the same blastoderm or close to one another,\\nin which case they may afterward fuse. Fusion is more frequent at\\nthe caudal extremity, but occasionally it occurs at the cephalic end or\\nelsewhere along the vertebral axis. In the subsequent growth the\\nembryos usually develop unequally until one becomes a mere parasite\\non the other. In conformity with this explanation is the fact that der-\\nmoid teratoid formations in the region of the coccyx are proportionately\\ncommon. At the cephalic end, in the region of the hypophysis, tera-\\ntoid tumors are occasionally met with, the origin of which could be\\nexplained upon the same hypothesis. Williams, on the contrary, is\\nfirmly convinced that such tumors are produced not by blending of\\ntwo distinct embryos, but by giant growth of undifferentiated cells\\nOccasionally a mass of undifferentiated protoplasmic cells manifests\\nreproductive properties similar to those of the hydra, so that from a\\nsingle cell two or more individuals may proceed. Thus, when the\\ndivision of the undifferentiated embryo into two symmetrical parts is\\ncomplete, and each of these develops into a new being, homologous\\ntwins are the result and this, so common a mode of reproduction in\\nthe lower animals and plants, is the only instance of reproduction by\\ngemmation in the highest animals. In this way double monsters arise.\\nThe locality and degree of fusion present many variations. The usual\\npoints of attachment are the sacrum, sternum, umbilicus, and head.\\nThe sex of the individuals in homologous twins and double monsters\\nis invariably the same. In other instances the distribution of proto-\\nplasmic cells in the embryo is unequal, so that only one of the two\\nfetuses attains full development. The former are called autosites;\\nthe latter, parasites, because they depend for nutrition upon the body\\nto which they are attached. The parasite is either attached to the sur-\\nface of the autosite by implantation or is surrounded by the tissues of\\nthe autosite by inclusion. Sometimes only a part of a new individual\\nis formed in such a manner, which gives rise to tumor-like formations\\ncalled by Virchow teratoma. Such tumors are found most fre-\\nquently in the region of the ovaries, testicles, sacrum, and sella turcica.\\nThey represent imperfect parasitic fetuses. Partial fission of the embryo\\nat the cephalic end gives rise, according to the degree of fission, to", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0675.jp2"}, "662": {"fulltext": "620 PATHOLOGY AND TREATMENT OF TUMORS.\\nduplication of the pituitary body, to the formation of two distinct and\\ncomplete faces. Additional masses of protoplasmic cells result in the\\nformation of all kinds of deformities, as supernumerary fingers and toes,\\nsupernumerary mammary and thyroid glands, and, if the cells only\\npossess the intrinsic capacity to produce one tissue, all conceivable forms\\nof local hypertrophies, such as angiomas, moles, warts, lipomas, etc.\\nThere can be but little doubt that double monstrosities are the\\nresult of fusion of two distinct embryos, as symmetrical segmentations\\nof an embryo to this extent in man and the higher animals is not likely\\nto occur. We have also reason to believe that ectogenous and en-\\ndogenous parasites originate in a similar manner, while the different\\nvarieties of dermoids, the teratomata proper, originate in the manner\\nindicated by Williams and others.\\nEndogenous Teratomata. These tumors are represented by the\\nhistioid and organoid varieties. The histioid variety is represented by\\nheterotopic tumors, such as chondroma branchiogenes, branchial cysts,\\nand the simplest forms of dermoid cysts. The organoid tumors spring\\nfrom displaced embryonal matrices representing different tissues and\\norgans, and occur in localities where in the embryo displacement of\\ntissue has taken place. The capacity of tissue-proliferation of the cells\\nof which the matrix is composed does not exceed that of the cells of\\nthe corresponding normal tissue. For instance, a dislocated tooth-\\ngerm will produce a* tooth not larger than a normal tooth, and a dis-\\nlocated acinus of a gland will produce an acinus which in size does\\nnot exceed the acinus of a corresponding normal gland.\\nSutton describes a rare case of ovarian mamma removed from a\\nwoman twenty-six years of age, supposed to be suffering from tubercu-\\nlar peritonitis. Upon opening the abdomen a considerable quantity of\\npus escaped, mixed with hair and sebaceous material, showing it to be\\nthe remains of a dermoid cyst. On examination, a peculiar, rounded\\nbody, growing from the wall of the cyst, was found, recognized as an\\novarian mamma, and removed. It presented an ordinary nipple and\\na cluster of glandular material, the ducts of which traversed the nipple.\\nThe endogenous skin-teratoma is the most frequent form of fetal\\ninclusion. Portions of the embryonal skin become buried in the meso-\\nblast and are isolated by constriction from the skin, and serve later as\\nmatrices for dermoid tumors. In many endogenous teratoid tumors\\nthe matrix, derived in a similar manner, has a more complicated struc-\\nture, and from it develop teeth, bone, portions of the alimentary canal,\\netc. In such a manner originate, in the interior of the skull, tumors\\ncontaining striated muscular fibres (Arnold) and teeth (Hugo Beck).\\nEctog-enous Teratomata. Ectogenous teratomata are produced by", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0676.jp2"}, "663": {"fulltext": "TERATOMA.\\n621\\nthe blending or fusion of two distinct embryos. The tumors originate\\neither by the allantois of one fetus entering the cavities of the body of\\nthe other fetus, where its vessels enter into communication with those\\nof the other, or by attachment between two impregnated ova, of which\\none grows around the other. In the first case inclusions, allantoid\\ninclusions, are formed in connection with the umbilical cord and the\\nplacenta-like productions in the latter instance the development of the\\nincluded fetus is impaired by the greater development of the organs\\nand tissues of the autosite, and often only remnants are found in the\\nplace formerly occupied by the parasitic fetus.\\nIn the museum of the College of Physicians and Surgeons in Lon-\\ndon is the most perfect specimen of foetus in fcetu. The autosite, a boy,\\nlived to be fourteen years of age and was well developed. At the post-\\nmortem there was found in the abdominal cavity a perfect, full-grown\\nfetus surrounded by a sac or membrane.\\nAhlfeld collected 20 cases of foetus in foetu, but he believes that in\\nperhaps half of them the diagnosis was erroneous, dermoid cysts hav-\\ning been mistaken for inclusio foetalis. Inclusion-cysts not only contain\\na diversity of tissue elements and organs, but they are almost always\\nmultilocular while, on the other hand, dermoid cysts are lined with\\nskin, which presents all the structures of normal skin epidermis, rete\\nFig. 429.\u00e2\u0080\u0094 The inclusion of one embryo within the cephalic fold of the other (Ahlfeld).\\nMalpighii, papillae, sweat and sebaceous glands, hair, teeth, etc. and in\\nmost cases the cyst is unilocular (Fig. 429).\\nIn some of these cases of fetal inclusion parts of the parasitic fetus\\ngrow, while other parts are dwarfed by insufficient vascular supply,\\ncease to grow, and are removed by absorption.\\nTo the pre-allantoid teratomata belong the fetal implantations in", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0677.jp2"}, "664": {"fulltext": "Fig 430. Laloo, a Hindoo with an acardiac parasite attached to the thorax.\\nFig. 431.\u00e2\u0080\u0094 Dipygus (Wells).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0678.jp2"}, "665": {"fulltext": "TERA TOMA. 623\\nwhich parts of the parasitic fetus are contained in cysts. Such cysts\\nare found in the mediastinum, the brain, the abdomen, the ovaries, and\\nthe testicles. Ahlfeld separated from these tumors what he calls fetal\\ntransplantation cases in which rudimentary fetal parts are engrafted\\nupon the surface of the body. In partial fetal inclusions the acardiac\\nparasite may present externally to the autosite all limbs (Fig. 430), or\\nthe upper part of the body may be destroyed by inclusion and the\\nlower limbs may project from the autosite (Fig. 431).\\nThe included parasitic fetus is often blighted at a very early stage,\\nand none of its organs reaches a full degree of development. The more\\nimportant organs either are absent or are present in only a rudimentary\\nform. This form of teratoma has been well described by Sutton as\\nacardiac fetus.\\nIn some cases the fetus consists simply of a shapeless mass in\\nwhich only traces of the skeleton and of the more important organs\\nare found. The sex is invariably the same as that of the autosite; the\\nacardiac can occur only in plural births.\\nAcardiacs may appear in plural births as separate beings, or they may\\nbe attached to the twin autosite in a variety of ways. In a few instances\\nthe autosite and the acardiac parasite have lived and attained maturity.\\nThe diagnosis of included parasites according to their location is\\nusually impossible and is at all times uncertain. The recognition of\\nparasitic fetuses or parts of them on the surface of autosites is attended\\nby no difficulty.\\nSutton has well said that parasitic acardiacs are in almost all cases\\nso valuable as sources of gain in dime museums, fairs, shows, and large\\ncities that the parents or the unscrupulous individuals who get pos-\\nsession of these children will not permit operative interference, and\\nhence it is useless to discuss the propriety and feasibility of operation\\nin cases of autosites bearing an acardiac fetus.\\nThe different forms of superfetation and blending of twins by attach-\\nment or by allantoid inclusion, so interesting to embryologists and\\npathologists, are of little practical value to the surgeon. The surgical\\ninterest of teratoma attaches itself to those tumors caused by displace-\\nment of fetal tissues, parts, or organs, to which Virchow applied the\\nterm teratoma, or, from their resemblance to a terato, teratoid\\ntumors. We shall discuss at greater detail the tumors included in\\nthis class branchial and dermoid cysts.\\nBranchial Cysts.\\nTumors in the branchial clefts are not so very rare as was formerly\\nbelieved. Chondroma branchiogenes was described in the section on", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0679.jp2"}, "666": {"fulltext": "624\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nChondroma. Branchial ftstnlce and cysts result from imperfect oblitera-\\ntion of one of the branchial clefts.\\nAnatomy and Embryology. Toward the end of the first month\\nof fetal life we see under the frontal process, open in front and bounded\\non the sides by four plates, the pharyngeal cavity. The upper pair\\nof plates constitute the first branchial arch. The next three pairs of\\nplates make up the second, third, and fourth branchial arches, which\\ndecrease in size from above downward, so that their median interspaces\\nin front are narrow above and wider lower down. Between each pair\\nof branchial arches on each side remains a transverse cleft, the branchial\\nclefts, which are obliterated during early fetal life, with the exception\\nof the first one, from which the external auditory canal, the cavity of\\nthe tympanum, and the Eustachian tube are developed. From the\\nsecond branchial arch are developed the styloid process, the stylo-\\nhyoid ligament, and the lesser horn of the hyoid bone. The third arch\\nforms the large horn and the body of this bone. The fourth arch\\nassists in forming the soft tissues of the neck. The larynx, the\\ntrachea, and the adjacent glands are developed from other centres\\nof fetal growth.\\nThe primary starting-point of branchial cysts must necessarily cor-\\nrespond with the location of one of these branchial clefts, and clinical\\nobservation has demonstrated that branchial\\ncysts are most frequently found in the region\\nof the second and third clefts, in the vicinity\\nof the larynx and pharynx, and in intimate\\nrelation with the sheath of the large vessels\\nof the neck, in contradistinction to dermoid\\ncysts about the orbits and the scalp, which\\nare more superficially located (Langenbeck).\\nWe shall have frequent occasion to allude\\nto the intimate connection of these tumors\\nwith the sheath of the large vessels of the\\nneck, and consequently it is very important\\nto study their anatomical relations to these\\nimportant structures. The jugular vein is\\nsurrounded throughout its whole course in\\nthe neck by a distinct and separate sheath of areolar tissue, which on\\nthe outer side of the artery penetrates into the deep tissues of the neck,\\nthus completely separating the two vessels. The jugular, enclosed in\\nits sheath, may easily be drawn over the artery toward the median\\nline without producing any change of location of the artery. The\\nFig. 432.\u00e2\u0080\u0094 Branchial cyst of the\\nthird branchial cleft in a woman\\nthirty-eight years old.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0680.jp2"}, "667": {"fulltext": "TERATOMA. 625\\nvein being in front of the artery and covering half of the circumference\\nof the latter, it can readily be understood that when the vein is drawn\\nforward with its sheath it can be injured, while the artery is not exposed\\nto the same danger. Branchial cysts of the second and third clefts\\nare always found in the sheath of the large cervical vessels, usually in\\nthe carotid triangle above the omo-hyoid muscle. These cysts, which\\nappear to occur more frequently on the left side of the neck, are\\ninvariably round or oval, with a smooth surface. The contents of\\nthese cysts being either fluid or semi-fluid, fluctuation can be felt, more\\nparticularly if the tumor is palpated between two fingers from the\\npharynx or the floor of the mouth and the external surface. Only\\nlateral motion of the tumor is possible, on account of its peculiar\\nattachments to the deep tissues of the neck. If the tumor is of only\\nmoderate size, the pulsations of the carotid artery can be felt on its\\ninner margin. If the tumor is large, it overlaps the artery, and the\\npulsations of the vessel are communicated to the tumor. Small tumors\\ncan be made to pulsate by bending the head backward and in a direc-\\ntion opposite to the tumor.\\nHistory. Branchial fistulae, persistent branchial clefts, have been\\nknown longer than branchial cysts. It appears that Hunczowski\\nmore than a hundred years ago described two cases of congenital\\nfistulous openings in the side of the neck. About fifty years later Roser\\nmade the statement that many of the so-called ranulas about the\\nbase of the tongue, the mucoid and dermoid cysts of the upper cer-\\nvical region, are due to imperfect closure of one of the branchial tracts.\\nAll these tumors he included in one group under the name branchial\\ncysts. He described three distinct conditions which may result from\\nentire absence or from imperfect obliteration of any one of the branch-\\nial clefts: 1. Branchial fistula, in case the entire tract remains open;\\n2. Cystic fistula, in case only one end of the cleft is obliterated, while\\nthe other open end communicates with the pharynx or with the cutane-\\nous surface; 3. Branchial cysts, in the event that the cleft is closed\\nat both ends, while between them it remains open, and by proliferation\\nfrom the inner surface produces an accumulation the contents of the\\ncyst.\\nHensinger in 1862 collected a number of cases of branchial cysts,\\nand associated them with the branchial clefts discovered by Rathke.\\nBranchial fistulae are always congenital. Branchial cysts are congenital\\nin the sense that patients are born with the tumor-matrix, which con-\\nsists of the unobliterated portion of a branchial cleft but the tumor\\nfrequently does not appear until the person arrives at the age of\\npuberty, when, by the stimulus imparted by an increased physiological\\n40", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0681.jp2"}, "668": {"fulltext": "626\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nfunction of the skin, active tissue-proliferation of the cells composing\\nthe cyst-wall sets in, resulting in the formation of the cyst-contents.\\nAlthough these cysts are by no means common, being less frequent\\nthan congenital branchial fistulae, a sufficient number of cases have been\\nplaced on record to remove all doubt as to the etiological relations\\nexisting between imperfectly obliterated branchial clefts and the serous,\\nthe dermoid, and the so-called deep-seated atheromatous tumors of\\ncongenital origin located in the regions formed by the branchial arches.\\nThese tumors have been made a special object of study by Langen-\\nbeck, Liicke, Gurlt, Virchow, Schede, Esmarch, and Hensinger.\\nClassification. Branchial cysts must be classified according to\\ntheir contents. The cyst-wall being lined with epithelium displaced\\nfrom the pharynx or from the skin, the only histological element in\\nthe contents is epithelium (Fig. 433). The wall is composed of con-\\nFig. 433.\u00e2\u0080\u0094 Structure of wall of branchial cyst, from case represented in Figure 444 X 280 a, blood-\\nvessel; b, inflammatory infiltration; c, connective tissue; d, epithelial lining of cyst; e, contents of cyst.\\nnective tissue lined on the inside with epithelial cells. In most instances\\nthe epithelium lining the cyst-wall and contained in the cyst-contents\\nrepresents the epithelium of the skin (Fig. 434) but Rehn discovered,\\nin a blind congenital fistula ending near the mucous membrane of the\\npharynx, ciliated epithelium, which, of course, must have been derived\\nfrom the pharynx. Neumann found cylindrical and pavement epithe-\\nlium in two cystic tumors of the neck one of the tumors was con-\\ngenital, while the other was developed in later years. The presence\\nof ciliated epithelium may be explained by assuming its origin to have\\nbeen in the upper part of the cleft, the fornix pharyngis, where these", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0682.jp2"}, "669": {"fulltext": "TERATOMA.\\n627\\nfistulae oftentimes end and where ciliated epithelium normally exists.\\nThe lower end was probably derived from the skin, and was lined with\\nflat cells.\\nThe physical and chemical properties of the cyst-contents will\\ndepend largely on the kind and degree of regressive transformation\\nFig. 434. Contents of branchial cyst; X 140.\\nof the epithelial proliferation. In making the character of the cyst-\\ncontents a basis for classification it is, however, important to remember\\nthat, as in ordinary retention-cysts, the contents of a branchial cyst are\\nliable to undergo changes depending on the retrograde changes of the\\nepithelial product, on hemorrhage and other transudations into the sac,\\nor on the occurrence of inflammation in the cyst-wall itself. It is only\\nduring the earliest stages that the characteristic secretion is found in\\nits purity. In the course of time the original character of the cyst-\\ncontents may be lost completely by retrograde metamorphosis or by the\\naddition of new material.\\nClinical experience and pathological investigations have shown that\\nbranchial cysts, according to the physical properties of their contents,\\nmay be divided into the following principal varieties I. Mucous cysts\\n2. Atheromatous cysts 3. Serous cysts 4. Hemato-cysts. Variable\\nas the contents of these different varieties of cysts may be, more\\nuniformity is observed in the structure of the cyst-wall. In the begin-\\nning the cyst-wall consists of a connective-tissue capsule with an\\nepithelial lining on its inner surface (Fig. 433), and a delicate layer of\\na loosely connected reticulum of connective tissue, the pericystium,\\nwhich is very vascular and which covers the outer surface of the cyst.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0683.jp2"}, "670": {"fulltext": "628 PATHOLOGY AND TREATMENT OF TUMORS.\\nA high degree of intracystic pressure may cause atrophy of the\\nepithelial lining and thinning of the walls of the sac on the contrary,\\ninflammatory proliferation produces great thickening of the cyst-wall.\\nWhile dermoid cysts contain the characteristic secretions of the skin\\nand its appendages, the branchial cysts contain the product of epithelial\\ncells, because their walls do not contain any hair-follicles, sebaceous\\nglands, or sweat-glands, as the branchial clefts close before these\\nappendages are formed.\\nMucous Branchial Cysts. As a primary tumor this form of\\nbranchial cyst is found in the upper part of the branchial clefts. The\\norigin of mucous branchial cysts is attributable to an imperfect closure\\nof the upper portion of a branchial tract consequently the cyst-wall\\nmay derive its lining from the mucous membrane of the pharynx, and\\nthe retention of the physiological secretion produces a mucous cyst.\\nMany of the so-called ranular cysts about the base of the tongue\\nbelong to this variety of tumors.\\nCongenital mucous cysts in the region of the base of the tongue\\nand the sides of the larynx in the majority of cases are due to an\\nimperfect closure of the upper portion of one of the branchial tracts.\\nAtheromatous Branchial Cysts. This form of branchial cyst has\\nbeen described as a deep-seated atheromatous cyst of the neck (Schede)\\nand as a dermoid cyst of the sheath of the large vessels of the neck\\n(Langenbeck). The cysts are usually located in the second or third\\nbranchial tract, in the region of the hyoid bone, and they are inti-\\nmately connected with the sheath of the large vessels. They contain\\nan atheromatous material resembling the contents of an ordinary reten-\\ntion-cyst of the sebaceous glands. They never contain lanuginose\\nhair, as do many of the dermoid cysts. Gurlt mentions the great\\nsimilarity existing between the contents of these tumors and those of\\nsome ovarian cysts. Besides fat-globules and epithelial debris these\\ncysts contain an abundance of cholesterin-crystals and of small pris-\\nmatic crystals which seem to be some form of inorganic salt, as well\\nas lime in granular form. In some cases the inner surface of the cyst-\\nwall is covered with papillomatous excrescences, the product of epithe-\\nlial proliferation.\\nThese atheromatous branchial cysts may occur in the first branchial\\ncleft, as is shown by a case reported by Virchow, who described the\\ncyst as an auricular teratoma. The patient was a seamstress twenty-\\nfour years of age. The tumor was first noticed when she was fourteen\\nyears old, when it was as large as a filbert it increased slowly in size,\\nand when first seen by Virchow it was as large as a goose-egg it was\\nlocated between the angle of the jaw and the mastoid process, and was", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0684.jp2"}, "671": {"fulltext": "TERATOMA. 629\\nfirmly attached to the sheath of the carotid artery. The cyst was filled\\nwith a creamy yellowish fluid which contained free fat and epithelium.\\nThe portion attached to the sheath of the vessels contained a plate of\\ncartilage resembling the cartilage of the ear hence Virchow designated\\nthe tumor as an auricular teratoma. Virchow, who attributed the\\norigin of this and of analogous growths to an imperfect obliteration\\nof the first branchial cleft, in his classification of tumors includes among\\nthe teratoid tumors the cysts developed from branchial clefts.\\nSerous Branchial Cysts. This form of branchial cyst is composed\\nof thin cyst-walls and serous contents. The cysts very much resemble\\nin structure and contents the lymphangiectatic cysts of the neck, for\\nwhich cysts they have often been mistaken. They occupy one of the\\nbranchial clefts, and they are lined by epithelial instead of endothelial\\ncells, as is the case in cysts originating from lymphatics. The lymph-\\nangiectatic cysts are usually congenital. We have seen that branchial\\ncysts are not necessarily developed during intra-uterine life or soon\\nafter birth. All that is necessary is that the matrix for the cyst be\\npresent at the time of birth from this matrix, at some future time, the\\ntumor is developed. These tumors appear as either single or multiloc-\\nular cysts with thin membranous walls their internal surface is lined\\nwith epithelial cells. Besides serous fluid they contain epithelial cells\\nand cholesterin-crystals. Clinically, they may be recognized from their\\nlocation, their globular form, their soft fluctuating feel, and their pain-\\nless growth. The existence of pavement epithelium upon the inner\\nsurface of these cysts has been demonstrated by Neumann and Baum-\\ngarten. When these cysts spring from the second or third branchial\\nclefts they are usually deeply located. Hueter, in extirpating a tumor\\nof this kind in a child two years of age, found that the tumor extended\\nbetween the two carotid arteries back to the pharynx. That these\\ntumors may sometimes grow to an enormous size is evident from a case\\nreported by Treves. The tumor, which occurred in an infant, took its\\norigin in the region of the inferior maxilla and occupied the whole side\\nof the neck and the upper part of the thorax on the same side, whence\\nit extended as far as the umbilicus. It contained one large and numer-\\nous smaller cysts, and it corresponded with the region of the second\\nbranchial tract. No histological report of the specimen was made.\\nVonwiller reports a case of double serous branchial cyst. The writer\\nhas seen a number of such cysts in young children. The cysts wore\\neither present at the time of birth or developed a few months later.\\nHemato-cysts of Branchial Clefts. In some instances of serous\\nbranchial cysts the fluid is discolored by an admixture o( blood from\\nminute hemorrhages into the sac but when the contents are of such", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0685.jp2"}, "672": {"fulltext": "630 PATHOLOGY AND TREATMENT OF TUMORS.\\ndark color as to resemble venous blood the cysts are properly called\\nhemato-cysts, and from a pathological, clinical, and diagnostic point\\nof view they constitute a distinct and well-marked variety of branchial\\ncysts. Albert remarks that two kinds of these cysts have been ob-\\nserved I. Those which can be emptied by pressure and which are\\nin direct communication with blood-vessels 2. Those which are not\\naffected by pressure, and which simulate the appearance of an ordinary\\nserous cyst so closely that their nature is recognized only by explora-\\ntory puncture. The latter class of cysts, when they occur in the neck,\\nusually belong to the branchial cysts, because they are observed during\\nearly life and originate in places which correspond with the location of\\nbranchial clefts. This variety of cysts has been called hematocele colli\\nby Michaux, and hematocele by J. P. Frank. Aside from their origin\\nfrom branchial clefts and the admixture of blood with the contents of\\nserous cysts, hemato-cysts may develop from dilated veins, both extrem-\\nities of the dilated portion undergoing contraction and finally complete\\nobliteration, completely isolating the contents of the cyst from the\\ngeneral circulation. Again, a vein may dilate at one point, forming\\na pouch or a sac, and by contraction and obliteration of the orifice\\na blood-cyst is formed.\\nHemato-cysts resemble serous cysts in every particular, with the\\nexception of the presence of blood in their contents. Their diagnosis,\\nhowever, is more difficult than that of serous cysts, and it should\\nalways be made by exclusion, due attention being given to the location\\nof the cyst, its time of development, and the character of its contents.\\nThe last point can be settled definitely by an exploratory puncture.\\nEtiology. Branchial cysts of the neck, as compared with other\\ntumors in this locality, are of rare occurrence. The statistics of\\nbranchial tumors cannot be relied upon in estimating the comparative\\nfrequency with which these tumors occur, as many branchial cysts have\\nbeen classified and described under the generic and indefinite term\\ncystic tumors of the neck, without regard to their etiology. Gurlt\\nin 1855 compiled 44 cases of serous and 6 cases of atheromatous cysts.\\nSince that time a great many more cases have been reported. The\\nserous variety is more apt to develop early. The tumors are often\\ncongenital or appear during infancy or childhood, while the athe-\\nromatous cysts are most frequently met with in young adults. Of 53\\ncases tabulated by Schede, 9 occurred between the first and tenth years,\\n21 between the eleventh and twentieth, 10 between the twenty-first and\\nthirtieth, 6 between the thirty-first and fortieth, 5 between the forty-first\\nand fiftieth, and 2 between the fifty-first and sixtieth years. Like the\\ndermoid cysts, the branchial cysts show a tendency to develop during", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0686.jp2"}, "673": {"fulltext": "TERATOMA. 631\\nthe period of puberty, at a time when the tissue of epiblastic origin\\nenters upon a new and more active phase of development. The\\nremnant of a branchial cleft may remain dormant as a matrix for\\nthe future growth of the tumor for an indefinite period of time, and\\nbecome the seat of tissue-growth during puberty or upon the advent\\nof any other determining cause or causes. There are undoubtedly\\nmany instances where remnants of fetal tissue remain latent in the\\nbranchial tracts throughout a long lifetime for want of an adequate\\nexciting cause, which is necessary to stimulate into morbid activity the\\nslumbering forces inherent in the histological elements of the matrix.\\nDiagnosis. To diagnose the presence of a branchial cyst is often\\nno easy task. The importance of the tissues and organs in close and\\nintimate relation with these tumors renders it imperative upon the\\nsurgeon to make a correct diagnosis before an operation is undertaken\\nfor their removal. All signs and symptoms should be investigated\\ncarefully, and every diagnosis should be fortified by eliminating by\\nexclusion the existence of all other forms of tumors and infective\\nswellings. The following conditions may stimulate a branchial cyst\\n1. Aneurysms; 2. Hemato-cysts and lymphangioma 3. Dermoid\\ncysts; 4. Retention-cysts; 5. Lymphangiectatic cysts; 6. Struma\\ncystica. After eliciting a careful clinical history as to the location and\\nthe time of development of the tumor, these affections should be gone\\nover seriatim in making a differential diagnosis between them and\\na branchial cyst. The exploratory syringe will frequently be called\\ninto requisition to ascertain the character of the cyst-contents.\\nPrognosis. Branchial cysts, although heterologous formations,\\nalways remain purely local affections, manifesting no tendency to\\ndestroy life except when they are of a size sufficient to interfere by their\\npresence with the performance of important functions of neighboring\\norgans. The tumor may encroach upon the cavity of the mouth, inter-\\nfering with speech, mastication, and deglutition, or it may compress the\\nlarynx or the trachea, thus interfering with respiration.\\nBranchial cysts manifest no tendency to spontaneous cure, and prove\\nexceedingly rebellious to all kinds of treatment short of complete\\nextirpation. In a case of branchial cyst of the second branchial cleft\\nwith mucous contents, the writer was informed by the patient that she\\nhad been operated upon more than fifty times, the tumor reappearing\\neach time within a few weeks after the operation. That part of the\\ncyst-wall which had not been extirpated was found greatly thickened\\nand firmly attached to the internal carotid artery and the hyoid bone.\\nThe serous variety is most amenable to the milder forms of treat-\\nment. Frequently the tumor attains a certain size and then remains", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0687.jp2"}, "674": {"fulltext": "632 PATHOLOGY AND TREATMENT OE TUMORS.\\nstationary, but the tendency is to increase in size progressively until\\nimportant organs are encroached upon, when the suffering and distress\\noccasioned demand prompt operative interference.\\nTreatment. The inner surface of branchial cysts being lined with\\nepithelium, it is evident that obliteration of the sac can be secured only\\nafter the destruction or removal of this epidermal lining. The surgical\\ntreatment must have for its object the production, in the interior of the\\nsac, of an artificial inflammation of sufficient intensity to destroy the\\nepidermal matrix, or complete extirpation of the cyst. The former\\nprocedure is exceedingly unreliable in its results, and extirpation in\\nmany instances may be looked upon as a formidable and dangerous\\noperation. The following methods have been resorted to in the treat-\\nment of branchial cysts: 1. Incision; 2. Actual cautery; 3. Seton;\\n4. Puncture, with subsequent injection; 5. Extirpation; 6. Antiseptic\\ndrainage. In all cases where incision was practised the relief from\\nexisting symptoms was prompt. The cyst collapsed a certain amount\\nof inflammation followed usually, after the healing of the wound there\\nremained a small nodule which in a few weeks became the seat of\\nactive tissue-growth, and a speedy recurrence followed. The result\\nwas not materially modified in case the sac was drained and injected\\nwith iodine or with other irritating solutions.\\nIn infants the laying open of cysts of the neck is a perilous plan\\nof treatment. Volkers relates a case where a cystic tumor was laid\\nopen in a new-born child, which died sixteen days later in consequence\\nof the operation.\\nIn the case of serous cysts where the seton and iodine injections\\nhave occasionally been successful in producing obliteration, it seems\\nto the writer that the same object would be accomplished more\\nspeedily and safely by incision and drainage, practised in a manner\\nsimilar to that in Volkmann s operation for hydrocele.\\nDieffenbach employed the actual cautery in opening the cyst in one\\nof his cases, after he had made an unsuccessful attempt at removal by\\nextirpation, and after incision had failed in producing obliteration of the\\nsac. The use of the cautery also failed in producing obliteration of\\nthe sac.\\nIt would seem to the writer that incision, combined with a use of\\nthe actual cautery sufficiently energetic to destroy the entire thickness\\nof the epithelial lining, would be most applicable in the more danger-\\nous and formidable class of cases namely, in cysts that have become\\nfirmly adherent to the sheath of the larger vessels by repeated attacks\\nof inflammation provoked by inefficient treatment. After cauterization\\nthe wound should be packed with iodoform gauze. If, during the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0688.jp2"}, "675": {"fulltext": "TERATOMA. 633\\nprogress of the healing of the wound from the bottom by granulation,\\nit becomes apparent that the entire matrix has not been destroyed, the\\nuse of the actual cautery can be repeated.\\nThe seton has resulted in a permanent cure in a few cases of serous\\ncysts, but its use should be abandoned, as the result is uncertain and\\nthe consequences are often disastrous. Butlin reports a case where,\\nin a young child, a seton was passed through a serous cyst death\\nfrom inflammation followed on the third day. For this and other\\nobvious reasons the seton should never be employed in the treatment\\nof branchial cysts.\\nEsmarch s experience with puncture and injection of Lugol s solu-\\ntion of iodine (iodini, pot. iod., gm. 1.25 aquae, 30.0) has been favorable.\\nThe following remarks were made by him on this subject at the fourth\\nmeeting of the Congress of German Surgeons\\nI have cured about a dozen cases by puncture and subsequent\\ninjection of Lugol s solution of iodine. Against this treatment it has\\nbeen urged that complete extirpation of the cyst can always be done\\nand is free from danger. I must deny this assertion, because in a\\nmajority of cases the cyst is adherent to the sheath of the internal\\njugular vein a fact which may remind you of a paper on this subject\\nby Prof, von Langenbeck, which served as an introductory to his\\nArchiv in i860. In this paper Langenbeck called special attention to\\nthe dangers connected with this operation. But even if the operation\\nwere free from danger, yet by resorting to it we obtain an unsightly\\ncicatrix in the neck, to which the female sex objects. I can, on the\\nother hand, recommend injections of iodine as an efficacious and en-\\ntirely safe procedure. If some of you have failed to see its benefits,\\nit is, I believe, because you have not had the necessary patience and\\nperseverance. As a rule, I have repeated the operation whenever oblit-\\neration did not promptly follow the first puncture. It is very essential\\nto irrigate the sac thoroughly before the introduction of the iodine.\\nI have generally proceeded as follows By means of a fine hydrocele\\ntrocar I empty the sac of its contents, and then make repeated injec-\\ntions of a 1 per cent, solution of carbolic acid. This removes the\\nmasses of epithelium adherent to the cyst-wall. I continue these injec-\\ntions until the water returns perfectly clear, and then I inject 10 to 20\\ngrams of Lugol s solution of iodine, which, after gentle pressure to\\nbring it in contact with the inner surface of the sac, is allowed to escape.\\nThe patient is then directed to return in six or eight weeks. Like a\\nhydrocele, the cyst refills rapidly and becomes somewhat painful.\\nIf, after the lapse of time mentioned, it has not greatly decreased in size,\\nI repeat the same operation and tell the patient to return in six months,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0689.jp2"}, "676": {"fulltext": "634 PATHOLOGY AND TREATMENT OF TUMORS.\\nwhen the cyst will be found atrophied to a small tubercle. In most\\ncases the cure has been permanent.\\nIn the discussion which followed Langenbeck said I have treated\\na number of dermoid cysts with fatty contents by means of injections\\nof iodine, but the injections always required repetition. I punctured\\nthe cyst with a large trocar, introduced a piece of elastic catheter, and\\nmade daily injections. A few cases were cured after three or four\\ninjections. In one case the tumor returned. I consider it very diffi-\\ncult to cure these fatty cysts with injections of iodine or any other\\nsubstance.\\nRoser admitted that injections of iodine might succeed in serous and\\nmucous cysts, but that they would prove of no avail in atheromatous\\ncysts. Baum asserted that extirpation was an easy matter, and that\\nthese cysts could be removed without difficulty.\\nBardeleben believed that some of these cysts, especially those which\\nextend behind the sternum, could not be extirpated, but obliteration\\nin one instance was accomplished by antiseptic drainage. Volkmann\\nspoke in favor of extirpation, and warned against injections of iodine,\\nas in case of failure they would render a subsequent excision more\\ndifficult.\\nIt is evident that most German surgeons who have given attention\\nto this subject have no confidence in the efficacy of iodine injections\\nin obliterating branchial cysts. If we consider the numerous failures\\nof iodine injections in cases of hydrocele, where the anatomical con-\\nditions for success are so much more favorable than in branchial cysts,\\nwe will be better prepared to appreciate the causes of the still more\\nfrequent failure of this method when used in the treatment of branchial\\ncysts. Again, clinical experience has shown that a branchial cyst can\\nbe extirpated with comparative ease and safety before the cyst has\\nbecome firmly fixed to the subjacent cervical vessels by inflammatory\\ninfiltration, and that in this class of cases iodine or any other injections\\nwill not only prove useless, but will render a subsequent extirpation\\nstill more difficult. In infants even simple tapping is not always devoid\\nof danger, as one instance is recorded of death caused by puncture.\\nThe case occurred to Volkers, who tapped a cystic cervical tumor in\\nan infant eight days old, the child dying of trismus on the third day.\\nExtirpation. A positive diagnosis made, the best plan to pursue\\nis to make an incision over the most prominent portion of the tumor,\\nparallel with the sterno-mastoid muscle in case the adhesions can\\nbe separated without endangering the deep cervical vessels, the entire\\ncyst should be removed. If inflammatory infiltrations obscure the field\\nof operation at the base of the tumor, and after careful examination", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0690.jp2"}, "677": {"fulltext": "TERATOMA. 635\\nit is deemed inadvisable to perform complete extirpation, the sac\\nshould be opened and the lateral walls excised, and the epidermal\\nmatrix, which remains adherent to the sheath of the cervical vessels,\\ncan be destroyed completely by a careful but vigorous use of the\\nactual cautery. The treatment of the wound should be conducted as\\nin cases of complete excision. If an early diagnosis is made and prompt\\ntreatment is instituted, complete extirpation should always be attempted,\\nand will in the majority of cases prove successful and comparatively\\nfree from danger.\\nAntiseptic Drainage. In the case of infants and very young children\\nsuffering from large serous cysts it would be imprudent to resort to\\nany of the severer measures with a view to a radical cure. In such\\ninstances drainage under antiseptic precautions should be resorted to as\\na temporary measure, and in some cases it may be followed by perma-\\nnent results. The same course of treatment should be adopted in\\nadults suffering from cysts which are inaccessible to any other opera-\\ntion and in which irritating injections are contraindicated.\\nThe writer s experience in the extirpation of branchial cysts, amount-\\ning now to about fifteen cases, has been uniformly favorable. No deaths\\noccurred from the operation, and in every case the result was permanent.\\nIn one case the internal jugular vein was cut in dissecting away the\\nadherent inflamed sac from the vessels of the neck. The hemorrhage\\nwas controlled by the use of hemostatic forceps on both sides of\\nthe wound. The forceps were allowed to remain until the cyst was\\nremoved, when the jugular vein was completely divided and both ends\\nwere tied with catgut. The patient made an uneventful recovery.\\nDragging upon the vein if the cyst-wall has become adherent should\\nbe avoided. Branchial cysts which have not become adherent by\\nantecedent attacks of inflammation can readily be removed by enu-\\ncleation.\\nDermoid Cysts.\\nA dermoid cyst is a teratoid tumor. It is called dermoid because\\nit contains skin derived from the epiblast by displacement of an embry-\\nonal epiblastic matrix, from which, during the development of the\\ntumor by proliferation of the skin and its appendages, the principal\\ncontents of the tumor are formed. In the simplest varieties of dermoid\\ncysts the contents of the cyst are composed of epithelial proliferation\\nalone, when nothing is found in the cyst but epithelial cells and their\\ndetritus mixed with serum, forming the peculiar atheromatous material\\nwhich constitutes the characteristic contents of retention-cysts o\\\\ the\\nsebaceous glands. This kind of cyst is produced from a matrix derived", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0691.jp2"}, "678": {"fulltext": "636 PATHOLOGY AND TREATMENT OF TUMORS.\\nfrom the epiblast before differentiation has advanced to the formation\\nof the appendages of the skin. A matrix derived from the epiblast\\nafter its differentiation into appendages of the skin (hair-follicles, seba-\\nceous glands, and sweat-glands) has taken place not only yields epithe-\\nlial cells, but produces also hair and the secretion of sebaceous glands\\nand sweat-glands. In tumors from such a matrix hair is constantly\\nfound.\\nSuperficial dermoid cysts are due to inclusions of parts of the\\nepidermis, and which Chiari taught remained connected with the\\nsuperficial epithelium. The fissural position of the dermoids that\\nis, their presence in places where fcetal fissures had existed or\\nwhere clefts were closed supports such a conclusion. The deep-\\nseated dermoids, in the abdomen, lungs, etc., must be explained by\\na complete separation of the epithelial cells from which they take\\ntheir origin.\\nAccording to Epstein, in new-born infants it is not uncommon to\\nfind isolated pearls of epithelial cells which have become buried in the\\nconnective tissue by inclusion. It would therefore be more proper to\\nlook upon subcutaneous atheroma as the product of tissue-prolifera-\\ntion from such an isolated island of epithelial tissue, as was done by\\nHeschl, than as a sebaceous cyst.\\nThe difference between a dermoid and such an atheroma would be\\nthat in the former a whole section of skin had become buried, while in\\nthe latter only a projection of epidermis with a single hair had taken\\nplace.\\nHeiberg demonstrated the identity of the lining of a dermoid cyst\\nof the neck with normal skin from a practical standpoint. He utilized\\nthe lining membrane as grafts in the healing of a large ulcer of the leg.\\nThe grafts united promptly with the granulating surface, and the new\\nskin showed the same properties and structure as in cases of skin-\\ngrafting.\\nSome dermoids contain not only skin, but also mucous membrane,\\nthe latter owing its existence to a matrix derived from the hypoblast.\\nThe term dermoid is, however, also used to designate cysts with\\nmore complicated contents, such as teeth, bone, cartilage, and combina-\\ntions of different parts and organs that could originate only from a\\ndisplaced matrix representing different tissues and organs.\\nDefinition. A dermoid cyst is a heterotopic tumor containing the\\nproduct of epithelial proliferation, hair, teeth, etc. Dermoid cysts were\\nfirst described in 1852 by Lebert, who applied the term dermoid to\\nall cysts lined by a cyst-wall resembling in structure that of the exter-\\nnal skin. Dermoid cysts are found most frequently in the ovary and", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0692.jp2"}, "679": {"fulltext": "TERATOMA.\\n637\\nin parts of the body where, during development, the different germinal\\nlayers meet, as about the orbita, the neck, and the coccygeal region.\\nIn 188 cases of dermoid cysts Lebert found that the ovary was the\\nseat of the tumor in 129.\\nHistology. The wall of a dermoid cyst is composed of connective\\ntissue; its inner surface is often smooth, resembling a serous surface,\\nbut microscopical examination always reveals an epithelial lining com-\\nposed, according to the character of the epithelial cells, of one or more\\nA\\nB\\nfart\\ntee\\nfee\\nnap\\nrasps\\nFig. 435. Section from a congenital teratoma of the coccygeal region X 90 (after Perls), a a, ciliated\\nepithelial lining of cysts b, smooth muscle-fibres in which the striations are indistinct c, cartilage d, fatty\\ntissue, b, wall of a cyst lined by ciliated epithelium X 350 (after Perls).\\nlayers (Fig. 435). If the cysts are lined with columnar or ciliated\\nepithelium, the cells arc arranged, as a rule, in a single layer if, on the\\nFig. 436.\u00e2\u0080\u0094 Sacral tumor (Mutter Museum, College of Physicians, Philadelphia).\\ncontrary, the matrix represents skin in place of mucous membrane,\\npavement cells in many layers line the cyst. In cyst-walls supplied", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0693.jp2"}, "680": {"fulltext": "638 PATHOLOGY AND TREATMENT OF TUMORS.\\nwith the appendages of the skin these appendages are seen and occupy\\nthe same relations to the cutis as in normal skin.\\nHair is the most frequent of the many cutaneous appendages in\\ndermoids. The hair in a dermoid, called by Virchow lanugo, is fine\\nand of a blonde or light-brown color, even in negroes. In birds\\ndermoids contain feathers in pigs, bristles. In sequestral dermoids\\nthe hair is short in ovarian dermoids it is often several feet in length.\\nThe hair in dermoids of aged persons turns white, and baldness of the\\nFig. 437. Dermoid cyst of ovary; section through wall X 18 (after Karg and Schmorl). On the sur-\\nface, to the left of the picture, the cyst is covered with a thin layer of flat epithelial cells (a), with remnants\\nof glands and hair; next follows the infiltrated corium (b), beneath which are bundles of flat muscle-fibres (c)\\ncut transversely and longitudinally d, hollow spaces surrounded by a layer of unstriped muscular fibres and\\nlined with cylindrical epithelium; between these hollow spaces is myxomatous tissue.\\ninner surface of dermoid cysts is as often met with as baldness of the\\nscalp. The hair grows, as on the skin, from perfect hair-follicles\\n(Fig. 437)-\\nTeeth and bone are found most frequently in ovarian dermoids.\\nTeeth have also been found in dermoid cysts of the rectum and behind\\nthe rectum, in cysts of the first and second branchial clefts, and in\\nexceptional cases in dermoids of the brain. The teeth are composed\\nof dentine, enamel, and cementum, arranged in the same manner as\\nin normal teeth, and they are developed on the same plan.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0694.jp2"}, "681": {"fulltext": "TERATOMA.\\n639\\nThe so-called epithelial pearls, resembling in structure the\\ncholesteatomata, are also found in some dermoid cysts. They form\\nwhere the epithelial cells are crowded together they arrange them-\\nselves in onion-like layers (Fig. 438).\\nThe cutaneous lining of dermoid cysts, like the external skin, is\\nsubject to the formation of benign and malignant tumors. Carcinoma\\nmay develop in a dermoid cyst. Benign epithelial tumors, papilloma,\\nand adenoma are frequently met with.\\nRegressive Metamorphoses. The degenerative changes which\\ntake place in a dermoid cyst consist in retrograde metamorphoses of\\nthe cells which constitute its lining, and which are detached and con-\\nstitute a part of the cyst-contents. Squamous epithelium undergoes most\\nfrequently fatty degeneration. The contents of the cyst are then com-\\nposed of granular detritus, free fat-globules, and cholesterin-crystals.\\nFig. 438.\u00e2\u0080\u0094 Epithelial pearl (after Kanthack).\\nFatty degeneration of the epithelial cells in dermal tumors is often so\\nextensive that the cyst contains pure oil. Mr. Hunter preserved a\\nspecimen of what he marked oil from an adipose encysted tumor,\\ntaken from a cyst that grew between the bony orbit and the upper eye-\\nlid of a young man. The liquid fat burned with a very clear light and\\ndid not mix with water, and when it was exposed to cold it became as\\nsolid as human fat.\\nThe hair which falls out in a dermoid cyst forms masses suspended\\nin the emulsion. In cysts lined by columnar epithelial cells the gland-\\nular secretion is mucus, which accumulates in the cyst. In old cysts", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0695.jp2"}, "682": {"fulltext": "640 PATHOLOGY AND TREATMENT OF TUMORS.\\nthe mucus is frequently transformed into serum. Inflammation of the\\ninterior of the cyst by the entrance into it of pyogenic microbes occa-\\nsionally takes place, whereupon the products of the suppurative inflam-\\nmation of the cyst-wall are added to the contents of the cyst, resulting\\nin great distention; frequently the inflammation extends beyond the\\nlimits of the sac, producing, in the case of ovarian dermoids, peritonitis,\\nand in other localities a phlegmonous inflammation. Inflammation\\nalways results in firm adhesion of the outer surface of the cyst-wall\\nto the adjacent tissues or organs.\\nA dermoid cyst is not infrequently the starting-point of a carcinoma.\\nCarcinoma of the branchial clefts, carcinoma branchiogenes, was first\\ndescribed by Volkmann. Primary carcinoma in localities in which no\\nepithelial cells exist not infrequently starts from a dermoid cyst that\\nperhaps had never been discovered, or from a dermoid cyst-matrix.\\nSarcoma may develop from a matrix of a dermoid cyst containing\\nthe essential tumor-matrix of embryonal connective tissue.\\nDiagnosis. Dermoid cysts grow slowly and, as a rule, do not attain\\na very large size. With the exception of dermoids of the ovary, tumors\\nlarger than a hen s egg are rare. They produce no pain except from\\npressure or when they become the seat of inflammation. They develop\\nmost frequently during the age of puberty, although they occur some-\\ntimes as congenital tumors. They occupy localities where, during\\nembryonal life, the most complicated tissue-changes take place. It has\\nbeen asserted that the ovary is the most frequent seat of dermoids\\nthis is probably a mistake the impression has been caused by the\\nfact that subcutaneous dermoids, constituting insignificant affections\\nfrom an operative standpoint, are not recorded so constantly as der-\\nmoids of the ovary, which have a peculiar fascination for the abdominal\\nsurgeon. We have reason to believe that the subcutaneous tissue is\\nthe most frequent seat of dermoid tumors.\\nDermoid cysts accessible to palpation fluctuate in proportion as the\\ncontents have undergone liquefaction. If the contents are solid and\\nthe cyst-wall is tense, fluctuation is absent. Subcutaneous dermoids\\nare frequently mistaken for retention-cysts of the sebaceous glands.\\nRetention-cysts of the sebaceous glands commonly occupy the hairy\\nscalp, where dermoid cysts are comparatively rare. The retention-\\ncysts usually retain their connection with the skin, while, the skin is\\nnot connected with the subcutaneous dermoid. In dermoids of the\\novary, as compared with other cysts, the slow growth of the tumor\\nserves as an important point in the differential diagnosis. The differen-\\ntial diagnosis of sacral dermoids and of spina bifida is often very diffi-\\ncult, and conclusions should be postponed in doubtful cases until an", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0696.jp2"}, "683": {"fulltext": "TERATOMA. 641\\nexploratory puncture has demonstrated the character of the contents\\nof the cyst.\\nPrognosis. The prognosis in dermoid tumors is generally favor-\\nable, as these tumors grow slowly and often reach only a certain\\ndefinite size, thereafter remaining stationary. Ovarian dermoids often\\nbecome dangerous to life from inflammatory complications. The con-\\ntents of a dermoid cyst of the ovary must always be regarded as of\\nan infectious nature. The escape of the contents into the peritoneal\\ncavity during removal of a cyst has frequently caused septic peri-\\ntonitis of a most violent character. The sudden increase in size of a\\ndermoid cyst that has for a long time been in a quiescent state indicates\\neither the existence of an inflammation or the transformation of a\\nbenign into a malignant tumor.\\nTreatment. The proper surgical treatment of a dermoid cyst\\nis complete extirpation. Tapping, seton, irritating injections, and\\ncaustics are all inappropriate measures in the treatment of dermoid\\ncysts. In the removal of dermoid cysts it must be remembered that\\nthe tumor will surely return if the slightest particle of the lining of\\nthe cyst-wall is allowed to remain. The dissection is frequently a very\\ndifficult one, and recesses of the cyst-wall are often overlooked these\\nrecesses become the starting-point of the recurrent tumor. If possible,\\nthe cyst should be removed without rupturing the cyst-wall. If this\\ncan be done, the surgeon has the satisfaction of knowing that the\\nlining has been removed completely, and he can give the patient the\\nassurance that no recurrence will take place.\\nIn the extirpation of dermoid cysts a knife not much larger than\\na tenotomy-knife should be employed, and very little traction upon the\\ncyst-wall should be made, as this is sometimes exceedingly fragile and\\neasily torn.\\nTopography.\\nDermoid cysts are found most frequently in those parts of the\\nbody where, during the development of the embryo, the different\\ngerminal layers meet and blend this is more especially the case with\\ntumors of complicated structure, in the production of which all the\\ngerminal layers take part.\\nTrunk. In the embryo the two lateral halves of the body blend in\\nthe median line posteriorly from the occipital protuberance to the\\ncoccyx. It is in the centre of the body, following the line of coalescence,\\nthat dermoids are found, more especially in the region of the sacrum\\nand the coccyx. In this locality dermoid cysts are very apt to be\\nmistaken for spina bifida if the opening in the spinal canal is small\\n41", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0697.jp2"}, "684": {"fulltext": "642 PATHOLOGY AND TREATMENT OF TUMORS.\\nand the integument covering it is normal. The difficulty in diagnosis\\nis increased if, as sometimes happens, the spina bifida is associated\\nwith a dermoid. Wild has reported the case of a man twenty-two\\nyears old who was born with what was supposed to be a spina bifida\\nin the lumbo-sacral region. The swelling never caused him any pain\\nor inconvenience until it became inflamed, when it suppurated and\\nopened spontaneously, discharging a large quantity of offensive pus,\\nhair, and sebaceous material. The cyst was freely incised. Its wall\\nshowed numerous openings of sweat-glands, from which drops of\\nsweat escaped when the patient perspired.\\nAt the junction of the sacrum with the coccyx, and over the coccyx\\nat a point corresponding with the post-anal dimple, dermoid cysts are\\nquite frequently found. They are usually small, and they are often\\nassociated with a blind fistulous tract. In a number of cases where\\ncysts in this locality had suppurated a small fistulous opening remained,\\nand when this opening became closed the swelling reappeared and\\nagain suppurated.\\nIn the removal of suppurating dermoids in the sacro-coccygeal\\nregion the careful use of the probe is necessary to ascertain the extent\\nand exact location of the cyst. The writer has usually found more or\\nless hair as a part of the cyst-contents. The displacement of skin\\ntakes place here so frequently because of the early adhesion of the\\nskin to the underlying bone, and the subsequent growth of the sur-\\nrounding fat and muscle-tissue, causing the dimpling, sinus-formation,\\nor epithelial inclusions as the case may be.\\nNo operation for a supposed dermoid anywhere over the spine\\nshould be undertaken until spina bifida has positively been excluded\\nby an exploratory puncture, which can be repeated if necessary.\\nThorax. Dermoid tumors of the thorax are rare. They are\\nfound usually over the median part of the chest, over the sternum, or\\nin the anterior mediastinum. Bramann reported a case in which a\\ndermoid cyst of small size was located over the sternum, at the junc-\\ntion of the manubrium with the gladiolus, and a similar cyst in the\\nanterior median line of the neck near the left cornu of the hyoid bone\\n(Fig. 439). Cahan saw a dermoid cyst over the sternum in a child\\neight months old. The tumor at birth was not larger than a pea.\\nChitten removed a dermoid having the same situation from a female\\nthirty-nine years of age the cyst contained eleven ounces of atheroma-\\ntous material.\\nThe dermoids in the mediastinum spring from a matrix of skin that\\nin the embryo became imprisoned between the two lateral halves of\\nthe sternum, becoming detached when coalescence of the sternum", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0698.jp2"}, "685": {"fulltext": "TERA TO MA. 6 43\\ntook place. A remarkable specimen of this kind was presented by\\nMr. Kingdon to the museum of St. Bartholomew s Hospital, London.\\nIn the anterior mediastinum of a woman twenty-one years old a\\ntumor, probably of congenital origin, contained portions of skin and\\nfat, serous fluid, sebaceous material, and two pieces of bone, like parts\\nof an upper jaw, in which seven well-formed teeth were imbedded.\\nFig. 439. Dermoid situated over the junction of the manubrium and the gladiolus of the sternum there was\\nalso a dermoid near the left cornu of the hyoid bone (after Bramann).\\nIn a case of substernal dermoid which projected above the manu-\\nbrium of the sternum, Roser incised the tumor after decomposition\\nof its contents had taken place he trephined the sternum, securing in\\nthis way efficient drainage.\\nA large dermoid cyst in the mediastinum may simulate inflamma-\\ntory disease of the lungs or pleura or a malignant tumor. A suppurat-\\ning dermoid with rupture into the bronchial tubes would perfectly\\nresemble empyema unless hair were to be discovered in the expec-\\ntorated material, making the diagnosis of dermoid cyst positive. In\\nsuppurating substernal dermoid it would be necessary to resort to\\nresection of a part of the sternum over the cyst to secure efficient\\ndrainage and disinfection. Farther than this it would not be prudent", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0699.jp2"}, "686": {"fulltext": "644 PATHOLOGY AND TREATMENT OF TUMORS.\\nto extend the operative procedure, owing to the importance of the\\nvarious organs to which the cyst-wall would necessarily be attached\\nfirmly.\\nFace. Facial dermoids occur in the lines of the facial fissure in\\nthe embryo. The central portion of the face in the early embryo is an\\nopening from which five fissures radiate (Fig. 440). The upper pair\\nare the orbito-nasal the two lower fissures are\\ntermed mandibular; and a fifth, not shown in\\nthe figure, the intermandibular fissure. The\\nmedian fold projecting into the opening from\\nabove is the fronto-nasal process, which ulti-\\nmately forms the nose. As it develops, a rounded\\nprominence known as the globular process\\nforms at each angle and gives rise to a portion\\nof the ala of the nostril and the corresponding\\npremaxilla. These globular processes fuse to-\\ngether in the middle line to form the central\\npiece, or philtrum, of the upper lip. The elon-\\nFig. 440.\u00e2\u0080\u0094 Head of an early r r rsr r\\nhuman embryo, showing the gation of the fronto-nasal process necessarily\\n2\u00c2\u00b0r S Hfs).\u00c2\u00b0 fthefaCialfiSSUreS len g thens the orbito-nasal fissures. Eventually\\nthe sides of the fronto-nasal plate coalesce super-\\nficially with the maxillary processes in such a way as to leave a cleft\\non each side, which becomes the orbit, the line of union being perma-\\nnently indicated in the adult by the naso-facial sulcus or groove, and\\nindicated still more deeply by the lachrymal duct, which is a persistent\\nportion of the original orbito-nasal fissure. The union of the fronto-\\nnasal plate with the maxillary processes completes the nose, cheeks,\\nand upper lip (Sutton).\\nFrom the foregoing description of the development of the face it\\nwill be understood that dermoid cysts will appear in certain definite\\npositions, such as the inner and outer angles of the orbit, the upper\\neyelid, in the naso-facial sulcus, on the cheek slightly posterior to\\nthe angle of the mouth, in the middle line of the chin, and on the\\nnose. Dermoid cysts in all these localities seldom exceed a filbert\\nin size. They often contain hair, and they sometimes contain pure\\noil. The underlying bone shows a shallow or deep depression after\\ntheir removal. They are firmly attached to the bone they are\\nfrequently congenital; fluctuation is distinct; and the skin overlying\\nthem is normal. The most frequent location of dermoid cysts of\\nthe face is at the outer angle of the eye. In this situation the\\norbital arch of the frontal bone often shows a depression deep enough\\nto hold one-half of the cyst. If the cyst occupies the inner angle of", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0700.jp2"}, "687": {"fulltext": "TERATOMA.\\n645\\nthe eye, the nasal process of the frontal bone suffers from pressure-\\natrophy. The depression in the bones of the face caused by tumors\\nFig. 441. Dermoid arising in naso-facial sulcus (after Bramann).\\nthat have existed for a long time diminishes somewhat after their\\nremoval, but is never entirely effaced a matter\\nto be taken into consideration when patients,\\nespecially young girls, request an operation\\nfor cosmetic reasons.\\nNasal dermoids are situated either on the\\nside or over the centre of the nose (Fig.\\n441).\\nPalate and Pharynx. In the hard palate\\nvery complicated teratoid tumors containing\\neven a part of a limb have been found. The\\nsoft palate is more frequently the seat of ordi-\\nnary dermoids than the hard palate (Fig. 442).\\nThe tumors may attain the size of a hen s f*g. ^.-Pedunculated dermoid\\negg; they contain often numerous epithelial tumor from the pharyngeal aspect\\nof the soft palate (after Arnold).\\npearls, and the stroma frequently undergoes\\nmyxomatous degeneration. As these tumors are always encapsulated\\neven when pendulous, they can be removed by enucleation.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0701.jp2"}, "688": {"fulltext": "646 PATHOLOGY AND TREATMENT OF TUMORS.\\nScalp and Dura Mater. Retention-cysts of the sebaceous glands\\nof the scalp may occur on any part of its surface, while dermoid cysts,\\nowing to the manner of development of the cranium in the embryo, are\\nfound almost exclusively in the median line, at the occipital fontanelle,\\nand over the anterior fontanelle. Occasionally these tumors are con-\\nnected with the dura mater. Sutton describes such a specimen.\\nCases have been recorded in which the tumor reached the size of a\\ncocoanut. As these tumors are congenital and are most frequently\\nlocated over the anterior fontanelle (Fig. 443), it is not astonishing\\nFig. 443. Congenital tumor over the anterior fontanelle (after Hutchinson).\\nthat they have usually been mistaken for meningocele. This decep-\\ntion is increased from the fact that in some cases the tumor pulsates.\\nSuch a case was published by Arnott. In the case recorded by\\nGiraldis aspiration was performed and a clear serous fluid was with-\\ndrawn, but when the tumor was removed some time later it was found\\nto be a typical dermoid.\\nDermoids of the scalp are underneath the periosteum they pro-\\nduce great defects in the bone from pressure. In some instances\\nthe pressure-atrophy was so extensive that the bone was perfo-\\nrated. In other cases the tumor was surrounded by a new wall of\\nbone. In rare cases dermoids originate in the bones of the skull.\\nAccording to Mikulicz, the petrous portion of the temporal bone, the\\noccipital bone, and the frontal bone are the most frequent seats of\\ndermoids.\\nIn the differential diagnosis between retention-cysts of the scalp and\\ndermoid cysts it is important to remember that the former never appear\\nbefore puberty, while the latter are either congenital or, at any rate,\\noccur during infancy or childhood. The wall of a dermoid cyst is much\\nthinner than that of a retention-cyst. Dermoid cysts are less apt to\\nbecome infected than retention-cysts.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0702.jp2"}, "689": {"fulltext": "TERATOMA. 647\\nIn the operative treatment of dermoid cysts the possibility of a\\nconnection with the dura mater should not be forgotten.\\nBye. The first cases of open dermoids of the bulb were described in\\n1853 by Riba. Sutton classifies open dermoids of the conjunctiva with\\nmoles. They occur most frequently at\\nthe margins of the cornea, and usually in\\nthe line of the palpebral fissure. In the\\nembryo the tissue which becomes the\\nconjunctiva is continuous with the skin,\\nand by differentiation is derived from the\\nskin. If a part of the epiblast that is\\nintended to form conjunctival tissue\\nshould become transformed into skin, Fig. 444.\u00e2\u0080\u0094 Mole on the caruncle, as-\\n.11 1 j\\\\ -11 r sociated with an eccentric pupil (after\\nit will remain as skin and will form an Demours)\\nopen dermoid, such as that shown in\\nFigure 444. Open dermoids of the bulb are consequently frequently\\ncomplicated by congenital defects of the upper eyelid, especially the\\none known as Colombo, which corresponds in its location with the\\ndermoid of the conjunctiva.\\nTongue. Barker collected sixteen cases of dermoid tumors of the\\ntongue and made a special study of their anatomical location. Bryk,\\nwho made a most valuable contribution to this subject, removed a\\ntumor, the size of a fist, which filled the entire cavity of the mouth and\\nformed a large swelling in the upper anterior part of the neck, whence\\nit was successfully removed. Bauer and Linhart reported similar cases.\\nGiiterbock removed from the lateral aspect of the base of the tongue\\na cyst of this kind that contained atheromatous material and fine\\nhairs.\\nCentral lingual dermoids are rare. Richet removed one from a\\nchild a few days old. Sutton reports, in a man twenty-four years\\nof age, a case of central lingual dermoid which during nine years\\nhad been operated upon, without success, seven times. Sutton\\nfound the cyst firmly adherent to the body of the hyoid bone, and\\nextending from the genio-hyoglossi to the foramen cecum. Dermoids\\nlying in the middle of the tongue arise in the lingual duct, which\\nextends from the foramen cecum on the dorsum of the tongue to the\\nposterior surface of the body of the hyoid bone. They originate from\\nunobliterated parts of the duct, in the same manner as the branchial\\ncysts originate from partially obliterated branchial clefts. An enormous\\ntumor of this kind was removed from a negro by Wellington Gray\\n(Fig. 445). The tumor contained forty ounces of atheromatous material.\\nIn a case operated upon by Stephen Paget, in a child four years old, the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0703.jp2"}, "690": {"fulltext": "PATHOLOGY AND TREATMENT OF TUMORS.\\ntumor was congenital and cc: ed a yellowish serum. A rare form\\nof tumor of the tongue ir the neighborhood of the foramen cecum\\nresembles in structure thyroid tissue. Bernays, who removed such a\\ntumor from a girl seventeen years of age, traced its origin to the lingual\\nFig. 445-\u00e2\u0080\u0094 Large lingual dermoid protruding from the mouth (after Gray).\\nduct. Similar cases have been reported by Butlin, Rushton, Parker,\\nand Wolf. Wolf believed that thyroid tumors of the tongue originate\\nfrom accessory thyroid glands.\\nSmall lingual and sublingual dermoids can be removed successfully\\nthrough the mouth by enucleation, as the tumors are always well\\nencapsulated and, unless the walls have become firmly adherent in\\nconsequence of inflammation or of inadequate treatment, enucleation\\ncan be effected without difficulty. If the tumors are too large for\\nintra-oral operation, they should be removed through a median incis-\\nion extending from the symphysis mentis to the upper border of the\\nthyroid cartilage. As soon as the pericystium is reached the enuclea-\\ntion is begun. The operation is facilitated by removing the contents\\nof the cyst, after which the sac can be removed through a small incision.\\nIn several cases the writer has been able to remove sublingual der-\\nmoids the size of a goose-egg through a small incision in the mouth\\nby first evacuating their contents, and then dragging the sac out in the\\nsame manner as in the removal of the sac of a retention-cyst of the\\nsebaceous glands.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0704.jp2"}, "691": {"fulltext": "TERATOMA.\\n649\\nRectum.\u00e2\u0080\u0094 Dermoids of the rect Kind of the space between the\\nrectum and the sacrum are not uncommon j. they usually occur as con-\\ngenital tumors. Sutton explains their embryological origin as follows\\nIn the early embryo the central canal of the spinal cord and the ali-\\nmentary canal are continuous around the caudal extremity of the noto-\\nchord. This passage, which brings the developing cord and gut into\\nsuch intimate union, is known as the neurenteric canal When the\\nproctodeum invaginates to form part of the cloacal chamber, it meets\\nthe gut at a point some distance anterior to the spot where the neuren-\\nteric canal opens into it hence there is for a time a segment of intestine\\nextending behind the anus, and termed in consequence the post-anal\\ngut. Afterward this post-anal\\nsection of the embryonic intes-\\ntine disappears, leaving merely a\\ntrace of its existence in the small\\nstructure at the tip of the coccyx,\\nknown as the coccygeal body.\\nThere is good reason to re-\\ngard the post-anal gut as the\\nsource of that variety of congen-\\nital sacro-coccygeal tumor named\\nby Braun and several writers who\\nfollowed him congenital cystic\\nsarcoma. What was regarded\\nby Braun as tumors of Luschka s\\ngland and congenital cystic sar-\\ncoma are thyroid-dermoids.\\nDiverticula from the central\\nspinal canal forming cysts are\\nsometimes displaced laterally, as\\nin a case operated upon by Wolff\\nin Central Africa, the specimen of which was examined by Virchow.\\nManuel refers to two dermoid tumors situated in the loose connective\\ntissue between the peritoneum and the levator ani. Konig observed\\nin a young girl a case of suppurating dermoid in the same location\\nfrom the tumor numerous pieces of bone, teeth, and hair escaped.\\nIn rare cases such tumors are also found between the bladder and the\\nrectum.\\nThyroid-dermoids in the coccygeal region acquire a large size (Fig.\\n446). Middeldorpf first associated them with the post-anal gut. In the\\ninterior of the tumor are spaces or cysts lined by columnar epithelium\\nthese spaces contain a ropy mucus.\\nFig. 446.\u00e2\u0080\u0094 Thyroid-dermoid (after Hutchinson).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0705.jp2"}, "692": {"fulltext": "650 PATHOLOGY AND TREATMENT OF TUMORS.\\nDermoid cysts between the rectum and the sacrum often attain great\\nsize, and frequently they suppurate. They are found as frequently in\\nmen as in women. Interesting cases of dermoids in this location have\\nbeen reported by Bryant, Ord, and Page.\\nOpen dermoids of the rectum and bladder were first described in\\n1874 by Danzel and Martini (Fig. 447). The tumors are furnished\\nFig. 447.\u00e2\u0080\u0094 Rectal dermoid (after Danzel).\\nwith long locks of hair that protrude from the anus sometimes they\\nalso contain teeth. It was formerly supposed that dermoids of the\\nrectum originated in the ovary and reached the rectum by invagination\\nan opinion which is no longer tenable. In Danzel s case the tumor\\nwas as large as an apple and was said to contain brain-substance en-\\nclosed in a bony capsule a tooth projected from the tumor. Clutton\\nremoved a rectal dermoid from a girl nine years of age. In the rec-\\ntum as well as in the pharynx dermoid tumors eventually become\\npedunculated.\\nAuricle. The external ear in the embryo is formed by coalescence\\nof a number of tubercles. If, during the process of fusion, an island\\nof skin becomes buried, it forms a matrix from which at any time a\\ndermoid cyst may grow. Dermoids of the auricle never attain large\\nsize, and they are usually mistaken for sebaceous cysts. The tumor\\nsometimes occupies the groove between the pinna and the mastoid\\nprocess.\\nThe removal of pedunculated open dermoids of the rectum offers\\nno difficulties on the contrary, the extirpation of perirectal tumors\\nrequires often a formidable operation. Usually the difficulties of ope-\\nrative removal are increased by inflammation and suppuration, which\\nrender the dissection tedious and difficult. The writer remembers dis-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0706.jp2"}, "693": {"fulltext": "TERATOMA.\\n651\\ntinctly a case of post-rectal dermoid which had suppurated and ruptured\\njust below the coccyx. When the\\ncase was examined there was found\\nFig. 448. Dermoid of the auricle and nevus of\\nthe palpebral conjunctiva (after Lannelongue).\\nlarge enough to admit\\nan opening\\nthree fingers, lined by skin and lead-\\ning into a cavity, the size of a child s\\nhead, lined with hairy skin. In this\\ncase the decision was against opera-\\ntive interference, as the cyst-wall gave\\nrise to no inconvenience, and the\\nwriter could hardly imagine in what\\nmanner such a large cavity could be\\nmade to heal after dissecting out the\\nentire sac.\\nIn suppurating dermoids it may\\nbecome necessary to make counter-\\nincisions for the purpose of establish-\\ning more efficient drainage and the removal of the entire cyst-wall\\nin suppurating post-rectal dermoids may require excision of the coccyx\\nand of one or more of the sacral vertebrae as a preliminary step to the\\nremoval of the tumor.\\nTumors which are attached to the sacrum should not be removed,\\nas they may be connected with the spinal canal.\\nOvary. Olshausen, who collected from different sources statistics\\nof 3275 cases of ovariotomies, ascertained that dermoid tumors were\\nrepresented by about 3^ per cent. Ponpinel collected 44 cases in which\\nboth ovaries were similarly affected.\\nHistology a,7id Histogenesis. Waldeyer offered a novel explanation\\nof the origin of dermoid tumors in the ovary. He maintained that the\\nnormal epithelial cells of the ovary, which must be considered as unde-\\nveloped ovum-cells, under certain circumstances, without intercurrence\\nof spermatozoa, undergo a parthenogenetic development during which\\nthey furnish, in the direction of an imperfect embryonal development,\\nproducts different from themselves. This theory could hardly be enter-\\ntained seriously at the present time, in view of the embryological inves-\\ntigations which have been made regarding the origin of similar tumors\\nin other organs. Epithelial cells cannot produce bone and teeth only\\ngrow from a matrix of cells producing their essential histological parts,\\ndentine, enamel, and cementum.\\nDermoids of the ovary arise, as do dermoids of any other part or\\norgan, from matrices derived from an erratic development in the em-\\nbryo. In the embryo the ovaries develop from the genital ridge, which", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0707.jp2"}, "694": {"fulltext": "652 PATHOLOGY AND TREATMENT OF TUMORS.\\nat an early date is intimately associated with the cells lining the peri-\\ntoneum and connected with the peritoneal funnels. The origin of the\\nWolffian duct is intimately connected with the epiblast consequently\\nthe ovaries are the seat of the most complicated histological processes\\nduring their development, and must necessarily frequently become the\\nseat of rests which, when excited to active tissue-proliferation, furnish\\nFig. 449. Dermoid cyst of the ovary (after Wyder). The cyst-wall was filled by a fatty mass enclosing\\nreddish hairs. The structure of the wall is seen to be like that of the skin. The upper stratum in the illus-\\ntration (the inner layer of the cyst) is formed of closely-packed cells, flattened toward the surface by mutual\\npressure. Beneath are two layers of fibrous tissue separated by loose adipose tissue. The fibrous stroma\\nof the latter is formed by fibrillar from the two connective layers. An important detail of this specimen is\\nthe presence of sweat-glands by the side of sebaceous glands and hair-follicles.\\nthe material for the different kinds of dermoids. We observe here the\\nsimplest kinds of dermoid cysts, containing nothing but atheromatous\\nmaterial, as well as the most complicated forms, in which there are\\nfound not only hair and teeth, but also brain-tissue, mucous mem-\\nbrane, and incomplete skeletons. So many fetal parts are sometimes\\nfound in dermoid tumors of the ovary that they have been regarded\\nas instances of ovarian pregnancy, and have been the means of ques-\\ntioning the morality of many innocent patients.\\nCyst-walls which represent the external skin in their structure fre-\\nquently contain all the appendages of the skin (Fig. 449). The papillae\\nof the skin are usually not well developed in other instances they", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0708.jp2"}, "695": {"fulltext": "TERATOMA. 653\\nbecome the seat of papillomatous excrescences. Cysts with a dermal\\nlining contain the product of epithelial proliferation, which forms a pul-\\ntaceous mass, variable in its consistency, resembling in every respect\\nthe contents of sebaceous cysts. The lanuginose hair may consist of\\na fine down or may grow to the length of several feet (Fig. 450). The\\nhair is of a yellowish or reddish color, and as it is shed from the fol-\\nlicles it accumulates in the cyst in masses pasted together by the seba-\\nceous material.\\nPlates of compact bone are frequently found in the cyst-wall they\\nare sometimes connected by a fibrous union, as was first pointed out\\nby Labbe and Verneuil. The teeth, which are never perfect, project\\nFig. 450. Switch of hair five feet long taken from dermoid cyst (after Munde).\\ninto the cavity they are often loosely inserted into imperfect alveoli,\\nand they may vary in number from one to several hundred. Auten-\\nrieth found in one dermoid cyst over three hundred teeth. The teeth\\nare often surrounded by tufts of hair (Fig. 451). Cruveilhier quotes\\na case where nails were found in a dermoid cyst. In a specimen\\nexamined by Baumgarten, besides skin, hair, and teeth, there was\\nfound a body which represented an imperfect eye. Brain-matter was\\nfound by Virchow, Key, and Rokitansky other pathologists have\\nfound nerve-filaments supplying the teeth. Cholesterin-crystals are\\nusually present in abundance in the atheromatous material in der-\\nmoid cysts.\\nMucous cysts in dermoid cysts of the ovary are derived from rests", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0709.jp2"}, "696": {"fulltext": "654 PATHOLOGY AMD TREATMENT OF TUMORS.\\nof the embryonic intestinal canal. They are lined with columnar\\nepithelium. The contents of such cysts consist of mucus, and in\\ncases of long standing the mucus is often converted into a serous\\nFig. 451. Part o\\\\ cyst-wall from dermoid cyst of ovary (after Winckel) a, canine tooth; b, two molar\\nteeth.\\nfluid and the stroma is very likely to undergo myxomatous degen-\\neration.\\nClinical Aspects\u00e2\u0080\u0094 -Ovarian dermoids grow very slowly, but they\\nmay eventually attain great size. The beginning of the growth can\\nusually be traced to the age of puberty. The tumor-matrix participates\\nin the increased physiological activity observed in the skin and its\\nappendages at this time. At first the tumor is movable and painless.\\nLocalized peritonitis, which undoubtedly occurs frequently in conse-\\nquence of a mild infection, is productive of pain and is followed by\\nadhesions. If the tumor is movable and pedunculated, it may rotate\\non its axis, thus leading to torsion of the pedicle. This accident results\\nin serious disturbances of the circulation in the tumor. If the veins\\nare more obstructed than the arteries, there results intense venous con-\\ngestion, manifested by pain and by an increase in the size of the tumor.\\nIf the circulation is completely interrupted in acute torsion, gangrene\\nof the tumor and death from septic peritonitis will follow. If the cir-\\nculation is interrupted more gradually, the tumor often receives a new\\nblood-supply from adjacent organs through adhesions. In a few cases\\nof this kind the pedicle disappeared entirely and the tumor was found\\nattached to adjacent organs. Such a tumor, which had become attached\\nto the omentum, from which it received its blood-supply exclusively,\\nwas removed by Sir George Humphrey.\\nVery often a dermoid tumor is associated with cystic disease of the\\novary, in which case it is overshadowed by the symptoms produced by\\nthe cystic part of the tumor, which is frequently the largest part of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0710.jp2"}, "697": {"fulltext": "TERATOMA. 655\\nmixed tumor. There may be a dermoid cyst on one side and a mucoid\\ncyst upon the other. Rupture of a dermoid is often the cause of a fatal\\nperitonitis. In a few instances this accident has been followed by mul-\\ntiple secondary dermoids on the peritoneum. The secondary tumors,\\neach of which is furnished with a tuft of lanugo-like hair, are usually\\nthe size of a cherry, and occur in clusters or imbedded in adhesions.\\nThe entrance of pyogenic microbes into a dermoid cyst, either\\nthrough a small perforation in the intestine, by puncture with an aspirat-\\ning needle, or by the localization of floating microbes, produces a sup-\\npurative inflammation with all its immediate and remote consequences.\\nDeath from peritonitis is a frequent termination of this complication.\\nIf the peritonitis is circumscribed, rupture of the cyst occurs, with\\nescape of its contents at the umbilicus or through the rectum, vagina,\\nor bladder.\\nThe escape through the sinus of hair, teeth, or fragments of bone\\nindicates the character of the cyst. Spontaneous healing of the fistula\\nin such cases seldom if ever takes place unless the entire cutaneous\\nlining of the cyst is destroyed by the inflammation.\\nIn the removal of ovarian dermoids the trocar must be used with\\ncaution, as the escape of the contents of the cyst may cause septic\\nperitonitis or dissemination of the tumor by epithelial infection.\\nThe removal of suppurating dermoid cysts which have ruptured\\non the surface or into one of the adjacent organs is always an exceed-\\ningly difficult operation, and one attended by great risks to life. Many\\ncases of suppurating dermoid cysts have been mistaken for extra-\\nuterine pregnancy.\\nIn dermoid cysts which are adherent to the floor of the pelvis\\nextirpation through the sacral route offers great advantages.\\nScrotum. There is no doubt that most of the cases of dermoid\\ntumors of the testicle that have been reported were not within the\\ntesticle, but were upon it that is, were dermoids of the scrotum.\\nThat dermoids in this locality are not common is evident from the\\nfact that Kocher found only fourteen cases recorded in literature. The\\nteratoid tumors of the scrotum are always congenital, and a correct diag-\\nnosis is generally made only after the character of the contents has been\\nascertained by suppuration and rupture or during an operation for\\nremoval of the tumor. Verneuil attributed their origin to fetal inclu-\\nsion inclusion scrotale et testiculaire fcetus in fcctu. Lebert and Paget\\nregarded them as heterotopic tumors. They originate undoubtedly,\\nlike the dermoids of the ovary and of other organs, from misplaced\\nmatrices of embryonal tissue. Scrotal dermoids present often a very\\ncomplicated structure. The simplest cysts contain sebaceous material", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0711.jp2"}, "698": {"fulltext": "656 PATHOLOGY AND TREATMENT OF TUMORS.\\nand hair. In the more complicated cysts brain-substance, striated\\nmuscular fibres, and bone have been found. The cysts grow slowly\\noccasionally they suppurate and rupture spontaneously, in which event\\nthe character of the escaping material indicates the nature of the cyst.\\nThe testicle is usually found atrophied from pressure and function-\\nally useless. If the cyst is extirpated, the testicle should be removed\\nwith the tumor. Extirpation of the tumor without castration has not\\nyielded satisfactory results.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0712.jp2"}, "699": {"fulltext": "XXX. RETENTION-CYSTS.\\nAll true tumors are composed of new tissue produced from\\nmatrices of embryonic cells. All inflammatory swellings are composed\\nof, or are derived from, pre-existing tissue. It remains for us to discuss\\nin this section a form of swelling composed of a sac of pre-existing\\ntissue, with an accumulation of some one of the secretions or excre-\\ntions of the body as its contents.\\nDefinition. A retention-cyst is a swelling due to the retention in a\\npre-existing space of a physiological secretion or excretion by obstruction\\nof the outlet of a gland.\\nThe enlargement of a part should be named in accordance with the\\nhistogenetic source of its cellular elements, according to which a\\nhypertrophy consists of a numerical increase of the tissue-elements\\nof a part or an organ. The term tumor should be restricted to\\na localized production of tissue independently of mature normal cells\\ninflammatory swellings should include all enlargements consisting\\nof cells derived from the blood or by proliferation of mature tissue, or\\nof accumulations of serum or synovia in pre-existing spaces and\\nretention-cysts should occupy the ground covered by the definition\\npreceding this paragraph.\\nThe greatest confusion exists in the minds of the student in differ-\\nentiating, from etiological and pathological standpoints, between the\\ndifferent kinds of cysts this confusion is largely due to the manner in\\nwhich the subject is treated even in the most recent text-books. A\\ncystoma is a true tumor in which both walls and contents are new\\nproducts derived from a tumor-matrix.\\nWe have seen that all tumors undergo cystic degeneration by\\nregressive metamorphoses or by the cells producing a secretion which\\naccumulates in the tumor-tissue, owing to the absence of an excre-\\ntory duct. A cyst may also form in consequence of the extravasation\\nof blood into tumor-tissue or into normal tissue and, lastly, many\\nso-called pseudo-cysts are produced by transudations into pre-\\nexisting serous spaces. It would be just as proper to call a hydrops\\nof the knee-joint a hydrothorax, or a hydrocephalus a cyst, as\\na hydrocele.\\nPathological accumulations of synovia or of scrum in serous cavi-\\n42 657", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0713.jp2"}, "700": {"fulltext": "658 PATHOLOGY AND TREATMENT OF TUMORS.\\nties and in parasitic cysts do not come under the head of retention-\\ncysts. They are inflammatory products, and have no place in a treatise\\non tumors. The writer will therefore exclude from this section the\\nhydroceles, diverticula, bursae, neural cysts, and parasitic cysts. A true\\nretention-cyst can form only in organs that produce a physiological\\nsecretion or excretion which is discharged by an outlet upon the skin\\nor upon a mucous or serous surface in other instances the secretion\\nis absorbed at the place where it is produced.\\nThe only instance in which, normally, a glandular secretion is dis-\\ncharged into a serous cavity is furnished by the Graafian follicles of the\\novary. The secretion of the follicles of the thyroid gland in a normal\\ncondition is absorbed; but if, for any reason, absorption is suspended,\\nthe follicles become dilated and eventually form retention-cysts.\\nHistology. The cyst-wall is composed of the connective tissue,\\nbasement membrane, and epithelial lining of the follicle, tubule, acinus,\\nFig. 452.\u00e2\u0080\u0094 Wall of atheromatous cyst (after Boyce) a, fibrous wall b, epithelial layer c, horny amorphous\\ntransformation of epithelium. (Obj. inch, without eye-piece.)\\nor duct which has become obstructed. The amount of connective tis-\\nsue as compared with the normal structure of the part affected varies\\ngreatly. If the obstruction is acute and the part on the distal side con-\\ntinues to secrete, the pre-existing spaces, according to the activity of\\nthe physiological function of the part affected, dilate rapidly, resulting\\nin distention of the gland or duct, with thinning of the wall. If the\\nobstruction forms slowly and the amount of the retained secretion", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0714.jp2"}, "701": {"fulltext": "RE TENTION-CYSTS.\\n659\\naccumulates slowly, the cyst-wall is often enormously thickened by the\\nformation of new connective tissue. The best illustration of the former\\ncondition is furnished by acute hydronephrosis, and of the latter by\\nsebaceous cysts. The epithelial cells which line the cyst-wall corre-\\nspond in structure and manner of arrangement with the epithelial cells\\nwhich exist normally in the lining of the obstructed space.\\nCysts of glands lined by stratified epithelium show stratified layers\\nof squamous epithelium (Fig. 452). If the cyst forms in a duct or\\na gland lined by columnar epithelium, the cyst, at least in its early\\nstages, is lined by columnar epithelium.\\nFig. 453. Section of the wall of a cyst of the vagina (after Schroder). The external surface is the pavement\\nepithelium of the vagina; the internal, the cylindrical epithelium of the cyst.\\nIn branchial cysts, as well as in retention-cysts of other tubes or\\nducts lined by similar epithelium, the cyst-wall is always found lined\\nby ciliated epithelium. Through great pressure the columnar epithe-\\nlium is often flattened, resembling squamous epithelium, but it always\\nretains its intrinsic capacity to produce, under more favorable auspices,\\ncells of its original type.\\nRetention-cysts result from mechanical obstruction of the outlet\\nof glands, leading to the accumulation of the secretion behind the point\\nof obstruction. If the obstruction is located near the point at which\\nthe secretion is produced, the cyst forms at this point, as is the case\\nin obstruction in a ductlet of an acinus of a gland. If the obstruction\\nis located in a duct some distance from the point at which the secretion\\nis produced, the obstructed duct becomes distended and forms the wall\\nof the retention-cyst.\\nThe cyst-contents are subject to various changes. If inflammation\\nof the cyst-wall occurs, the contents of the cyst are modified by the\\naddition of inflammatory products. Hemorrhage into the cyst, accord-\\ning to its amount, may simply stain or may constitute the bulk of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0715.jp2"}, "702": {"fulltext": "66o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\ncyst-contents. In cysts lined by stratified epithelium the product of\\nepithelial degeneration forms the well-known atheromatous material,\\nwhich is subject to still further changes. In young cysts this material\\nappears as a hard mass composed of cells arranged in concentric layers,\\nwhile in old cysts the cells disintegrate and the detritus is suspended\\nin a serous fluid, presenting the appearance of a thin emulsion. The\\naddition of fat- and cholesterin-crystals further modifies the appearance\\nof the cyst-contents. In mucous cysts the mucoid material is fre-\\nquently transformed into a clear serous fluid. Cysts frequently become\\nisolated from the gland in which they originated by complete oblitera-\\ntion and detachment of the duct. In retention-cysts that have not been\\nthe seat of inflammation the outside of the cyst-wall is surrounded by\\nFig. 454. Chronic interstitial nephritis (after Boyce) a, glomerulus with connective-tissue cell-proliferation;\\nb, commencing cystic dilatation of renal tube c, fibroid glomerulus. (Obj. inch, without eye-piece.)\\na delicate, loose, vascular layer of connective tissue which supplies the\\ncyst with blood-vessels, and which is such an important structure in\\nremoving cysts by enucleation the pericystium.\\nEtiology. The mechanical obstruction which is invariably the cause\\nof retention-cysts maybe 1. Inflammation; 2. Cicatricial stenosis; 3.\\nTumors; 4. Flexion of a duct, and 5 valvular closure; 6. Altered secre-\\ntion 7. Impaction in the duct of a foreign body, a concretion, or a\\nparasite. By far the most frequent cause of mechanical obstruction is\\ninflammation and its consequences.\\nThe effect of inflammation in the production of an obstruction to the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0716.jp2"}, "703": {"fulltext": "RETENTION-CYSTS. 66 1\\noutflow of a secretion can be studied most profitably in the kidney. In\\nchronic interstitial nephritis the over-production of connective tissue\\nobstructs the outflow of urine by obstructing the tubules (Fig. 454).\\nThe cicatricial contraction of the connective tissue narrows the tubules,\\nresulting in increased intratubular pressure and destruction of the\\ntubule above the seat of obstruction.\\nThe immediate effects of acute inflammation of the mucous mem-\\nbrane of a gland-duct is well illustrated in catarrhal duodenitis, which\\nso constantly results in retention of bile and in icterus. Catarrhal in-\\nflammation of the mucous membrane of the cecum is a frequent cause\\nof retention of secretion in the appendix vermiformis, resulting from\\nnarrowing of the lumen of the organ on the cecal side. Acute inflam-\\nmation, as a rule, gives rise to temporary obstruction, which disappears\\nwith the subsidence of the inflammation. The acute inflammation,\\nhowever, may be followed by conditions resulting in permanent obstruc-\\ntion from cicatricial contraction or flexion of a gland-duct. Cicatricial\\nstenosis of a duct follows most localized ulcerative processes. Valvular\\nobstruction may exist as a congenital affection, as is the case in hydro-\\nnephrosis developing in consequence of a valvular obstruction at a point\\nwhere the ureter expands into the pelvis of the kidney or it may exist\\nin consequence of inflammation. The secretion of a gland may be so\\naltered that it cannot escape through the normal outlet of the gland\\nthis condition in itself would result in accumulation and progressive\\nincrease of the mechanical difficulties, as the retention of the secretion\\nwould naturally produce irritation, and the irritation would give rise to\\nprogressive stenosis of the outlet of the gland.\\nThe effect of the impaction of a concretion in the gland-duct in\\nproducing obstruction is well shown in cases of impaction of a biliary\\ncalculus in the cystic or common duct, and of a renal calculus in the\\nureter. In rare cases a gland-duct is made partially or completely im-\\npermeable by the impaction of a foreign substance or of one of the large\\nparasites which infest the human body. Tumors may produce obstruc-\\ntion of a duct by growing into its lumen, by compression, or by the\\nproduction of a flexion.\\nSymptoms and Diagnosis. The swelling increases in size slowly\\nor quickly according to the degree of obstruction, the size of the gland,\\nthe character of its secretion, or the quantity of secretion produced.\\nAn atheromatous cyst increases very slowly in size, while an acute\\nobstruction of the duct of the gall-bladder or of the ureter results in\\nrapid destruction of the obstructed organ and the formation of a swell-\\ning of considerable size in a short time. The writer has made numerous\\nexperiments on dogs to ascertain the immediate effects of complete", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0717.jp2"}, "704": {"fulltext": "662 PATHOLOGY AND TREATMENT OF TUMORS.\\nobstruction of the ureter. The ureter was cut transversely about\\nthree inches below the pelvis of the kidney the proximal end was\\ntied in a knot, and loosening of the knot was prevented by tying it\\nwith a catgut ligature. Almost all the animals survived the operation.\\nThey were killed in from a few days to six months after the operation.\\nConsiderable destruction of the pelvis of the kidney and the ureter was\\nobserved a week after the operation. The distention continued pro-\\ngressively, so that after three months the kidney on the side operated\\nupon was at least four times as large as the opposite one. After six\\nmonths the kidney consisted simply of a large bag filled with a clear\\nfluid. To the naked eye all kidney-tissue appeared to have been\\nremoved by pressure-atrophy, but under the microscope sections of\\nthe thin cyst-wall showed normal kidney-tissue, but in an exceedingly\\natrophic condition.\\nIt is of interest in this connection to relate the effects of nephrotomy\\non the kidney. Soon after a lumbar renal fistula was established the\\namount of secretion began to increase, and it was shown by examination\\nof the kidney at different periods after the nephrotomy that regeneration\\nof kidney-tissue occurred, so that in a few months the kidney nearly\\nrecovered its normal size and function.\\nRapid growth of the cyst in some organs which produce large\\nquantities of secretion as, for instance, the liver and the pancreas is\\nprevented by the absorption of the secretion. Mechanical obstruction\\nof the common bile-duct does not produce marked distention of the\\nbile-duct or gall-bladder, because the bile is removed by absorption,\\nwhich in this instance is well demonstrated by the progressive icterus\\nwhich follows the obstruction. The intensity of the icterus is a\\ngood indication of the extent of the obstruction. Obstruction of\\nthe cystic duct leads to distention of the gall-bladder, because the\\nsecretions of the gall-bladder are not removed to the same extent by\\nabsorption.\\nThe writer made a long series of experiments on dogs for the pur-\\npose of studying the effects of obstruction of the pancreatic duct in\\nthe production of cysts of the pancreas. He had been led to believe\\nthat mechanical obstruction to the escape of pancreatic juice was the\\nprincipal factor in the etiology of pancreatic cysts. The pancreatic\\nduct was divided near the duodenum, and the distal end was obstructed\\nin various ways. In some of the cases the distal end was left open,\\nthe gland continued to secrete, and the pancreatic juice was absorbed\\nfrom the abdominal cavity as rapidly as it escaped into it, without any\\ndetriment to the animal in fact, animals thus treated were after several\\nweeks in a better condition than when the distal end was tied. In the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0718.jp2"}, "705": {"fulltext": "RETENTION-CYSTS. 663\\nnumerous experiments made by dividing the duct and ligating the\\ndistal end, only in one case did the writer find, after many weeks, the\\nduct uniformly dilated to the size of an ordinary lead-pencil in the\\nother cases little or no dilatation of the duct was produced by the\\nligation. The pancreatic juice was absorbed as fast as it was produced,\\nand in the case in which the dilatation of the duct reached the size of\\na lead-pencil there were found in the pancreas textural changes which\\nmust have seriously interfered with auto-absorption of its secretion.\\nCyst-formation to any considerable extent is therefore only to be\\nexpected in obstruction of the outlet of glands the secretion of which\\nis not amenable to auto-absorption and in which the obstruction to the\\nescape of the secretion is complete.\\nPain is present, as a rule, only in cases in which rapid distention\\ntakes place and the swelling acquires considerable size. Pain becomes\\na conspicuous clinical feature in all cases of retention-cysts complicated\\nby infection and inflammation.\\nRetention-cysts are much more liable to become infected than other\\ncysts, because the spaces which serve as starting-points for the cysts\\nnot infrequently contain, in a normal condition, pathogenic microbes,\\nor when the obstruction is incomplete, as is most often the case,\\nmicrobes enter later. The microbes in retained secretions are much\\nmore liable to assert their specific pathogenic qualities than when the\\nsame number are present in the space in a normal condition, because\\nthey are retained with the secretion, and the latter frequently constitutes\\na favorable culture-medium for their growth and reproduction. The\\nretention of the secretions can often be ascertained by evidences\\npointing to their absorption, as is the case in absorption of the com-\\nmon bile-duct or it can be learned from examination of the secretion,\\nas is always done by examination of the urine in suspected renal affections.\\nThe location of the cyst is of great importance in the differential\\ndiagnosis between retention-cysts and other cysts. A retention-cyst\\nalways occupies the location of the affected organ. An atheromatous\\ncyst can occur only in parts of the skin in which sebaceous glands\\nnormally exist. A retention-cyst of the gall-bladder will occupy the\\nposition in which the gall-bladder is normally situated. A hydro-\\nnephrotic kidney will be found in the location normally occupied by\\nthe kidney. A retention-cyst, from its size, may wander away from\\nthe place at which it had its starting-point, but the early history of the\\ncase usually points to the position normally occupied by the affected\\norgan.\\nThe character of the contents of a retention-cyst can often be ascer-\\ntained only by an exploratory puncture.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0719.jp2"}, "706": {"fulltext": "664 PATHOLOGY AND TREATMENT OF TUMORS.\\nPrognosis. The danger to life from a retention-cyst depends upon\\nthe physiological importance of the organ affected and upon the occur-\\nrence of complications. Small retention-cysts of unimportant glands\\nnot only are harmless, but give rise to no symptoms. Retention of\\nurine caused by obstruction of one or of both ureters may destroy\\nlife in a short time. Rupture of a retention-cyst of any of the\\nabdominal organs often results in fatal peritonitis. All retention-\\ncysts are apt to become infected, when the complicating suppurative\\ninflammation and its consequences constitute the chief sources of\\ndanger.\\nTreatment. The treatment of a retention-cyst has for its aims the\\nremoval of the primary cause, the obstruction, and, if this cannot be\\ndone, the establishment of an external fistula or the extirpation of\\nthe cyst. If the outlet of the gland has become obstructed by inflam-\\nmation, the rational treatment consists in combating the inflammation.\\nIf the duct of a gland has become blocked by the impaction of a con-\\ncretion or a foreign substance, the removal of the impacted body, if\\nthis can be done, is indicated. If the duct has become completely\\nobliterated by cicatricial stenosis, the formation of an external or an\\ninternal fistula or extirpation of the cyst constitutes the proper surgical\\ntreatment. If the lumen of the duct has become narrowed by inflam-\\nmatory thickening of its mucous lining, the removal of intracystic\\npressure by the formation of a temporary external fistula is often the\\nmost efficient way in which to subdue the inflammatory affection and\\nto restore the normal size of the passage. Should this treatment not\\nyield the desired result, a radical, operation will prove safer after inflam-\\nmation has subsided.\\nIn the extirpation of retention-cysts surrounded on all sides by\\ntissues, the cyst should be exposed by an incision made in such a way\\nas to render the cyst most accessible, and as soon as the pericystium\\nis reached the cyst should be enucleated by the use of the fingers and\\nof blunt instruments, and, if the cyst is not too large, without rupturing\\nthe sac. If the sac, as the result of inflammation, has become adherent\\nto the adjacent tissues, it can be removed safely and completely only by\\na careful dissection. In retention-cysts which have ruptured externally\\nand which cannot be removed safely a radical cure can often be effected\\nby enlarging the fistulous opening sufficiently to render the whole\\ninterior of the cyst accessible, after which the epithelial lining may be\\ndestroyed by deep cauterization with the Pacquelin cautery the cavity\\nis then packed with iodoform gauze until the surgeon can satisfy him-\\nself that every particle of mucous membrane has been destroyed, when\\nthe wound is allowed to heal by granulation.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0720.jp2"}, "707": {"fulltext": "RE TENTION- C YS TS. 665\\nTopography.\\nThyroid Gland. The thyroid gland is one of the ductless glands,\\nand in case the secretion from any part of the gland fails to become\\nabsorbed, it accumulates in one or more follicles of the gland, resulting\\nin a simple cyst or in follicular cysts. We have already described\\ncystoma and adenomatous cysts of the thyroid gland, as well as cystic\\ndegeneration of other tumors of this organ, but follicular cysts are the\\ngenuine retention-cysts of the thyroid gland. The pre-existing con-\\nnective tissue of the gland forms the capsule of the cyst, which in its\\ninterior is lined by endothelial cells these cells, as cystic dilatation pro-\\nceeds, are very apt to disappear, leaving the cyst-wall bare or barren.\\nBy the coalescence of several follicular cysts there are formed cysts\\nof considerable size that fluctuate distinctly. Cholesterin-crystals are\\nfrequently found in retention-cysts of the thyroid gland.\\nUnless complicated by inflammation, retention-cysts of the thyroid\\ngland can readily be removed by enucleation. Their treatment by\\ntapping followed by the use of irritating injections is uncertain and\\nunsatisfactory.\\nOvary. The ovary is another organ in which we find genuine\\nretention-cysts. If, from thickening of the walls of a Graafian follicle,\\nrupture and escape of the ovum fail to take place, the follicle becomes\\ndistended and a follicular cyst is the result. All the large ovarian cysts\\nare tumors which develop from a tumor-matrix, as an adenoma, a\\ncystoma, or a dermoid. The impression still prevails that many of the\\nlarge cysts of the ovary are retention-cysts. This view is no longer\\ntenable, as it has been shown that single follicular cysts of the ovary\\ndo not acquire a size larger than that of a walnut, and that by coales-\\ncence of several cysts masses larger than a fist are seldom met with.\\n(See Fig. 100, p. 193.) The imprisoned ovum in the hydropic follicle\\nis destroyed. These cysts contain a clear yellowish or bloody serum.\\nIn one case Pozzi found, besides serous cysts, others which contained\\na cheesy or lardaceous material which he regarded as the product of\\nepithelial degeneration. The cysts are lined by cylindrical epithelium,\\nand upon the most prominent parts of the cyst- wall small blood-vessels\\nare visible. Ovula have been found in retention-cysts of the ovary by\\nRitchie and Webb, Lawson Tait, and Rokitansky. Very often both\\novaries are simultaneously affected.\\nThe removal of retention-cysts of the ovary is more akin to a\\ncastration than an ovariotomy, so far as the technique and the ease\\nwith which the operation can be performed through a small incision\\nare concerned.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0721.jp2"}, "708": {"fulltext": "666\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nSkin. The skin is the seat of retention-cysts of the sebaceous\\nglands and the sweat-glands, the former of which are by far the most\\nfrequently affected. The sebaceous cysts are also called atheromatous\\ncysts, from the character of their contents. They are found most\\nfrequently in the scalp, but they may occur in the skin of any part\\nof the body where sebaceous glands are present. As the sebaceous\\nglands are connected with hair-follicles, the retention-cysts frequently\\ncontain fine lanuginose hair.\\nComedo represents the smallest sebaceous cyst. The outlet of the\\ngland is obstructed by a minute black mass which completely blocks\\nthe lumen of the duct. If the duct of a comedo becomes com-\\npletely obliterated by cicatricial contraction, and its contents inspissate,\\n^w\\nFig. 455. Atheromatous cyst of the skin of the cheek; X 18 (after Karg and Schmorl). Under the\\nnormal epithelium (a) lies a small atheromatous cyst, the wall {b) of which is composed of connective tissue\\nin which can be seen remnants of sebaceous glands flattened by pressure the cyst is lined by stratified\\nlayers of squamous epithelium; the pultaceous contents consist of fat-needles and plates of cholesterin\\nthe cutis is infiltrated c, shaft of hair d, sebaceous gland e, sweat-glands.\\nit presents itself under the epidermis as a small white spot, but slightly\\nelevated, which is called a milium. The different forms of acne are\\ncomedos in a state of inflammation.\\nIn the deeper forms of sebaceous cysts the cyst-wall is separated\\nfrom the cutis and the connection with the skin is finally lost (Fig. 455).\\nAstley Cooper first pointed out that sebaceous cysts result from\\nobstruction. The obstruction is first the result of accumulation of the\\nsecretion at the inflamed outlet of the gland, while material from with-\\nout forms the black plug in comedo later the inflammation results in\\ncicatricial stenosis, and finally in complete obliteration of the duct and", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0722.jp2"}, "709": {"fulltext": "RETENTION-CYSTS. 66j\\nisolation of the cyst from the skin. The cyst is surrounded by the\\nvascular pericystium and is lined by stratified epithelial cells. The\\nexfoliated cells in young cysts are closely packed together in concen-\\ntric layers. When they undergo fatty degeneration they form the cha-\\nracteristic pultaceous atheromatous contents. Besides this material\\nsebaceous cysts contain cholesterin-crystals, and often lanuginose hair.\\nIn old cysts the sac becomes very much thickened, so that it can easily\\nbe extracted. At the same time the atheromatous material frequently\\nundergoes liquefaction, so that the contents appear as a thin emulsion.\\nThe contents of the cyst are apt also to undergo cretefaction, in which\\nevent the cyst shrinks and can be felt as a hard mass under the skin.\\nIn sebaceous cysts of the scalp a deep dent in the bone, produced by\\npressure-atrophy, marks the location of the cyst after extirpation.\\nSebaceous cysts often appear multiple in the scalp and other parts of\\nthe body, notably the face and the scrotum.\\nInflammation and suppuration of a sebaceous cyst may terminate\\nin a permanent cure if the entire lining of the cyst is destroyed if\\nthis is not effected, suppuration continues, and sometimes a fungous\\nmass of granulations appears, suggesting a transformation of the lining\\nof the cyst-wall into a carcinoma. The origin of carcinoma in a cyst-\\nwall that had undergone this change has been observed.\\nA sebaceous cyst that has never been the seat of inflammation can\\nbe removed quickly by enucleation. The skin covering a sebaceous\\ncyst is usually bald, but before performing this little operation it is\\nadvisable to shave the surface a little beyond the margin of the cyst,\\nto disinfect the skin very thoroughly, and to resort to every other\\nantiseptic precaution, as infection is very liable to occur during this\\noperation, and has occasionally resulted in the death of the patient.\\nCarelessness in performing this otherwise insignificant operation is\\ninexcusable.\\nThe best method in removing a sebaceous cyst quickly and\\nthoroughly is to transfix the base of the swelling with a narrow bistoury,\\nto cut through its centre from within outward, then to grasp the cyst-\\nwall where it is thickest which is at one of the angles of the wound\\nwith a pair of rat-tooth forceps, and by gentle traction extract the\\nthe cyst. Every particle of the lining of the cyst-wall must be removed,\\notherwise a recurrence is sure to take place. After carefully arresting\\nthe hemorrhage the wound is closed by two or three sutures of fine\\ncatgut over the sutures an antiseptic dressing is applied this dressing\\nis held in place in such a manner as to exert gentle pressure, in order\\nto keep the skin in contact with the opposite side of the wound. If\\ncompression is omitted the parenchymatous oozing will furnish enough", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0723.jp2"}, "710": {"fulltext": "668 PATHOLOGY AND TREATMENT OF TUMORS.\\nblood to form a swelling the size of the cyst, preventing an ideal heal-\\ning of the wound, besides increasing the risk of infection.\\nInflamed sebaceous cysts must be removed by excision, as enucle-\\nation usually fails on account of the presence of firm adhesions between\\nthe capsule and the adjacent tissue. If the scalp is the seat of numer-\\nous sebaceous cysts, and the patient desires their removal at one sit-\\nting, it is better, from a cosmetic as well as a surgical point of view, to\\nshave the entire scalp, thereby enabling the surgeon to procure for the\\ndifferent fields of operation a perfectly aseptic condition.\\nVery little is known regarding retention-cysts of the sweat-glands.\\nVerneuil described adenoma, and Foerster described retention-cysts of\\nthe sweat-glands, and there can be no doubt, owing to their great\\nresemblance, that one has been mistaken for the other. As a pathog-\\nnomonic symptom is mentioned the occasional appearance of moisture\\nupon the surface of the swelling, caused by leakage through a partially\\nobstructed duct.\\nCysts of the sweat-glands are naturally of a very glandular type,\\nresembling the cystic adenomata in general. The few cases that have\\nbeen recorded were found in the skin of the face and in the vicinity of\\nthe external ear. The cyst-wall is so delicate that the swelling can be\\nthoroughly removed only by excision.\\nMucous Membrane. The mucous membrane anatomically resem-\\nbles very closely the external skin but, instead of stratified layers of\\nsquamous epithelium, it is with few exceptions lined by columnar\\nepithelium in a single layer, and is more richly supplied with glands.\\nThe mucous crypts present in all of the mucous membranes are the\\nanalogues of the sebaceous glands of the skin, and retention of their\\nsecretion results in the formation of cysts resembling the three varieties\\nof sebaceous cysts comedo, milium, and deep cysts. Crypts are\\nfound in the mucous membrane of the bladder, the ureters, and the biliary\\nducts. In the neck of the uterus they are normally in a cystic condi-\\ntion, and are described as the ovules of Naboth. They are especially\\nwell developed and very long in the mucous membrane of the intestinal\\ncanal and the uterus.\\nThe post-tracheal glands occupy the entire thickness of the tracheal\\nwall, and when obstructed they form retro-tracheal cysts. If the crypts\\nare superficial, their cysts resemble the comedos and acne of the skin\\nif they are deep, retention of their secretion results in the formation of\\nlarger swellings.\\nThe columnar epithelial cells are attached to the basement mem-\\nbrane of the delicate cyst-wall, and they produce the mucus, the\\ncharacteristic contents of a cyst of the mucous membrane. By pres-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0724.jp2"}, "711": {"fulltext": "RE TENTION-CYSTS.\\n669\\nsure the columnar epithelial cells are often flattened, appearing under\\nthe microscope as squamous cells. The mucus in old cysts is usually\\nliquefied and converted into a serous fluid, so that old mucous cysts\\npresent themselves as serous cysts. These cysts were called by the old\\nauthors hydatids.\\nInflammation of the cysts transforms mucous cysts into acne and\\nmolluscum in the same manner as retention-cysts of the sebaceous\\nglands of the skin are formed. If the larger mucous cysts become\\nelongated, polypoid, we speak of polypi cystici or liydatidosi. This\\nform of mucous cyst is seen frequently in the rectum and in the neck\\nof the uterus.\\nMucous cysts of the mucous membrane of the mouth are quite\\ncommon. They contain a viscid fluid, and after spontaneous rupture\\nFig. 456.\u00e2\u0080\u0094 Transverse section through the upper part of the cervix, showing the entire mucous mem-\\nbrane (after Cornil). The central cavity is the cervical canal; b,b, internal surface of mucous membrane,\\npresenting small folds, superficial glandular depressions, and large incisions of the arbor vita: (d) g,g, deep\\nglands a, ovules of Naboth m, m, muscular tissue of the uterine wall.\\nthey often leave a circular deep ulcer, which usually heals promptly\\nafter thorough cauterization with nitrate of silver. They are met with\\nmost frequently in the mucous membrane of the lips. Their walls are\\nexceedingly delicate, and the mucous membrane covering them is so\\nthin that it is generally excised with the cyst.\\nMultiple mucous cysts of the inner surface of the lips result in", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0725.jp2"}, "712": {"fulltext": "670\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nsuch great thickening of the lips that they appear to be double. The\\nremoval of the cysts restores the normal size and shape of the lips.\\nCysts of the soft palate, especially of the pillars in the vicinity of\\nthe tonsils, which are of such frequent occurrence, are retention-cysts.\\nThey never attain large size, and they can be destroyed effectually by\\nignipuncture.\\nIn the antrum of Highmore there have been found mucous cysts\\nof such enormous size that they not only filled the entire cavity, but\\nalso caused distention of the bony walls (Giraldes). Such cases have\\nusually been mistaken for hydrops of the antrum, as the cyst-wall\\nwas not discovered. Retention-cysts of this size in the antrum of\\nHighmore should be removed after making a temporary resection of\\nthe anterior wall by detaching from the mouth, with a small chisel,\\na quadrangular muco-osseous flap on three sides, and fracturing its\\nfourth or upper side, and by\\nraising the flap exposing the an-\\ntrum so thoroughly that every\\npart of it is accessible to direct\\ntreatment. Free drainage through\\nthe nose should be established be-\\nfore the flap is brought down and\\nfastened in place by a few points\\nof chromicized catgut sutures.\\nThe ovules of Naboth are of\\nspecial interest to gynecologists.\\nThese mucous crypts are of un-\\nusual size in a normal condition\\nwhen the cervix is in a condition\\nof chronic inflammation they be-\\ncome greatly enlarged, frequently\\nacquiring the size of a filbert\\n(Fig. 456). The cyst-wall of\\ndilated Nabothian glands is ex-\\nceedingly delicate, and the mu-\\ncous membrane over the glands\\nis atrophied. They often rupture\\nspontaneously, and they are fre-\\nquently punctured in the treat-\\nment of chronic cervical metritis.\\nThe glands of Bartholin, which Henzier called vulvo-vaginal\\nfrom their location, and which have also been called Duverney s\\nor Cowper s glands, are frequently affected by chronic inflammation\\nFig. 457. Retention-cyst of Bartholin s gland (after\\nWinckel) a, left labium minus b, left labium majus\\nc, cyst laid open.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0726.jp2"}, "713": {"fulltext": "RETENTION-CYSTS. 671\\nof their excretory duct and retention of their contents. The cysts\\nare located on the internal aspect of the labium majus (Fig. 457).\\nThe swelling, which often acquires the size of a walnut, is either\\nunilocular or multilocular, is generally unilateral, and is elongated in\\nthe axis of the greater lip. Either the duct or the gland, or both, may\\nbe affected. In the former case the cyst is superficial in the latter\\ninstance it is more deeply located. The cysts contain mucus, to which\\nis often added blood or inflammatory products.\\nIn the differential diagnosis of cysts of Bartholin s glands it is\\nimportant to consider solid tumors in that locality, hydrocele, hemato-\\ncele, hernia, other cysts, and abscesses. Cysts of Bartholin s glands\\nare exceedingly apt to become infected they then appear clinically\\nas abscesses. Incision affords prompt relief, but seldom effects a cure.\\nRetention and inflammation repeat themselves from time to time until\\nthe whole cyst-wall is extirpated. In open suppurating cysts the advice\\nof Pozzi should be followed to inject the cyst with hot spermaceti\\nbefore the dissection is commenced, as otherwise there is a great prob-\\nability that the removal of the lining of the cyst will be incomplete.\\nPozzi recommends the same procedure in the extirpation of non-sup-\\npurating cysts. After tapping the cyst and washing it out with hot\\nwater he injects melted paraffin at a low temperature. When the cavity\\nis distended ice is applied, and after the mass has been solidified the\\ndissection is begun with the anesthesia produced by the cold, and by\\ncocaine if necessary.\\nHydrokolpos. A retention-cyst of the vagina is produced by oblit-\\neration of the cervix above and atresia of the lower part of the vagina\\nthe mucus secreted by the vaginal glands accumulates in the interven-\\ning part of the vagina, which becomes the cyst-wall. Winckel describes\\na case of this kind in a woman fifty-seven years of age who died of\\ncarcinoma of the rectum. The atresia of the cervix and the vagina\\noccurred independently of the rectal carcinoma, as can be seen from the\\nillustration (Fig. 45 8). Atresia of the lower part of the vagina, acquired\\nor congenital, in menstruating women would result in hematokolpos\\ninstead of hydrokolpos.\\nHydrometra. Hydrometra occurs in women after the menopause.\\nIt is one of the conditions attending senile involution of the uterus\\nit results from stenosis or complete closure of the cervical canal pro-\\nduced by chronic catarrhal cervical endometritis, enlargement of the\\nNabothian glands, and sharp posterior flexions of the uterus. Some-\\ntimes obliteration of the lower part of the uterine cavity leads to hydro-\\nmetra of the upper part (Fig. 459). As the uterine glands continue to\\nfunctionate, and the escape of secretion is prevented by obstacles in the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0727.jp2"}, "714": {"fulltext": "672\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nlower part of the uterus or cervix, accumulation leads to distention of\\nthe cavity, and in the course of time the mucus is converted into\\nserum, hydrometra resulting. In women before the menopause the\\nsame conditions result in hemato-\\nmetra. Hydrometra in the aged,\\nresulting from imperfect closure of\\nthe cervical canal or the lower part\\nof the uterine cavity from stenosis\\nor retroflexion, is very apt to be\\nfollowed by pyometra, and the offen-\\nsive discharge incident to this con-\\ndition has frequently been taken as\\n^y\\nFig. 458-\u00e2\u0080\u0094 Acquired hydrokolpos in a woman fifty-\\nseven years of age (after Winckel) a, vaginal cyst\\nb, several inches of vagina obliterated by cicatricial\\ncontraction c, lower end of vagina.\\nFig. 459- Hydrometra in a woman past the\\nmenopause (after Winckel): a, hydrometra; b, ob-\\nliteration of lower part of uterine cavity.\\nan indication of the existence of malignant disease of the uterine\\ncavity.\\nHydrosalpinx. Hydrosalpinx results from partial or complete\\nclosure of the fimbriated extremity of the Fallopian tube and obstruc-\\ntion to the escape of secretions on the uterine side, and retention of the\\nsecretion produced by the mucous glands in the mucous lining of the\\ntube. The tubes may be partially or completely closed the tubes\\napertce and tubce occIuscb of Froriep. As closure of the distal end of\\nthe tube occurs usually from adhesions produced by pelvic peritonitis,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0728.jp2"}, "715": {"fulltext": "RE TENTION-CYSTS.\\n673\\nthe affection is frequently bilateral, as is the case in pyosalpinx. The\\nlumen of the tube on the uterine side in a normal condition is quite\\nsmall frequently it is narrowed by the catarrhal salpingitis which pre-\\ncedes the peritonitis, or the escape of the tubal secretion is prevented\\nby valvular closure of the orifice.\\nBy far the most frequent cause of catarrhal salpingitis, and of the\\nsubsequent pelvic peritonitis which obliterates the fimbriated extremities\\nof the tubes, is gonorrheal infection. If the infection is of a mild cha-\\nracter, little or no pus is produced, and the retained secretion in the\\ntube consists at first of mucus which is later changed into serum, the\\ncharacteristic contents of a hydrosalpinx. The serum frequently leaks\\ninto the peritoneal cavity, producing recurrent attacks of plastic peri-\\nFiG. 460.\u00e2\u0080\u0094 Hydrosalpinx (after Winckel) a, fundus uteri b, tube c, hydrops of tube.\\ntonitis if the fimbriated extremity of the tube is only partially closed\\nor it escapes at times through the uterus in the form of intermittent\\nprofuse serous discharges. If the entire tube becomes distended, the\\nswelling assumes a sausage-like shape, as the tube is not only dilated,\\nbut is also elongated (Fig. 460). The tube is often displaced by adhe-\\nsions. If only a small part of the tube remains patent, the swelling\\nis round or oval in shape.\\nHydrosalpinx is rare as compared with pyosalpinx, but in the\\nmajority of cases it precedes the latter affection. If gonococci are\\npresent in sufficient quantity, the suppurative inflammation of the\\n43", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0729.jp2"}, "716": {"fulltext": "674 PATHOLOGY AND TREATMENT OF TUMORS.\\nmucous membrane of the Fallopian tube converts the hydrosalpinx\\ninto a pyosalpinx. This change in the pathology and clinical aspects\\nof the tubal affection is sure to occur if, as is so often the case, the\\ninterior of the tubal swelling becomes the seat of secondary or mixed\\ninfection with pus-microbes.\\nThe removal of the uterine appendages in cases of single or double\\nhydrosalpinx is a much easier and less dangerous procedure than in\\ncases of pyosalpinx. There is here a rich field for conservative surgery,\\nas in many cases mutilating operations can be rendered unnecessary by\\nIW^i\\nFig. 461. Hydrosalpinx, tube laid open (after Winckel).\\nintelligent and persistent treatment aimed at restoring the free commu-\\nnication between the uterus and the tubes by appropriate intra-uterine\\nand intra-tubal applications combined with other treatment calculated\\nto eliminate the primary cause of the tubal obstruction.\\nTrachea and Bronchial Tubes. Retention-cysts of the trachea are\\nrare. They occur in the posterior wall, because here the tracheal rings\\nare defective. The first indication of the formation of a cyst is the\\nappearance of a shallow depression, which as it deepens posteriorly is\\ndeflected laterally by the oesophagus and the spine. As the cyst elongates\\nits base contracts, the cyst finally becoming pedunculated eventually\\nthe pedicle may disappear, the cyst becoming completely isolated from\\nthe trachea. Such cysts may appear behind the clavicle and may\\notherwise mimic retro-sternal struma and dermoid cysts. Textor\\noperated upon a cyst of this kind successfully. In bronchiectasis sac-\\nculation may take place to such an extent that cavities of considerable\\nsize communicate only through a small opening with the bronchial\\ntube from which they started. The bronchial secretion is usually\\nmixed with an offensive purulent discharge.\\nAppendix Vermiformis. Affections of the appendix vermiformis\\nare attracting a great deal of attention. Virchow showed years ago", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0730.jp2"}, "717": {"fulltext": "RETENTION-CYSTS. 675\\nthat the appendix is richly supplied with glands he also described a\\nretention-cyst of the appendix as large as a fist. In this case the long\\nnarrow organ, obstructed on the cecal side, had become so much dis-\\ntended that the swelling was globular in shape. He also called atten-\\ntion to the fact that an obstructed appendix frequently gives rise to\\ntyphlitis.\\nAttention has elsewhere been called to the pathological conditions\\nusually found in cases of stricture or of cicatricial closure in different\\nparts of the lumen of the appendix. The writer has never seen reten-\\ntion-cysts of the appendix holding more than a teaspoonful of mucus, but\\nhe has been informed by Hecktoen of Chicago, who had an immense\\nexperience in the post-mortem room, that on several occasions he found\\nretention-cysts of the appendix vermiformis of the size of a hen s Qgg.\\nIt can readily be conceived that obstruction at the cecal end of the appen-\\ndix might result in considerable distention of the lumen of the appendix\\non the distal side. In the cases which have come under the writer s\\nobservation the stenosis or obliteration was characterized more by\\nincrease in the thickness of the wall of the appendix than by dilata-\\ntion. In the absence of a sufficient number of pus-microbes in the\\nexcluded portion of the lumen of the appendix, the mucous glands\\nbeing in an active functional activity, the intracystic pressure would\\neventually lead to dilatation and cyst-formation. Cysts of the appendix\\nvermiformis should be borne in mind in the differential diagnosis of\\nobscure swellings in the ileo-cecal region.\\nThe proper treatment of a retention-cyst of the appendix vermi-\\nformis is excision of the appendix. Rupture of the cyst should be\\navoided if possible, and proper preparation should be made for this\\naccident by excluding the intestines from the field of operation with\\naseptic compresses. The appendix should be amputated near the\\ncecum by the subserous circular method.\\nBile-ducts. Retention of bile in any part of the bile-ducts is fol-\\nlowed by absorption of the serous portion, leading to inspissation. In\\nthe inspissated bile there remain cholesterin, bilifulvin, and hematoidin.\\nCysts as large as a walnut, containing inspissated bile, are sometimes\\nfound in the substance of the liver. In obstruction of the hepatic and\\ncommon ducts moderate distention of the bile-ducts takes place, but\\nthe formation of large cysts is prevented by the absorption of the\\nretained bile. If this auto-absorption is interfered with by inflammatory\\nprocesses affecting the bile-ducts and the connective tissue of the liver,\\nretention of the bile produced by some intact portions of the liver takes\\nplace, and the bile-duct, and, in case of obstruction of the common\\nduct, the gall-bladder, become greatly distended.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0731.jp2"}, "718": {"fulltext": "676 PATHOLOGY AND TREATMENT OF TUMORS.\\nThe gall-bladder is that part of the bile-tract most apt to undergo\\ncystic dilatation. Retention of the secretions of the mucous crypts of\\nthe mucous membrane of the gall-bladder occurs most frequently in\\nconsequence of obstruction of the cystic duct by impaction of a biliary\\ncalculus or by cicatricial stenosis. The latter is not infrequently one\\nof the remote consequences of the injuries inflicted by the passage of\\na gall-stone. The pressure exerted by the gall-stone and the irrita-\\ntion and inflammation caused by the calculus result in destruction of\\nthe mucous membrane, and during the healing of the defect the lumen\\nof the duct becomes narrowed and even completely obliterated. The\\ngall-bladder under such circumstances may become enormously dis-\\ntended much more so than if it contain bile.\\nAs no bile can enter the gall-bladder if the cystic duct is obstructed,\\nand the bile that may be present is soon absorbed, the organ contains\\nat first mucus, which later is transformed into a serous fluid hence\\nthe term hydrops of the gall-bladder, or hydrocholecyst. A mod-\\nerately distended gall-bladder presents a pyriform shape, with the nar-\\nrow part of the swelling directed toward the liver.\\nHydrops of the gall-bladder, unless complicated by localized peri-\\ntonitis, is not attended by much pain, nor does it give rise to much\\ninconvenience unless the swelling is very large. A dull aching pain is\\noccasionally complained of. The suffering frequently attending this\\ncondition is referable to the presence of a stone in the cystic duct,\\ngiving rise to those characteristic paroxysmal pains known as biliary\\ncolic. In obstruction of the cystic duct icterus either is entirely\\nabsent or is slight and usually of short duration. Infection of the\\ninterior of a gall-bladder either by extension of a suppurative inflam-\\nmation of the bile-ducts or through a small fistulous opening between\\nthe gall-bladder and an adherent intestinal loop converts the hydrops\\ninto an empyema of the gall-bladder. The inflammation of the mucous\\nmembrane diminishes or arrests the functions of the mucous crypts, and\\npus soon takes the place of the serous fluid.\\nHydrops of the gall-bladder has occasionally, from the size of the\\nswelling, been mistaken for ovarian cyst. In distention of the gall-\\nbladder the early clinical history of the case points to a swelling in the\\nupper and right part of the abdominal cavity, while ovarian cysts are\\nfirst discovered by the patient when the tumor rises out of the pelvis.\\nAn ovarian cyst can always be reached with the finger from the vagina,\\nwhile this can seldom, if ever, be done in a distended gall-bladder.\\nIn distention of the gall-bladder the early clinical history points to the\\nexistence of causes leading to obstruction of the cystic duct, while in\\novarian cyst the early symptoms are referred to the pelvis. Tumors", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0732.jp2"}, "719": {"fulltext": "RETENTION-CYSTS. 677\\nand cystic disease of the right kidney have often been mistaken for\\na distended gall-bladder, and vice versa. In renal affections a careful\\nstudy of the clinical history of the case and chemical and microscopical\\nexamination of the urine will yield valuable information. The retro-\\nperitoneal location of a tumor or a swelling of the kidney can usually\\nbe demonstrated satisfactorily by rectal insufflation an important diag-\\nnostic resource in differentiating between an intraperitoneal and a retro-\\nperitoneal tumor or swelling. Another condition rendering a positive\\ndiagnosis of a distended gall-bladder often impossible is echinococcus-\\ncyst of the lower surface of the liver. Hirschberg strongly urged the\\nemployment of the exploring needle in the differential diagnosis of\\nfluctuating tumors or swellings in the region of the gall-bladder. This\\nvery useful diagnostic resource, if properly employed, is harmless in\\ncase the tumor or cyst is adherent to the anterior abdominal wall.\\nWe have no reliable means of ascertaining the presence and exact loca-\\ntion of mural adhesions. The writer believes, with Konig, that explor-\\natory puncture should never be resorted to in the diagnosis of tumors\\nor cysts in this locality unless there is positive evidence that the punc-\\nture can be made without invading the peritoneal cavity. The informa-\\ntion derived from an exploratory puncture does not balance the risks\\nto which it exposes the patient. Should the puncture be made through\\nthe peritoneal cavity, and the cyst should prove to be an echinococcus-\\ncyst, the escape of its contents into the preperitoneal cavity would be\\nsure to result in dissemination of the parasitic disease and an early fatal\\ntermination. Should the cyst prove to be an empyema of the gall-\\nbladder, escape of pus through the puncture could hardly fail to\\nproduce a diffuse septic peritonitis.\\nShort of an exploratory puncture, we are not in possession of any\\nmeans to make a positive differential diagnosis between a hydrops and\\nan empyema of the gall-bladder. As we have advised against the\\nuse of the exploring needle, it is evident that in doubtful cases the\\nsurgeon should resort to an exploratory incision, fully prepared to do\\nwhat is necessary after a correct diagnosis has been made. The patient\\nshould understand that the operation is performed in the first place for\\nthe purpose of ascertaining the nature of the swelling, and that after\\nthis has been done the necessary operative procedure will follow. An\\nexploratory incision, in the writer s estimation, is safer and will yield\\nmore reliable diagnostic information than an exploratory puncture.\\nSeveral incisions have been suggested to expose the gall-bladder to\\ndirect surgical interference. Billroth preferred an incision parallel with\\nand about a finger s breadth below the costal arch. Other surgeons\\nadvise a vertical incision extending from the cartilage of the eighth", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0733.jp2"}, "720": {"fulltext": "678 PATHOLOGY AND TREATMENT OF TUMORS.\\nrib downward. Langenbeck in performing cholecystectomy makes\\na vertical incision from the costal arch to the outer border of the\\nrectus muscle, and joins it by a shorter incision extending from the\\nupper angle of the wound as far as the ensiform cartilage. Czerny\\nmakes an incision from the ensiform cartilage to just above the umbil-\\nicus, and joins it by a transverse incision extending through the rectus\\nmuscle on the right side. By reflecting the triangular flap the under\\nsurface of the liver is well exposed. The exploratory incision should\\nbe made over the centre of the swelling, from the costal arch down-\\nward. This incision will answer well if the conditions revealed require\\na simple cholecystotomy, and if it is deemed necessary to extirpate the\\ngall-bladder, the incision can readily be converted into Langenbeck s\\nincision. If a hydrops of the gall-bladder is found, the gall-bladder\\nshould be emptied by aspiration, after which it is drawn forward into\\nthe wound, and is held in place with forceps, or, still better, with two\\nsilk threads passed through the serous and muscular coats, one on\\neach side of the proposed incision. After packing gauze around the\\nempty bladder to protect the peritoneal cavity, an incision large enough\\nto admit the index finger is made in the long axis of the gall-bladder,\\nand through this incision, with finger and probes, search is made for\\nthe cause of obstruction. If a calculus is found in the cystic duct, it\\nshould be removed or crushed, after which the margins of the visceral\\nwound are stitched to the parietal peritoneum in the upper angle of the\\nwound, for the purpose of establishing a temporary biliary fistula. The\\nbalance of the external incision is closed by buried and deep sutures.\\nIf the cystic duct is found completely obliterated, the gall-bladder\\nshould be extirpated. In empyema the same surgical procedures are\\nindicated. A cholecystenterostomy is absolutely contraindicated except\\nin irremediable occlusion or obliteration of the common bile-duct.\\nClosely allied to hydrops of the gall-bladder are cysts of the\\npancreas.\\nPancreas. The pancreas, like other secretory organs, is prone to\\nbecome the seat of cystic swellings, the result of obliteration or obstruc-\\ntion of the common duct or of one or more of its branches. Cysts\\noriginating in this manner are true retention-cysts, containing the physi-\\nological secretion from the distal portion of the gland-tissue, with per-\\nhaps accidental products, such as altered secretions, blood, and the\\nproducts of inflammation.\\nOf the five cases of cyst of the pancreas which the writer has seen,\\ndetailed mention will be made of the first case that came under his\\nobservation\\nVolz, aet. nineteen, laborer, German, was admitted to Milwaukee", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0734.jp2"}, "721": {"fulltext": "RETENTION-CYSTS. 679\\nHospital November 28, 1884. He was small for his age and not robust,\\nbut he claimed that with one exception he had never been sick, and\\nthat no hereditary tendency to disease existed in his family. Five\\nweeks previously, while enjoying perfect health, he was thrown from\\na wagon, striking the ground on the left side of the abdomen, a heavy\\nkeg falling upon his back and increasing the force of the fall. The\\npain felt immediately after the accident was confined to his back, at\\nthe point where he was struck by the keg, but it was not sufficient in\\nintensity to prevent him from following his occupation as a mason s\\napprentice. In a few days, however, diarrhea set in, persisting for two\\nweeks and greatly reducing his strength and weight. If he had any\\nfever during this time, it was not sufficiently severe to attract his atten-\\ntion. His appetite was not impaired, and, although he vomited occa-\\nsionally, neither the vomiting nor the diarrhea seemed to be aggravated\\nby the time of eating or the kind or variety of food. After two weeks\\nhe noticed in the left hypochondriac region a tumor which was round,\\nsmooth, and painless. The tumor increased rapidly in size, and soon\\ngave rise to a sensation of fulness in the stomach, and later on to\\nregurgitation and vomiting soon after meals. His appetite was slightly\\nimpaired. At this time the patient was treated for a short time by\\nDr. F. H. Day of Wauwatosa, Wisconsin, who resorted to symptomatic\\ntreatment, and, observing no improvement, referred him to the writer\\nfor diagnosis and, in case it should be deemed advisable, surgical treat-\\nment. On his admission to the hospital he presented a considerable\\ndegree of emaciation and complained principally of a sensation of\\nfulness and weight in the region of the stomach, which was always\\naggravated after meals and only relieved by vomiting. On inspection\\na tumor was found occupying nearly the whole epigastric and the entire\\nleft hypochondriac region, its most prominent point being to the left\\nof the median line and about three inches below the xiphoid cartilage.\\nPercussion revealed a line of dulness extending from the left nipple\\nto within an inch of the umbilicus posteriorly the dulness reached\\nfrom the eighth to the lower margin of the twelfth rib in the epi-\\ngastric region a limited area of tympanitic resonance was discovered\\nalong the costal arch of the lower ribs on the right side. Palpation\\nshowed distinct fluctuation, the wave being conveyed from side to side\\nacross the whole area of dulness. The tumor was round in contour\\nand presented a smooth surface. The measurements were as follows\\nFrom the left nipple to the lowest point downward, 22 centimeters\\ntransverse diameter, 21 centimeters; anterior circumference, 63 centi-\\nmeters. The heart was pushed upward so that the impulse of the apex\\ncould be felt distinctly in the fourth intercostal space. The stomach", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0735.jp2"}, "722": {"fulltext": "68o\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nwas artificially distended with carbonic-acid gas, when it was ascer-\\ntained that it was pushed to the right and compressed by the tumor.\\nThe liver appeared to be unaffected by the tumor, as on percussion it\\nwas found in its normal location and of natural size. Both lumbar\\nregions were tympanitic. No evidences of ascites existed. Firm pres-\\nsure over any part of the tumor could be made without causing pain.\\nThe peculiar fremitus often felt in cases of echinococcus-cysts was\\nabsent. No pulsations could be felt in the tumor, and no impulse was\\nimparted to it by the underlying ab-\\ndominal aorta. The relative position\\nof the tumor was changed during\\nforcible inspiration and expiration.\\nFor the purpose of ascertaining the\\nnature of the contents of the tumor\\na hypodermic needle was thoroughly\\ndisinfected and introduced at a point\\nwhere the tumor was most promi-\\nnent when in place, the distal end\\nfig. 462-cyst of the pancreas -space wnhin of the syringe moved upward and\\ndotted lines indicates area of dulness a-b, line downward Synchronously with the\\nof incision.\\nrespiratory movements, showing that\\nthe adhesions with the parietal peritoneum, if any existed, were slight.\\nThe fluid removed, which was somewhat viscid and slightly opalescent,\\nwas alkaline in reaction and contained a considerable proportion of\\nalbumin, as it coagulated on applying heat and nitric acid. Under the\\nmicroscope it showed only a few morphological elements, epithelial\\ncells, a few leucocytes, and granular matter, but neither hooklets nor\\ncholesterin-crystals.\\nBy exclusion the diagnosis was narrowed down to one of two things\\na sterile echinococcus-cyst or a cyst of the pancreas. Against the\\nformer spoke the rapid growth of the tumor, its primary origin away\\nfrom the liver, its favorite location, the presence of a considerable\\namount of albumin, and the absence of hooklets, the presence of which\\nare diagnostic of echinococcus-cysts. In favor of a pancreatic cyst\\nspoke the history of traumatism in the region of the pancreas, the rapid\\ngrowth of the tumor, and the early disturbance of digestion as mani-\\nfested by diarrhea and vomiting, presumably caused by the partial\\nor complete retention of the pancreatic secretion. As the treatment\\nremained the same in either case, it was decided to perform laparotomy,\\nto stitch the cyst-walls to the peritoneal covering of the wound in the\\nabsence of adhesions, and to open and drain the cyst after adhesions\\nhad formed. This procedure was deemed preferable to the use of the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0736.jp2"}, "723": {"fulltext": "RETENTION-CYSTS. 68 1\\ntrocar or the aspirator, as it would with certainty prevent extravasation\\nof the cyst-contents into the peritoneal cavity, and the drainage-tube\\nwould guard against reaccumulation of the fluid, thus affording an\\nopportunity for the cavity to undergo obliteration by adhesion of the\\ninner surfaces of the cyst-walls. The patient, being cognizant of the\\nfact that no other form of treatment would promise any relief, readily\\nassented to the operation proposed. Every precaution was observed\\nto render the operation aseptic. The patient was given several baths\\nthe parts were shaved, and were carefully disinfected with a 5 per cent,\\nsolution of carbolic acid the instruments, sponges, and operating-room\\nwere prepared as for an ovariotomy. Before ether was administered\\nthe stomach was emptied and washed out by means of an elastic\\nstomach-tube, with a view to prevent retching and vomiting during\\nand after the operation. An incision five inches in length was made\\nobliquely over the most prominent portion of the tumor, about three\\ninches below, and parallel with, the left costal arch. A portion of the\\nrectus abdominis muscle was divided. After dividing carefully all the\\ntissues down to the peritoneum all hemorrhage was completely arrested.\\nOn opening the peritoneal cavity the omentum was brought into\\nview, the portion exposed containing an artery and a vein of consider-\\nable size. As these vessels were placed in a vertical direction, they\\ncrossed the wound, and it became necessary to apply, a double ligature,\\nthe omentum being then incised between the ligatures to the extent of\\nabout three inches. The omentum was slightly adherent to the pari-\\netal peritoneum and the surface of the tumor. Through the omental\\nincision the tumor could be seen and felt distinctly, presenting a smooth,\\nwhitish, and glistening surface. As it had formed at least slight adhe-\\nsions, it was decided to complete the operation. This plan was the\\nmore willingly adopted as it was evident that the intracystic pressure\\nwas great and the cyst-walls were thin, which would render stitching\\nthem to the margins of the wound difficult and unsafe. The sur-\\nface of the tumor was then seized with two dissecting forceps about an\\ninch apart, and gentle traction was made during incision and evacuation\\nof the cyst, so as to prevent all risk of extravasation of fluid into the\\nperitoneal cavity. The peritoneal covering was picked up and nipped,\\nand a grooved director was inserted into the opening made owing to\\nthe thinness of the walls of the sac, it penetrated the interior, and fluid\\nescaped along the groove with considerable force. The opening was\\nenlarged with the knife, when the fluid gushed forth in jets and was\\ncaught in basins. The contents were removed as completely as pos-\\nsible by making external pressure and by placing the patient on his\\nside. As the cyst was emptied its walls were drawn forward into the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0737.jp2"}, "724": {"fulltext": "682 PATHOLOGY AND TREATMENT OF TUMORS.\\nwound and stitched to the peritoneum, which had previously been\\nunited with the skin. The interior of the cyst was explored by insert-\\ning the index finger, which passed directly backward toward the tail\\nof the pancreas. The bottom of the cavity could, however, not be\\nreached. The inner surface of the cyst was smooth. Two large drain-\\nage-tubes were inserted to the bottom of the cyst, and the remaining\\nportion of the wound was united in the same manner as after ovariot-\\nomy, except that the rectus muscle was sutured separately. The fluid\\nremoved, estimated at three quarts, presented the same appearance as\\nthat removed by exploratory puncture. The wound was dressed with\\na large antiseptic compress, which was retained in situ with an elastic\\nrubber bandage. This bandage of rubber webbing not only retains the\\ndressing perfectly, allowing at the same time the movements of the\\nchest and the abdomen, but has an additional advantage, inasmuch as\\nit exerts equable pressure an important element in the after-treatment\\nof all abdominal operations.\\nThe patient never vomited during or after the operation, and expe-\\nrienced immediate relief on removal of the pressure caused by the\\ntumor. The pulse never rose over 90 and the highest temperature\\nobserved was ioo\u00c2\u00b0 F., the day after the operation. The appetite\\nincreased, and no unpleasant subjective symptoms were complained of\\nat any time. On the third day the dressing showed moisture on the\\nexternal surface, and it was changed. The gauze was saturated with\\nthe secretions from the cyst. The wound looked healthy, but the\\nsurrounding skin, as far as the dressing had extended, was red and\\nmacerated, and the epidermis could be removed in large flakes, leaving\\nbeneath a raw surface. The changes in the skin presented the appear-\\nances described by Kulenkampff and Gussenbauer, and claimed by\\nthem to be due to the digestive power of the pancreatic juice. The\\nexcoriated surface was sprinkled with salicylic acid and was again\\ncovered with a Lister dressing. On account of profuse secretion from\\nthe cyst the dressings were changed every few days, and at every change\\nthe skin was found excoriated as far as it had been moistened by the\\nsecretion. At the end of the first week the sutures were removed and\\nno further dressings were applied, whereupon the skin healed without\\nsuppuration, and only a minimum amount of pus escaped through the\\nfistulous opening with the secretion. The secretion became clearer\\nafter the operation, and continued to be discharged in varying quantities\\nfor almost four weeks. One of the drainage-tubes inserted at the time\\nof the operation was removed at the first change of the dressing, and\\nthe second was gradually shortened, being entirely removed three weeks\\nafter the operation. At the end of the second week the cyst was", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0738.jp2"}, "725": {"fulltext": "RETENTION-CYSTS. 683\\nexplored with a disinfected probe which passed to a depth of eight\\ninches in the direction of the tail of the pancreas. The fistulous tract\\nsoon became live with granulations and grew smaller in length and\\ndiameter at the end of eight weeks it was very narrow, so as to admit\\nonly a small probe, which could be passed only to a depth of four\\ninches. The skin around the fistulous opening was drawn inward,\\nforming a deep funnel-shaped depression.\\nJanuary 22, 1885, the patient was discharged cured. The fistula\\nwas completely closed. Retraction of cicatrix was very marked. The\\ngeneral health was good, the digestion perfect. No swelling could be\\nfelt in the region of the pancreas.\\nRemarks. It was the intention of the writer to collect some of\\nthe secretion for the purpose of ascertaining its digestive properties\\non different articles of food, but before this could be done the\\namount secreted daily became so small that it was impossible to\\nobtain corroborative diagnostic evidence from this source. The ana-\\ntomical location of the tumor, its relations to the surrounding organs,\\nits rapid growth, and the character of its contents can leave no pos-\\nsible doubt that we had to deal with a genuine retention-cyst of the\\npancreas. The question naturally arises, What was the cause of the\\nobstruction The history of the case points clearly to traumatism as\\nthe exciting cause. The patient had been in good health until he\\nreceived the injury, and since that time he had not been well, although\\nhe continued at his work for some time afterward. Whether the diar-\\nrhea from which he suffered for the first two weeks resulted from injury\\nto the pancreas we are unable to prove, but it may be possible that a\\nretention of the pancreatic secretion occurred after the traumatism, and\\nthat the diarrhea may have been produced by the absence of the fluid\\nin the intestinal tract. As the patient at this time was not under medical\\nobservation, the character of the stools was not ascertained. As the\\ninjury was inflicted in the region of the pancreas, it is reasonable to\\nassume that the pancreatic duct and the parenchyma of the gland were\\nlacerated at a certain point, producing obstruction to the outflow of the\\nsecretion from the distal portion of the organ, the nature of the injury\\nand the manner of obstruction being the same as in cases of rupture\\nof the male urethra. It would be difficult to imagine that the com-\\nmon duct could be distended by the accumulation of the retained fluid\\nto such an enormous extent in such a remarkably short time, hence we\\nare forced to conclude that laceration of the duct took place, and that\\nthe pancreatic fluid infiltrated the gland, the cyst being formed at the\\nexpense of its parenchyma and by distention of the capsule of the\\norgan. The cyst-wall anteriorly was so thin that after cutting the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0739.jp2"}, "726": {"fulltext": "684 PATHOLOGY AND TREATMENT OF TUMORS.\\nperitoneal covering the grooved director penetrated directly into the\\ninterior of the cyst without more than the slightest force being used,\\nshowing that nothing but a little connective tissue was interposed\\nbetween the peritoneum and the cyst-contents. The rapid growth of\\nthe cyst would indicate that the obstruction occurred at some distance\\nfrom the caudal extremity of the gland, thus making a considerable\\nportion of the secreting tissue contributory to the formation of the\\ncyst. The early cessation of the discharge of the secretion through\\nthe abnormal outlet would tend to prove either that after the removal\\nof the intracystic pressure the duct again became permeable, and thus\\nfurnished a free passage to the secretions into the intestinal canal\\nthrough the natural channel, or that the gland-tissue in the vicinity and\\ndistal to the cyst had been destroyed.\\nIn regard to the operation, it is necessary to say that the writer\\ndeviated from the usual plan in not making the incision through the\\nlinea alba. The incision was made over the most prominent part of\\nthe tumor, for the following substantial reasons\\n1. If adhesions had formed, they would naturally begin at a point\\nwhere the tumor impinged most firmly against the anterior abdominal\\nwall.\\n2. Incision over the most prominent portion of the cyst would\\nafford the best point for effective drainage.\\nThe band of connective tissue which would result from atrophy and\\nobliteration of the cyst would form a permanent bridge between the\\ncicatrix of the abdominal wound and the gland, consequently it is\\nadvisable to establish this necessary evil where it will do the least\\nharm by interfering with the functions of important organs.\\nAspiration of the cyst was not practised, because the exploratory\\npuncture had demonstrated that firm adhesions had not taken place,\\nand in the absence of these it was feared that some of the cyst-con-\\ntents might escape into the peritoneal cavity and produce peritonitis.\\nThe maceration of the skin was the result of the digestive action of\\nthe pancreatic juice, and this phenomenon furnished strongly corrobo-\\nrative diagnostic evidence in this as well as in previous cases.\\nSince this case was reported with six others which the writer had\\ncollected at that time, about thirty new cases have been recorded in\\nliterature, and in nearly all of these the formation of an external fistula\\nresulted in a permanent cure.\\nPathology and Morbid Anatomy. Cysts in the pancreas always\\nresult from retention of the secretion and subsequent dilatation of the\\nsecretory duct, or, in case of laceration of this structure, from extrava-\\nsation of the secretion into the parenchyma of the gland and subse-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0740.jp2"}, "727": {"fulltext": "RETENTION-CYSTS. 685\\nquent distention of its capsule. The size of the cyst is modified by\\nthe character and seat of the obstruction and by its relative position to\\nthe secreting gland-structure. The walls of the cyst are usually thin\\nfrom over-distention in cases of rapid-growing cysts, or much thick-\\nened when the growth of the tumor has been slow and accompanied\\nby chronic proliferation and induration of the connective tissue. The\\ncyst-walls in chronic cases may become cartilaginous or even ossified.\\nThe inner surface is either smooth or presents evidences of degenera-\\ntion similar to those occurring on the internal surface of arteries in\\nthe later stages of endarteritis. If the canal of Wirsung is obstructed\\nat or near its proximal end, the entire duct and its branches may become\\ndilated, presenting the appearance of varicose veins, or a more uniformly\\nrounded cyst may form, of the size of an orange, a child s head, or\\neven so large as to occupy the whole abdominal cavity, as in Boze-\\nman s case. As the cyst increases in size the gland-structure disap-\\npears by absorption in consequence of intracystic pressure. The cause\\nwhich constitutes the obstruction will often also lead to destruction of\\nthe parenchyma of the organ by inducing a chronic interstitial pancre-\\natitis which is followed by cirrhosis or fatty degeneration of the organ.\\nVirchow alludes to cysts of the pancreas under the name of ranula\\npancreatica, and describes two essential and distinct varieties. In the\\nfirst class the entire duct is found dilated, resembling in appearance\\na rosary. In the second variety the outlet of the excretory duct is\\nobstructed, and behind the seat of obstruction the duct undergoes\\ncystic dilatation. He mentions a case that came under his observation\\nwhere such a cyst had attained the size of a fist. He believes that\\ncicatricial contractions or the pressure of tumors upon the duct con-\\nstitutes the most frequent source of obstruction. Pancreatic juice in\\nits purity is found only in small and recent cysts. Later on, in old or\\nlarge cysts, various accidental products are added. Albuminoid degen-\\neration or suppuration not infrequently takes place, or hemorrhage\\nmay occur, so that the cyst-contents assume a bright-red or chocolate\\ncolor. Pepper found in such a cyst numerous crystals of hematoidin,\\nwhile Hoppe found in another instance urea in the proportion of 0.12\\nper cent, as one of the constituents of the contents of the cyst. The\\npressure of the cyst upon neighboring organs will result in secondary\\npathological conditions which will interfere with the physiological per-\\nformance of the functions of other organs, thus endangering the life\\nof the patient.\\nEtiology. The causes which result in the formation of small cysts\\nof the pancreas, or cysts which result from compression by tumors\\nwhich in themselves do not admit of an operation for their removal,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0741.jp2"}, "728": {"fulltext": "686 PATHOLOGY AND TREATMENT OF TUMORS.\\nand which at the same time constitute a source of danger to life, do\\nnot come within the scope of this discussion. In the latter instance\\nthe cyst is simply a sequence of the primary cause, and as such it will\\nseldom, if ever, become the sole or direct object of surgical treatment.\\nThe causes of retention in cysts amenable to operative treatment are\\nones which in themselves do not imperil the life of the patient. They\\nmaybe classified as follows I. Obstruction to the outflow of the secre-\\ntion from impaction of calculi in the common duct or in its branches.\\n2. Partial or complete obliteration of a portion of the duct from cica-\\ntricial contraction. 3. Sudden or gradual obstruction of the duct,\\nwithout diminution of its lumen, from displacements of the pancreas.\\nCalculi. The impaction of the pancreatic duct at its outlet may be\\ncaused by the presence of a biliary calculus in the ductus communis\\ncholedochus, at the junction of the former with the latter. A case of\\nthis kind has been reported by Engel. In such cases the obstruction\\ngives rise to retention of the secretions from the liver and the pancreas\\nand to dilatation of the excretory ducts in both organs. Calculous\\nconcretions in the pancreatic ducts have frequently been observed to\\ngive rise to retention-cysts. Johnson has collected thirty-five cases in\\nwhich, upon post-mortem examination, stony concretions were found\\nin the pancreas. Incrustations are not as frequent as free concretions.\\nGendrin has described a pancreatic cyst where the normal pancreatic\\nsecretion was converted into a fatty, chalky pap. The causes which\\nproduce a concretion in the pancreatic duct are chemical changes in\\nthe secretion itself or an obstruction to its free exit by inflammatory\\nchanges in or around the common duct. The degree of dilatation,\\nother things being equal, is in direct proportion to the completeness\\nof the obstruction to the outflow of the secretion. It may be well to\\nallude to the possibility that in some instances a pancreatic calculus\\nmay remain stationary for an indefinite period of time in the duct,\\ngiving rise to no symptoms and to only partial obstruction, until, by\\nthe action of some determining cause, it is forced into a position where\\nit effects complete mechanical obstruction to the outflow of the fluid\\nand a rapid increase in the size of the cyst. As an impacted biliary\\ncalculus may give rise to pancreatic obstruction, so a pancreatic calcu-\\nlus, when it is impacted at a point where compression of the common\\nbile-duct can take place, will produce icterus and dilatation of the gall-\\nbladder and the bile-ducts. Meckel has reported such a case.\\nAmong the specimens of pancreatic cysts so far examined which\\nwere caused by concretions, none of them had attained the size of those\\nwhich have been submitted to surgical treatment. As in most of these\\npreparations the calculi did not completely fill the calibre of the duct,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0742.jp2"}, "729": {"fulltext": "RETENTION-CYSTS. 687\\nthey caused only partial obstruction, which would furnish an explana-\\ntion of the slow growth and the comparatively small size of the tumor.\\nIn the specimen described by Gould it appears that the common duct\\nat its entrance into the duodenum was completely closed by two\\ncalculous concretions. This cyst had attained considerable size in\\nfact, it is the largest cyst on record where it was proved that the dila-\\ntation was caused by the presence of a calculus. As in the successful\\noperations on cysts of the pancreas it has been impossible to ascertain\\nthe exact nature of the obstruction, the possibility of retention from\\na calculus cannot be eliminated with certainty.\\nCicatricial Contraction. Cicatricial contraction is always the result\\nof an antecedent inflammation. The cicatrix may be located in the\\nperipancreatic tissue or in the substance of the gland itself. Hoppe\\nmade a post-mortem examination of a patient who had been deeply\\njaundiced during life. The gall-bladder and the bile-ducts were dis-\\ntended with bile which contained blood the pancreatic duct was also\\ncylindrically dilated, and many of its branches were distended into cysts\\nthe size of a hazelnut. The cause of retention of both secretions was\\nfound in a dense cicatrix which surrounded both ducts at their duodenal\\ntermination. Interstitial inflammation in the gland itself, with subse-\\nquent cicatricial contraction, is one of the most frequent causes of\\nretention, Wyss has reported a case where the interstitial inflamma-\\ntion was limited to portions of the head of the pancreas through which\\nthe common bile-duct and the ductus Wirsungii passed, and which had\\nresulted in dilatation of the latter and of its branches, which again com-\\npressed the bile-duct, producing in this manner intense icterus. Becourt\\nhas given a description of a similar specimen which he found in the\\nStrassbourg Pathological Museum. The patient had died of icterus.\\nThe gall-bladder and the bile-ducts were found distended the pancreas\\nwas converted into a dense tissue, which, being cut into, presented a\\nchalky deposit four to eight inches in length and of a yellowish color.\\nThe duct of Wirsung was dilated to such an extent as to form a large\\ncyst which occupied the whole length of the pancreas, its walls being\\ninseparable from the substance of the gland. In this case the inter-\\nstitial inflammation was more extensive and the cyst was much larger.\\nIn the cases reported by Pepper and Hjett the obstruction was due to\\nthe same cause. In Curnow s case the common duct had become\\nobliterated at its entrance into the duodenum by catarrhal inflamma-\\ntion. The pancreas was atrophic, and its duct was filled with numerous\\ncalculi. The pancreatic juice had become inspissated. The cystic duct\\nof the gall-bladder was impermeable, while in the common bile-duct\\na number of small gall-stones were found.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0743.jp2"}, "730": {"fulltext": "688 PATHOLOGY AND TREATMENT OF TUMORS.\\nThe writer has failed to find in literature an allusion to stricture of\\nthe duct the result of traumatism. The pancreas is an exceedingly\\nslender organ, of loose and somewhat friable texture, and hence,\\nalthough remotely located and well protected by surrounding organs,\\nit is more frequently the seat of injury than has generally been sup-\\nposed. If the stomach be empty and the abdominal muscles be\\nrelaxed, a blow over the region of the pancreas may result in serious\\ncontusion or laceration of the organ without rupture of its envelope.\\nAgain, a well-directed blow over either extremity of the gland may\\ncause a laceration of its tissue by traction force, the organ being\\nsecurely fixed in its place by firm connective-tissue attachments. The\\nclinical history of several cases of rapid-growing cysts tends to prove\\nthat obstruction occurred in this manner. If the duct escapes injury,\\nthe cicatricial contraction attending and following the reparative process\\nin the lacerated gland-tissue will gradually compress the duct, or by\\nlateral traction change its direction and thus impede the outflow of the\\nsecretion. If the duct is ruptured at the time of injury, its lumen may\\nbecome completely filled by a thrombus which renders it impermeable,\\ngiving rise to retention and extravasation of the secretion primarily, and\\nsecondarily to definitive occlusion of the duct by cicatricial contraction\\nat the point of injury. The writer is quite convinced that in the case\\nreported the retention was the direct result of traumatic stricture of\\nthe common duct. Although this view is not supported by evidence\\nfrom post-mortem examinations, it is confirmed by analogous produc-\\ntion of cysts in other locations. It is evident that this class of cases\\nwould furnish the most favorable conditions for successful surgical\\ntreatment.\\nObstruction from Displacement of the Pancreas. As the pancreas\\nis retained in its normal transverse position by the surrounding organs\\nand connective-tissue attachments, a relative change of position of por-\\ntions of the gland would result in a bending of the organ and obstruc-\\ntion in the duct at the point of flexion. This condition was the cause\\nof retention in a case related by Engel, who found in a woman sixty\\nyears of age that the tail of the pancreas formed a right angle upward\\nwith the principal duct of the gland. A dislocation of this kind can\\noccur in one of the following ways (i) Abnormal relaxation of the\\nconnective-tissue attachments of the gland, permitting a portion of the\\norgan to descend by its own weight lower in the abdominal cavity.\\n(2) Pressure upon the gland by tumors or exudations. (3) Cicatricial\\ncontractions in the substance of the organ or in the peripancreatic space.\\nThat the whole pancreas can become displaced is proven by the\\ncase reported by Dobrzycki. A man fifty years of age fell a distance", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0744.jp2"}, "731": {"fulltext": "RETENTION-CYSTS. 689\\nof some yards. After the fall there arose symptoms similar to those of\\na floating kidney. By palpation the displaced organ could be located.\\nSaline fluid resembling pancreatic juice was vomited. In the hypo-\\ngastrium could be felt a movable tumor corresponding in position and\\nshape with the pancreas.\\nDiagnosis. The question of diagnosis can be entertained only in\\ncases where the cyst has attained very considerable proportions. The\\nmost important points to be taken into consideration are the history of\\nthe case, the anatomical location of the tumor, and its relations to\\nthe surrounding organs. The cases which have been reported have\\noccurred exclusively in adults. Sex appears to exert no determining\\ninfluence. In a number of cases the clinical history points distinctly\\nand forcibly to traumatism as the exciting cause. In Gussenbauer s\\ncase the beginning of the illness was traced to indiscreet eating and\\ndrinking.\\nIn all instances of cystic tumors in the region of the pancreas close\\ninquiry should be made to ascertain the existence of antecedent inflam-\\nmatory affections of the organ or in its immediate vicinity. A history\\npointing toward the existence of a biliary or a pancreatic calculi will\\nalso prove valuable in arriving at positive conclusions. Rapid growth\\nof the tumor speaks in favor of its pancreatic origin. In Gussenbauer s,\\nKulenkampff s, and the writer s cases the tumors attained an enormous\\nsize within a few weeks. Considering the relations of these cysts to\\nimportant surrounding organs, it is remarkable that they give rise to\\nno serious symptoms aside from the pressure they exert upon adjacent\\norgans. Pain is not a constant symptom, and when it is present it is\\ndue more to the causes which produce the cyst than to the cyst itself.\\nIn this respect cysts of the pancreas form a counterpart to malignant\\ndisease when it affects this or neighboring organs. Emaciation is due\\neither to coexisting affection of the gland or to the impairment of function\\nof important organs by pressure of the cyst. It is never as marked in\\nthese cases as in malignant disease. The supervention of fatty stools\\nwould point toward the existence of some coexisting serious lesion of\\nthe pancreas rather than to the existence of a simple cyst of the organ.\\nThis symptom was not found present, or it was overlooked, in all cases\\nwhich have been operated upon. Of 28 cases of stearrhea which were\\ncompiled by Ancelet, 16 were examined post-mortem. In 5 of these\\nthere was occlusion of the ductus choledochus and pancreaticus in 3,\\nocclusion of the pancreatic duct alone in 1 inflammation of the pan-\\ncreas and some of the adjacent organs. In the remaining cases disease\\nof the liver and the bowels, or only marasmus, was found. In 13 cases\\nof pancreatic calculi collected by Johnson only in 3 were fatty stools\\n44", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0745.jp2"}, "732": {"fulltext": "690 PATHOLOGY AND TREATMENT OF TUMORS.\\nobserved in 6 cases, diarrhea in 4 cases, melena and constipation\\nin the remaining 6. The presence of fat in the stools is a symptom of\\ngreat importance in the recognition of pancreatic disease, but that it is\\nnot of absolute diagnostic significance is proved by the well-known\\nfact that the same condition will follow upon the obstruction of the\\nbiliary passages and affections which impair the functional activity of\\nother organs of digestion.\\nObstruction of the principal duct impairs digestion more than when\\nits distal extremity or one of the accessory ducts is involved. The\\nactual illness of the patient is usually preceded for a variable length of\\ntime by more or less marked symptoms of gastro-intestinal derange-\\nment, accompanied in some instances by pain in the region of the\\npancreas.\\nA peculiar color of the skin, which is believed by some to be cha-\\nracteristic of pancreatic disease, must be mentioned, as it was observed\\nin several cases of calculous affection and cysts of the pancreas. The\\nappearance presented by these patients is variously described as being\\nunhealthy, pale-yellow, dirty, or earthy. The intimate relations of the\\ncyst to the celiac plexus will explain the cause of celiac neuralgia which\\nis met with in some of these cases. Atrophy of the celiac plexus from\\nlong-continued pressure may give rise to mellituria for the same reason\\nthat Klebs has affirmed that partial extirpation or atrophy of the\\nceliac plexus will cause the presence of sugar in the urine. Diverse\\ndiseases of the pancreas have also been known to produce diabetes\\nmellitus. Cases of this kind have been reported by Cowley (1788),\\nBright, Elliotson, Frerichs, Fles, Hartsen, Silver, Recklinghausen,\\nMunk, Seegen, and Friedreich. Klebs demonstrated by his experi-\\nments that complete extirpation of the pancreas or ligature of its duct\\ninvariably gave negative results so far as diabetes was concerned, and\\nthis may account for the fact that no sugar was found in the urine of\\nthe case reported on page 679. The cyst, when examined early, before\\nit has attained considerable size, is always found in the region normally\\noccupied by the pancreas. The exact location, however, is not always\\nuniform, as it will depend upon the portion of the pancreas from which\\nthe cyst has taken its primary origin. It may be situated below the\\nright lobe of the liver, as in Kulenkampff s case in the epigastric\\nregion, as in Gussenbauer s case; or in the left hypochondrium, as\\nnoted in the writer s case. When the tumor has attained a large size\\nor occupies the whole abdominal cavity, it will be difficult, and in the\\nlatter instance impossible, to determine by any known means its pri-\\nmary origin. In such cases it is of paramount importance to study\\nits relations to adjacent organs. The tumor is invariably situated", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0746.jp2"}, "733": {"fulltext": "RETENTION-CYSTS. 691\\nin the bursa omentalis, and from this point, as it increases in size, it\\nencroaches upon the space occupied by adjacent organs. The stomach\\nis pushed forward in all cases, and later to the right. The transverse\\ncolon is displaced downward, the spleen to the left, and the diaphragm\\nand the contents of the chest upward. The cyst being in direct con-\\ntact with the diaphragm, it usually ascends and descends with the\\nrespiratory movements of the chest.\\nIn doubtful cases it will become necessary to inflate the stomach\\nand colon, with a view to ascertain their position relative to the cyst.\\nIf the patient is a female and the tumor occupies the entire abdominal\\ncavity, it will simulate cystic disease of the ovary so closely that a dif-\\nferential diagnosis between the two is impossible. The cases reported\\nby Liicke, Bozeman, and Rokitansky furnish adequate proof of the\\ncorrectness of this statement. The proximity of the abdominal aorta\\nis such that the impulse of the artery is imparted to the tumor, which,\\nhowever, pulsates only in one direction away from the artery a fact\\nwhich will always distinguish it from an aneurysm. Unless the cyst is\\nexceedingly tense, a sense of fluctuation is always imparted by palpa-\\ntion. Palpation is rendered difficult on account of the deep location\\nof the pancreas and the rigidity of the recti abdominis muscles. The\\nnormal pancreas can be felt under certain favorable conditions. Concern-\\ning this point Sir William Jenner says By deeply depressing the\\nabdominal walls about a hand s breadth below the umbilicus, by then\\nrolling the subjacent parts under the hand (the stomach and colon must\\nbe empty), it might be possible to detect it in an individual who is thin\\nand whose tissues are lax. In case the examination is rendered diffi-\\ncult on account of great rigidity of the abdominal muscles, this obstacle\\ncan be overcome by examining the patient while under the influence\\nof an anesthetic. An exploratory puncture with a fine and perfectly\\naseptic needle of a hypodermic syringe will not only add material\\ndiagnostic information by revealing the character of the cyst-contents,\\nbut the procedure will also settle the question as to the existence or\\nthe absence of adhesions between the cyst-walls and the parietal peri-\\ntoneum. In the differential diagnosis the following affections w r ill come\\nup for consideration: 1. Malignant disease of the pancreas or of the\\nadjacent organs 2. Aneurysm 3. Echinococcus-cysts of the liver,\\nspleen, or peritoneum 4. Affections of retroperitoneal lymphatic\\nglands; 5. Hydronephrosis or pyonephrosis; 6. Cystic disease of the\\nsuprarenal capsule 7. Circumscribed peritonitis with exudation 8.\\nAscites 9. Cystic disease of the ovary.\\nMalignant Disease of the Pancreas and of the Adjacent Organs.\\nCarcinoma and sarcoma of the pancreas or of the adjacent organs, as", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0747.jp2"}, "734": {"fulltext": "692 PATHOLOGY AND TREATMENT OF TUMORS.\\nin every other locality, always manifest their presence by their most\\ncharacteristic clinical features pain, emaciation, and progressive local\\nand general infection. The age of the patient and the previous history\\nof the case will also furnish important diagnostic information. Large\\npancreatic cysts are unilocular, while, on the contrary, if a malignant\\ntumor has undergone cystic degeneration, usually more than one cyst\\ncan be recognized. Hardness and irregularity of surface speak in favor\\nof malignancy smoothness and a regular round or oval contour of\\nthe tumor are constant features of a pancreatic cyst. The time that\\nhas elapsed since the beginning of the illness is also of importance.\\nA rapid-growing pancreatic cyst will in two or three weeks assume\\na size which even for a malignant tumor would require as many\\nmonths.\\nAneurysm. An aneurysm of the abdominal aorta can be distin-\\nguished from a pulsating pancreatic cyst by its pulsations being felt in\\nall directions and by the presence of a bruit. As a further test the\\nsuggestion of Dr. Pepper may be resorted to that of placing the\\npatient in the genupectoral position, when the tumor, by gravitation,\\nwill leave the aorta and all pulsation will cease. Steady pressure will\\ndiminish the volume of an aneurysm, but it will have no effect on a\\ncyst of the pancreas.\\nEchinococcus-cysts. An echinococcus-cyst of the liver, the spleen,\\nor the peritoneum could easily be mistaken for a cyst of the pancreas.\\nThe peculiar fremitus sometimes felt on palpating an echinococcus-cyst\\nshould always be sought for. Multiplicity of cysts would decide in\\nfavor of something else than a pancreatic cyst. The presence of hook-\\nlets in the aspirated fluid would furnish positive evidence in favor of the\\npresence of an echinococcus-cyst, while their absence would not exclude\\nthe possibility of the tumor being a sterile echinococcus-cyst. As the\\nsurgical treatment in both instances would be identical, it is sufficient\\nfor practical purposes to narrow the diagnosis down to a probable\\nexistence of either affection.\\nAffections of Retroperitoneal Lymphatic Glands. Neoplasms, inflam-\\nmation, suppuration, or hypertrophy of the retroperitoneal glands\\nbehind the pancreas might simulate a pancreatic cyst, and as a wrong\\ndiagnosis in such an event might prove disastrous to the patient and\\nreflect discredit upon the surgeon, every diagnostic resource should be\\nexhausted in order to prevent such an error. Enlargement of the lym-\\nphatic glands sufficient in extent to simulate a pancreatic cyst would\\nalmost of necessity give rise to serious constitutional disturbances and\\nto extension of the disease to neighboring organs.\\nHydronephrosis or Pyonephrosis. In hydronephrosis or pyonephro-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0748.jp2"}, "735": {"fulltext": "RETENTION-CYSTS. 693\\nsis the early clinical history will present a group of symptoms pointing\\ntoward some lesions in the pelvis of the kidney or in the ureter. A\\nchemical and microscopical examination of the urine may furnish con-\\nclusive evidence of the existence of some renal affection which has\\nproduced the obstruction. Tumors of the kidney usually occupy a\\nlower place and are more laterally located than tumors originating in\\nthe pancreas. In case of a pancreatic cyst the lumbar region below\\nthe kidney is tympanitic, which is not the case in hydronephrosis or\\nin pyonephrosis. In case of doubt an exploratory puncture may enable\\nus to arrive at a positive conclusion.\\nCystic Disease of the Suprarenal Capsule. The suprarenal capsule\\nmay be the seat of cystic degeneration, and may simulate a cyst of the\\npancreas so closely that a differential diagnosis is impossible. In Gus-\\nsenbauer s case the diagnosis remained doubtful between a cyst of the\\npancreas and a cyst of the suprarenal capsule. The bronzed skin so\\nfrequently observed in diseases of the suprarenal capsule has also been\\nseen in affections of the pancreas. As the operative treatment in either\\ncase would be the same, it is not essential for practical purposes to\\nmake a positive diagnostic distinction between the two.\\nCircumscribed Peritonitis with Exudation. Primary peritonitis with\\na circumscribed exudation in the region of the pancreas would reveal\\na history pointing toward an inflammatory affection accompanied by\\nthe usual symptoms attending inflammation of the peritoneum. Fever,\\npain, and tenderness are Symptoms which are either foreign to the\\nhistory of cysts of the pancreas, or, when present, are less intense than\\nin peritoneal inflammations. In peritonitis the exudation would neces-\\nsarily be in the peritoneal cavity, while pancreatic cysts always occupy\\nthe omental bursa.\\nAscites. The question of diagnosis between a cyst of the pancreas\\nand ascites can arise only in case the whole abdominal cavity is dis-\\ntended by the tumor or the effusion. The causes which produce ascites\\nmust be considered separately and individually as they are usually of\\nsuch a character as to exclude a suspicion of pancreatic disease, a satis-\\nfactory diagnosis can be reached without an exploratory puncture, but\\nif any doubt remains, this harmless procedure will furnish the requisite\\ninformation.\\nCystic Disease of the Ovary. From the cases reported we have\\ngleaned that in at least three cases large cysts of the pancreas were\\nmistaken for cystic disease of the ovary by surgeons of prominence\\nand ability who made thorough and repeated examinations. It is not\\ndifficult to conceive that in case the tumor has assumed such dimen-\\nsions as to fill the entire abdominal cavity, it would be impossible to", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0749.jp2"}, "736": {"fulltext": "694 PATHOLOGY AND TREATMENT OF TUMORS.\\ndifferentiate between a cyst of the pancreas and one of the ovary, even\\nby a most scrutinizing examination. The physical signs presented by\\neither condition resemble those of the other so closely that they can-\\nnot be relied upon in discriminating one from the other. The early\\nhistory of the case, if it can be obtained from a reliable source, is of\\nmore diagnostic value. In pancreatic cysts the early symptoms are\\nusually referred to disturbance of the digestive functions, and the\\npatient has been aware of the presence of a tumor in the upper\\nportion of the abdominal cavity. An ovarian tumor necessarily begins\\nin the opposite portion of the abdominal cavity, and gives rise to pelvic\\ndistress and disturbances of the menstrual function. As the surgical\\ntreatment in both instances would be the same, it is practically not\\nessential to make a positive distinction between the two before an\\nexploratory incision will reveal the true nature and origin of the cysL\\nIn recapitulation it may be stated that a positive diagnosis has so far\\nnot been made in a single instance, and that for all practical purposes\\nit is only essential to make a probable diagnosis between a pancreatic\\ncyst, or some other kind of a cyst which would call for the same kind\\nof surgical treatment. In very obscure cases an exploratory incision,\\nunder antiseptic precautions, for diagnostic purposes is a justifiable\\nprocedure.\\nPrognosis. Physiologists are agreed in assigning to the pancreas,\\na most important function in the digestion of organic food. We know\\nthat by a special ferment it assists in the transformation of starch into\\ndextrin and sugar, and aids in the digestion of albumins and fat. We\\nshould naturally expect that in diseases of this organ the digestion of\\nthese substances would be impaired in proportion to the amount of\\ngland-tissue destroyed. On the contrary, we have abundant evidence\\nto show that even total disorganization or destruction of the pancreas\\nis not incompatible with normal digestion and perfect health. It would\\nseem that in the absence of the pancreatic secretion other organs assume\\na vicarious action, and digestion proceeds unimpaired. It is also\\nimportant to remember that even a large cyst of the pancreas does not\\nnecessarily result in extensive destruction of the gland, and that the\\nremaining gland-tissue continues to secrete and discharge a sufficient\\namount of pancreatic juice. In Bozeman s case the cyst occupied\\nthe entire abdominal cavity, and yet at the operation the greater\\nportion of the gland was found healthy in structure. The integrity\\nof the structure and function of the gland depends less on the pres-\\nsure of the cyst than on the causes which were concerned in its\\nproduction. The dangers arising from the cyst itself consist in 1. Its\\ninterference with the functions of other abdominal organs by pressure", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0750.jp2"}, "737": {"fulltext": "RE TENTION- C YS TS. 695\\n2. Rupture of, the cyst and escape of its contents into adjacent hollow\\norgans or into the peritoneal cavity. Compression of the stomach\\nand interference with its normal peristaltic action are constant when\\nthe cyst has developed to any considerable size. When such is the\\ncase, vomiting soon after meals takes place, as was noted in a number\\nof cases reported. When the cyst is of very large size, almost all the\\nabdominal organs suffer by compression, and both digestion and absorp-\\ntion are impaired by mechanical pressure. The diaphragm being at the\\nsame time pushed upward, the heart and the lungs are displaced in\\nthe same direction, and embarrassment of circulation and respiration\\nfollows as a necessary sequence. Like any other benign abdominal\\ntumor, the cyst proves dangerous to life by interfering mechanically\\nwith the functions of more essential and important organs. The sec-\\nond source of danger is rupture of the cyst and escape of its contents\\ninto adjacent organs an accident which may be followed by immediate\\ndeath from hemorrhage, or by which the life of the patient is placed in\\njeopardy by suppurative inflammation in the interior of the cyst, or by\\nperitonitis in case the contents have escaped into the peritoneal cavity.\\nIn Pepper s case the immediate cause of death was hemorrhage conse-\\nquent upon rupture of the cyst into the stomach. At the post-mortem\\nexamination there was found in the stomach and the intestines a large\\nquantity of blood which had entered through an opening, about half\\nan inch in diameter, close to the proximal termination of the ductus\\ncommunis. A probe passed through this opening directly entered a\\ncyst in the head of the pancreas. A communication with any portion\\nof the gastro-intestinal tract would almost of necessity lead to infection\\nand suppurative inflammation in the interior of the cyst this infection,\\nunder unfavorable circumstances, might lead to a fatal termination from\\nsepticemia or from extension of the inflammation to adjacent organs.\\nThe prognosis may be said to depend (1) on the nature and cause of\\nthe obstruction, (2) on the size of the cyst, and (3) on the absence or\\npresence of complications.\\nTreatment. In the treatment of a pancreatic cyst the indications\\nare the same as in the treatment of any other kind of cysts, namely\u00e2\u0080\u0094\\n1. Extirpation of the cyst; 2. Evacuation of its contents and oblitera-\\ntion of the cyst.\\nExtirpation was attempted in Bozeman s and Rokitansky s cases, in\\nthe former instance with complete success in the latter the operation\\nwas not completed, and the patient died a few days afterward of septic\\nperitonitis. It is proper to state that in both cases the operation was\\ndone for the removal of a supposed ovarian cyst, and that a correct\\ndiagnosis was made in the first case during the operation, after the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0751.jp2"}, "738": {"fulltext": "696 PATHOLOGY AND TREATMENT OF TUMORS.\\npedicle was traced to the pancreas and the intact portions of the gland\\nwere identified. In the second case the post-mortem examination\\nrevealed the true nature and location of the cyst. The brilliant result\\nobtained by Dr. Bozeman is well calculated to stimulate others to fol-\\nlow his example. Extirpation of the cyst would guard most effectually\\nagainst the formation of a permanent pancreatic fistula but, on account\\nof the deep location of the pancreas, the shortness or absence of a\\npedicle, and the many obstacles thrown in the way of the operator by\\nadjacent organs, the procedure becomes one surrounded by innumer-\\nable difficulties, and in the present state of our science it is of doubtful\\npropriety. Simple evacuation of the cyst-contents by means of the\\naspirator offers two principal objections against its adoption in the\\ntreatment of cysts of the pancreas 1. Escape of cyst-contents into the\\nperitoneal cavity 2. Reaccumulation of secretion.\\nReasoning from analogy, we should naturally expect that when\\npancreatic juice is brought in contact with the peritoneum, it would\\nproduce a destructive effect upon it by its digestive properties, or it\\nmight even be followed by diffuse peritonitis. In opposition to this\\nassumption, it is affirmed that in experiments on the pancreas it hap-\\npens quite frequently that pancreatic juice escapes into the abdominal\\ncavity, from the cannula introduced into the pancreatic duct, without\\nany bad results on the animals. Concerning this point Heidenhain\\nsays The animals do not suffer from this circumstance, as the duct\\nis regenerated in spite of the wounded surface being bathed in the\\nsecretion. Nevertheless, it is difficult to explain this. Why do not\\nthe wounded and suppurating tissues undergo digestion by the pan-\\ncreatic juice? The efficacy of the albumin-ferment is destroyed in\\nsome way, probably by being changed into zymogen, the living tissues\\nhaving on the juice the effect observed by Podolinski on treating the\\npancreatic juice with pulverized zinc or yeast-ferment. Although small\\nquantities of pancreatic juice may escape into the peritoneal cavity of\\nan animal without any serious consequences, we have no evidence to\\nshow that the peritoneal cavity in man is possessed of the same im-\\nmunity against such accident, and it would not be prudent to expose\\na patient to such risk until more light is thrown on this subject by\\nfurther observation and experiment. At the same time, we must not\\nforget that pure pancreatic juice is found only in small cysts, as the\\ncontents of large cysts have undergone various transformations, and\\nare mixed with different accidental products which might prove an\\nadditional source of danger in producing peritonitis. In all the cysts\\nwhere a pancreatic fistula was established the artificial opening con-\\ntinued to discharge the secretion for a variable period of time, and in", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0752.jp2"}, "739": {"fulltext": "RETENTION-CYSTS. 697\\ntwo cases the discharge had not ceased at the time the report was\\nmade, and hence reaccumulation would have been inevitable in case the\\nfluid had been removed by aspiration. For these reasons the treatment\\nby aspiration should be limited to cysts of moderate size and where\\nadhesions have formed between the cyst and the anterior walls of the\\nabdomen. In cases presenting these favorable conditions aspiration\\ndeserves a trial, and the operation may be repeated as often as required,\\nor until symptoms arise which call for more radical measures. The\\nneedle should always be disinfected thoroughly by passing it through\\nthe flame of a spirit-lamp and by dipping it in a 5 per cent, solution\\nof carbolic acid. The puncture is made obliquely, so as to prevent the\\nformation of a fistulous opening. The fluid should be withdrawn slowly,\\nand the cyst be emptied as completely as possible.\\nAfter the operation gentle pressure should be made over the cyst\\nby applying a compress and an elastic bandage. The safest and at the\\nsame time the most efficient treatment consists in establishing a pan-\\ncreatic fistula. The operation which accomplishes this purpose most\\nsafely and in the shortest time consists in exposing the cyst by an\\nincision, stitching its walls to the margins of the wound. The same\\naseptic precautions must be observed before, during, and after the\\noperation as in any other abdominal operation. The stomach being\\ngenerally pushed forward, upward, and toward the right by the cyst,\\nit is advisable to empty this organ completely as a preliminary measure\\nby abstinence of food and by the use of the siphon irrigator. Except in\\nthe writer s case the incision was always made in the linea alba. It\\nseems to the writer that the incision should always be made over the\\nmost prominent part of the tumor, and as nearly as possible over the\\nseat of obstruction. In following this rule we select the place where\\nwe are most apt to find adhesions, and at the same time we establish\\nthe straightest and most direct route to the primary origin of the cyst.\\nAn incision through the linea alba or parallel with the costal arch will\\nafford the easiest access with a minimum risk of injury to important\\nparts. The external incision should be at least four inches in length,\\nwhile the peritoneum should only be opened to the extent of two\\ninches for the purpose of making an exploratory examination, the\\nincision being enlarged as occasion may require. If adhesions are\\nfound between the cyst and the omentum and the omentum and the\\nparietal peritoneum, the cyst is punctured with an exploratory needle,\\nand, if the diagnosis is corroborated, the operation is finished by incis-\\ning and draining the cyst. If no adhesions are found between the\\nomentum and the peritoneum, the former is incised so as to expose the\\ncyst-wall, when either of the following plans may be pursued The", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0753.jp2"}, "740": {"fulltext": "698 PATHOLOGY AND TREATMENT OF TUMORS.\\nparietal peritoneum is stitched to the skin with catgut. The margins\\nof the omental wound are pushed back under the abdominal walls so\\nas to expose the cyst freely, when the wound is packed from the bot-\\ntom with iodoform gauze, and an aseptic dressing is applied and\\nretained for six or eight days, or until adhesions have formed between\\nthe cyst and the margins of the wound, which have effectually shut off\\nthe peritoneal cavity, when the cyst is incised and drained.\\nSuturing of the cyst-wall to the margins of the wound as a prelim-\\ninary operation should never be resorted to, as, on account of thinness\\nof the cyst-walls, there is danger of escape of fluid into the peritoneal\\ncavity from the punctures made by the needle an occurrence which\\nthe procedure was intended to obviate. With proper care, however,\\nthe operation can be completed at once. The cyst-wall is grasped with\\ntwo many-toothed forceps, and is drawn forward so as to bring it in\\naccurate and close contact with the margins of the wound, when the\\nfluid is removed with an aspirator or a trocar with the same care as in\\nemptying an ovarian cyst. As the cyst becomes empty it is pulled\\nthrough the wound, obviating any further danger of escape of fluid\\ninto the peritoneal cavity. When the cyst is nearly empty it is freely\\nincised and sutured to the peritoneal lining of the abdominal wound.\\nThe drainage-tube should be fully three-quarters of an inch in diam-\\neter, and must reach from the bottom of the cyst to the surface of\\nthe wound. After emptying the cyst completely by compression and\\nplacing the patient on his side, a large Lister dressing is applied for the\\npurpose of guarding against infection and to absorb the secretions.\\nFrequent change of dressing may be required on account of copious\\nescape of pancreatic secretion. Past experience would dictate the advis-\\nability of protecting the skin against the digestive action of the pancreatic\\njuice by freely applying carbolated oil. The antiseptic dressings should\\nnot be abandoned until the peritoneal cavity has become completely\\nclosed by firm adhesions and the size of the cyst has been reduced to\\na fistulous tract. The drainage-tube is shortened from time to time\\nas the depth of the fistulous opening is diminished by obliteration of\\nthe cyst from the bottom of the tract. The speedy obliteration of the\\ncyst will depend on the continuance, abatement, or removal of the\\nobstructing cause or upon the condition of the gland-tissue distal to\\nthe seat of obstruction. If the stricture in the common duct of the\\npancreas is complete and of a permanent character, the obstruction\\nwill continue, and if healthy gland-tissue remains on the distal side, the\\nfistula will continue to discharge pancreatic juice. If the inflammation\\nwhich caused the obliteration of the duct subsides, and the passage\\nagain becomes permeable, the natural outlet will again be established", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0754.jp2"}, "741": {"fulltext": "RETENTION-CYSTS.\\n699\\nand the artificial duct will become obliterated. If an impacted calculus\\nhas caused the retention, and the fistula continues to discharge, a care-\\nful examination should be made to detect the calculus, and if found,\\nan effort should be made to remove it through the fistulous opening.\\nIf the obstruction has become permanent and the gland-tissue on the\\ndistal side has become destroyed either by the cause or causes which\\nproduced the obstruction or by the intracystic pressure, that portion of\\nthe organ has been deprived of its functional capacity, and, as no pan-\\ncreatic juice is secreted, definitive obliteration of the cyst and permanent\\nclosure of the fistulous tract will take place in a comparatively short\\ntime.\\nFig. 463.\u00e2\u0080\u0094 Congenital cystic kidney (after H. Morris).\\nKidney. Retention-cysts of the kidney occur in the substance of\\nthe kidney, constituting the hydrops renum cystiais, or the pelvis\\nof the kidney becomes distended from obstruction anywhere in the\\nurinary passage below a condition called hydronephrosis.\\nCystic Hydrops of the Kidney. Retention-cysts of the kidney fre-\\nquently occur as a congenital affection. In the congenital as well as", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0755.jp2"}, "742": {"fulltext": "700\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nin the acquired forms the cyst-formation is due to occlusion of urinifer-\\nous tubules. According to Erichsen, however, they may also form in\\nconnective tissue, in which the fluid is formed in the same manner as\\nin hydrocele. Congenital cysts of the kidney are frequently found on\\nboth sides, and so large that the swellings distend the fetal abdomen\\nto its utmost capacity. The kidney is in some cases a huge collection\\nof cysts with little or no kidney-tissue (Fig. 463), and the children are\\nborn dead or die soon after birth. At other times the cysts are small\\nand the kidney is contracted and is composed almost exclusively of\\nconnective tissue. The obstruction of the uriniferous tubules during\\nintra-uterine life is caused, as in the formation of cysts later in life,\\nby a general nephritis causing blocking of the tubes either by casts\\nor epithelial debris or by hyperplasia of the interstitial connective\\ntissue. A localized connective-tissue hyperplasia extending from the\\npelvis of the kidney, resulting from nephro-pyelitis fibrosa, pyelo-papil-\\nlitis fibrosa ascendens, or a nephritis nrica, from failure of union between\\nthe renal and collecting tubules, or\\nfrom rests of the Wolffian or supra-\\nrenal bodies, may cause blocking of\\nthe tubes. The cysts appear in\\ndifferent parts of the kidney (Fig.\\n464). The spaces, which are lined\\nwith cubical or flattened epithelium,\\nappear to be smooth-walled. As the\\ncysts enlarge many of them fuse\\nand form large cavities, so that ulti-\\nmately the kidney acquires a honey-\\ncomb appearance. In the adult, cysts\\nof this kind may form from small\\ncysts which originated during intra-\\nuterine life. In other cases they are\\nthe result of an interstitial nephritis\\n(Fig. 454). The cysts at first contain\\nurine, or at least urinary salts, which\\nlater disappear and are replaced by\\nserum. Children born alive with\\ndouble cystic disease of the kidney usually die of uremia in a short time.\\nIn the adult the same condition is developed in the course of a chronic\\ninterstitial nephritis, which generally affects simultaneously both organs,\\nin which case surgical treatment is out of the question. In children\\nwith congenital unilateral cystic kidney nephrectomy is indicated if the\\nsize of the swelling interferes with important functions.\\nFig. 464.\u00e2\u0080\u0094 Congenital cystic kidney, early stage\\n(after Shattuck).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0756.jp2"}, "743": {"fulltext": "RETENTION-CYSTS. 701\\nHydronephrosis. The effect of chronic obstruction to the outflow\\nof the urine can be studied profitably in cases of stricture of the\\nurethra or enlargement of the prostate. Dilatation of the urinary\\npassage occurs from the seat of obstruction and ascends progressively\\nthe entire length of the urinary apparatus. In prostatic or urethral\\nobstruction the bladder first becomes dilated, the valves guarding the\\nureteral orifices are rendered incompetent, the ureters dilate, and finally\\nthe back pressure results in distention of the pelves of both kidneys,\\nproducing a double hydronephrosis.\\nUnilateral hydronephrosis is the result of obstruction of the ureter.\\nAbnormal intracystic pressure often results in a localized yielding of\\nthe bladder-wall, sacculation, and eventually the formation of a pouch\\nwhich communicates with the bladder only through a very narrow\\nopening. The presence of a stone in such a pouch frequently eludes\\ndetection with the sound, and offers great difficulties in its removal\\neither by the perineal or the suprapubic route. In exceptional cases\\na diverticulum becomes completely detached from the bladder by\\nobliteration of the communicating opening. Virchow saw such an\\nisolated diverticulum in the perineum.\\nIn cases of unilateral hydronephrosis with a patent ureter Virchow\\nyears ago pointed out a valvular obstruction caused by a congenital\\nor an acquired defect at a point where the ureter dilates to form the\\npelvis of the kidney. This defect consists of an abnormal obliquity\\nof the ureter at this place. The most frequent causes of obstruction\\nof the ureter are impaction of a calculus, stricture, pressure, and the\\nextension to the ureter of a carcinoma of the uterus. Retroversion\\nof the uterus and benign tumors of the uterus and the ovaries may\\ncompress one or both ureters to such an extent as to cause hydro-\\nnephrosis. If the obstruction is located at the osteum urethrale pel-\\nvicum in the form of an impacted calculus, a stricture, or a valve,\\nthe accumulation of urine leads to progressive dilatation of the pelvis\\nof the kidney and to atrophy of the kidney-substance from pressure,\\nso that in the course of time the kidney is converted into a sac com-\\nposed apparently of a fibrous wall, and containing no longer urine, but\\na serous fluid. If the pelvis of the kidney does not yield to the abnor-\\nmal pressure, pouches form, while other parts of the kidney show to\\na lesser extent the effects of pressure. If the ureter is occluded or\\nobliterated below the pelvis of the kidney, the part of the ureter above\\nthe obstruction dilates simultaneously with the pelvis of the kidney.\\nIf the obstruction is not complete, the urine escapes from time to time\\nand the swelling diminishes in size or disappears altogether, to reappear", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0757.jp2"}, "744": {"fulltext": "702 PATHOLOGY AND TREATMENT OF TUMORS.\\nwith the accumulation of urine, constituting what is called an intermit-\\nting hydronephrosis.\\nCongenital impermeability of the ureter results in congenital hydro-\\nnephrosis, unilateral or bilateral according to whether one or both\\nureters are defective.\\nHydronephrosis, like all other retention-cysts, is prone to become\\nthe seat of secondary pathological conditions by the entrance into the\\ndilated pelvis of the kidney of pyogenic microbes. The suppurative\\ninflammation which then ensues converts the hydronephrosis into\\npyonephrosis. The suppurative pyelonephritis destroys the atrophic\\nparenchyma of the kidney, so that ultimately nothing remains but the\\ndilated capsule of the kidney filled with pus. Infection most frequently\\ntakes place by an ascending suppurative ureteritis, or it may occur by\\npus-microbes which reach the kidney through the circulation.\\nFrom a diagnostic point of view hydronephrosis is a retroperitoneal\\ncyst which begins in a region occupied by the kidney. If the swelling\\nis large enough to be palpable, fluctuation can usually be felt. In\\ncystic kidney the surface of the organ is usually uneven from the pres-\\nence of a number of cysts of unequal size. A hydronephrotic kidney\\npresents itself as a smooth swelling.\\nThe most important point in the differential diagnosis of hydro-\\nnephrosis and of intra-abdominal fluctuating swellings and tumors is\\nto demonstrate the retroperitoneal location of the swelling, which in\\ndoubtful cases can be shown satisfactorily by rectal insufflation. In\\nwomen catheterization of the ureters as described and practised by\\nKelly will often enable the surgeon to demonstrate not only the exist-\\nence but also the exact location of the ureteral obstruction. If the\\nswelling can be located positively in the retroperitoneal space, a lumbar\\nexploratory puncture under strict antiseptic precautions is not only\\npermissible but will settle the diagnosis between hydronephrosis and\\npyonephrosis and malignant tumor of the kidney. A careful chemical\\nand microscopical examination of the urine will often indicate the kidney\\nas the primary seat of the swelling.\\nTreatment. In unilateral hydronephrosis the opposite kidney under-\\ngoes compensatory hyperplasia. Experiments and clinical observation\\nhave shown that one healthy kidney is sufficient to eliminate the urea,\\nand numerous cases have been recorded in which a hydronephrotic\\nkidney was removed without any immediate or remote ill results. The\\nkidneys are, however, subject to so many accidents and diseases that\\nthere is no excuse for sacrificing a kidney unless its parenchyma has\\nbeen destroyed or the continuity of the urinary passage cannot be\\nrestored by some of the operative procedures that have recently been", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0758.jp2"}, "745": {"fulltext": "RETENTION-CYSTS. 703\\ndevised. The writer, who cannot agree with Morris and Sutton that,\\nin case the opposite kidney is in a healthy condition, the hydronephrotic\\nkidney should be removed, has shown that mechanical obstruction\\nof the ureter in dogs produces progressive hydronephrosis, and has\\ndemonstrated, by microscopical examination of the capsule of the cyst,\\nthe existence of atrophic kidney-tissue and the capacity of this tissue\\nto regenerate after a nephrotomy. It is different in cases of hydro-\\nnephrosis complicated by suppurative pyelonephritis. In such cases the\\nparenchyma of the kidney, already atrophic from pressure, is quickly\\ndestroyed by the suppurative inflammation. In uncomplicated hydro-\\nnephrosis it is the duty of the surgeon to relieve tension and to secure\\na new outlet for the secretion by a lumbar nephrotomy, and at the\\nsame time to search for and remedy the obstruction that has caused\\nthe hydronephrosis. Recent advances made in ureteral surgery dic-\\ntate such a conservative course. It is certainly easier to extirpate a\\nhydronephrotic kidney than to remove its primary cause, but this fact\\nis no argument in favor of mutilating surgery. With this additional\\nindication to meet, the kidney and the upper part of the ureter should\\nbe exposed by Konig s incision. This incision will expose the pelvis\\nof the kidney and the upper part of the ureter for a thorough examina-\\ntion by sight and touch. If the ureter below the pelvis of the kidney\\nis not dilated, the obstruction must be sought for at the pelvic orifice\\nof the ureter, through an incision into the lowest portion of the dilated\\npelvis. If an impacted stone is found, it is extracted, and the perme-\\nability of the ureter is demonstrated by catheterization. If a valve in\\nthe form of a projecting spur caused .by a too oblique insertion of the\\nureter is found, it can be excised and the mucous membrane be sutured\\nwith fine catgut or if this procedure is impracticable, the ureter may\\nbe cut transversely below the pelvis, the proximal end tied, and the\\ndistal end implanted into a slit in the dilated pelvis, in which location\\nit may be fixed by a few superficial sutures; the wound in the pelvis\\nmay then be closed, and an external temporary urinary fistula estab-\\nlished by an incision through the convex side of the kidney, the fistula\\nbeing kept open by a tubular drain. If the ureter at this point is com-\\npletely obliterated, a similar procedure is indicated. If it is narrowed\\nby cicatricial stenosis, a plastic operation such as the one devised by\\nHeineke-Mikulicz for cases of cicatricial stenosis of the pylorus will\\nyield an excellent result, as has been shown by the experience of\\nFenger.\\nImpacted calculi and cicatricial stenosis nearer the bladder are\\nattended by dilatation of the ureter above the obstruction the obstruc-\\ntion will therefore be found at the lower end of the dilated ureter.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0759.jp2"}, "746": {"fulltext": "704 PATHOLOGY AND TREATMENT OF TUMORS.\\nThe lower end of the ureter can be reached through the sacral route.\\nIf the cicatricial stenosis is found at or near the insertion of the ureter\\ninto the bladder, transverse section, ligation of the bladder-end, and\\nimplantation of the upper end into a slit of the bladder, as advised by\\nVan Hook, will restore the continuity of the urinary canal. In all\\nthese operations upon the ureter it is advisable to establish a temporary\\nrenal fistula in the lumbar region this fistula should be maintained\\nuntil the patency and efficiency of the ureteral part of the urinary\\npassage have been demonstrated. If a considerable part of the lower\\nportion of the ureter is impermeable, implantation of the upper portion\\ninto the rectum an operation the feasibility of which has been demon-\\nstrated by the experiments of Reed and the clinical experience of\\nChaput and others should be considered. The writer is firmly con-\\nvinced of the propriety of restricting primary nephrectomy in hydro-\\nnephrosis to cases in which the surgeon can satisfy himself that the\\nopposite kidney is intact, and in which the parenchyma of the affected\\nkidney has been destroyed. In all other cases a nephrotomy should\\nbe made, and, if possible, the ureteral obstruction be removed at the\\nsame time or subsequently. In the opinion of the writer, it is much\\nbetter to subject the patient to the slight inconvenience of a permanent\\nrenal fistula than to deprive him of an important organ capable of\\nparenchyma-regeneration. The writer has a number of patients who\\nwear a tube of special construction to which is attached a rubber\\nreceptacle the patients are perfectly comfortable, and they prefer this\\ncondition rather than subject themselves to a secondary nephrectomy.\\nIn a number of such cases it has been observed that while the escape\\nof urine soon after the operation was scanty, the amount of secre-\\ntion gradually increased until after a few months the diseased kidney\\nsecreted nearly as much urine as the opposite one the best possible\\nproof that the atrophic kidney-tissue after the operation resumed its\\nformer physiological importance.\\nHydronephrosis caused by obstruction of the ureter from malignant\\ndisease does not justify surgical interference. In hydronephrosis pro-\\nduced by pressure upon the uterus the cause of compression should\\nbe removed. This includes the removal of benign pelvic tumors,\\ninflammatory adhesions, and the correction of displacement of a patho-\\nlogical or a pregnant uterus.\\nTesticle. Cysts of the testicle arising from rests have been\\nconsidered in the section on Cystoma. We shall describe here cysts\\nresulting from obstruction of spermatic tubes. Such cysts are usually\\nthin-walled, spherical or oval cysts, imbedded in and loosely connected\\nwith the tissue of the cord. They may occur singly or in a group.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0760.jp2"}, "747": {"fulltext": "RETENTION-CYSTS. 705\\nTheir most frequent seat is just above the epididymis, but they may be\\nfound in any part of the spermatic cord. Mr. Lloyd and Mr. Liston\\ndiscovered, independently of each other, spermatozoa in the contents\\nof these cysts. Roth traces spermatic cysts to the retention of fluid\\nfrom congenital vasa aberrantia. Silcock attributes them to cystic\\ndilatation of tubules. The various forms of seminal cysts have been\\ndescribed fully by Curling. The capsule of the cyst is composed of\\nconnective tissue lined with squamous epithelium. Kocher and Rosen-\\nbach demonstrated by fine dissections of specimens the connection of\\nthe spermatoceles resulting from retention with the spermatic tubules.\\nRupture of retention-cysts on the surface of the epididymis and the\\ntesticle and rupture of Morgagni s hydatid (Roth) give rise to sperma-\\ntozoa in the fluid of hydrocele. Spermatoceles, which occur in persons\\nafter the age of puberty, grow slowly and occasionally attain large size.\\nPaget removed from a cyst of this kind, in a man seventy years old,\\neighteen ounces of a milky fluid which contained spermatozoa, and\\nStanley removed twenty-five ounces in a similar case. The cyst from\\nwhich the fluid was obtained, which furnished the histological elements\\nfor Fig. 465, occurred in a man seventy-four years of age, and had\\nFig. 465. Contents of spermatocele, showing spermatozoa and epithelial cells X 350.\\nattained the size of a filbert. The patient was suffering at the same\\ntime from double epididymitis and hypertrophy of the prostate gland.\\nThe swelling is smooth, fluctuates, and in many cases is translucent.\\nThe treatment consists in tapping with or without the injection of\\ncarbolic acid, incision of the cyst, suturing of the cyst-wall to the skin,\\nand drainage as in Volkmann s operation for hydrocele. In the case\\nof small cysts that give rise to no inconvenience operative treatment\\nis contraindicatcd. In cases in which repeated occurrences take place\\n45", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0761.jp2"}, "748": {"fulltext": "yo6\\nPATHOLOGY AND TREATMENT OF TUMORS.\\nafter tapping and injection, excision of the sac is indicated, and the\\noperation yields good results.\\nMammary Gland. In the mammary gland during lactation reten-\\ntion of milk in the gland-ducts occurs quite frequently in connection\\nwith obstruction produced by acute or chronic interstitial mammitis.\\nThis form of retention-cyst is called galactocele. If the obstruction of\\nthe duct remains permanently, the cyst-contents change. The milk is\\neither transformed into a cheesy mass or is absorbed, being replaced\\nHlf\\nFig. 466. Circumscribed interstitial mastitis with cyst-formation (after Konig) a, normal acini; b,\\ntransition of normal acini into small cysts; c, dilated duct; d, colostrum-corpuscles. The interstitial con-\\nnective tissue is infiltrated with young cells.\\nby a serous fluid which is often stained by the admixture of blood.\\nIn the causation of genuine cysts of the mammary gland, usually some\\nform of obstruction leads to dilatation of the lacteal ducts. In some\\ncases the cysts communicate with one another; in others multiple cysts\\nappear simultaneously or in succession independently of one another.\\nSometimes such cysts attain an enormous size. Mr. Paget quotes a\\ncase in which a cyst of this kind contained nine pounds of limpid\\nserosity which had developed in three months in a woman thirty\\nyears of age. In this case the walls of the cyst were thin and the", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0762.jp2"}, "749": {"fulltext": "RETENTION-CYSTS. 707\\nfluid was serous. Degeneration of the cyst-wall retards or arrests\\ngrowth, rendering the lining membrane which secretes the contents\\nbarren.\\nMultiple cysts are often produced, as pointed out by Konig, in\\nconsequence of chronic interstitial mastitis, which obstructs the milk-\\nducts (Fig. 466). This form of interstitial mastitis with cyst-production\\nhas often been mistaken for carcinoma.\\nChronic interstitial mastitis occurs, according to Konig, as a circum-\\nscribed and diffuse affection. Another variety of retention-cyst occurs\\nin elderly women, frequently as a multiple affection, in consequence of\\nsenile involution of the breast. The cysts give rise to no pain, but\\noccasionally they are the starting-points of carcinoma. The cysts are\\nsmall, and they contain a mucoid substance which causes them to\\nassume a bluish tint when the breast is examined after removal.\\nIn galactocele complicated by inflammation a free incision relieves\\nthe pain and tension and is followed by a speedy obliteration of the\\ncyst. In chronic cases incision followed by cauterization and packing\\nof the wound with iodoform gauze, or excision of the cyst, is indi-\\ncated. Chronic interstitial mastitis with cyst-formation, if circum-\\nscribed, indicates partial excision of the breast. If the disease is diffuse,\\nthe entire breast should be removed. Involution-cysts require no\\nsurgical treatment,\\nSalivary Glands. A retention-cyst of the ducts of the sublingual\\nand submaxillary salivary glands is called a ranula. Retention-cysts\\nof Stensen s duct have been seen and described by Bruns, but they are\\nexceedingly rare. Various interpretations have been given as to the\\norigin and nature of the sublingual cysts that were formerly classified\\nunder the head of ranula. Pauli believed that they consisted of a\\ndilated Wharton s duct, in which case he called the swelling a ptyal-\\nectasis, or, after rupture of the duct, an accumulation of saliva in the\\nconnective tissue, in which case he called the swelling a ptyalocele.\\nVirchow, for good reasons, objected to the latter mode of origin, as\\nhe asserted that the saliva extravasated into the connective tissue would\\nbecome absorbed. Fleischmann claimed that the salivary ducts could\\nnot dilate to the extent seen in cystic swellings under the tongue.\\nHe believed that these cysts are hygromata of the base of the genio-\\nglossus muscle. Gurlt and Bernard asserted that the submaxillary\\ngland secreted a mucoid substance analagous to the contents of the\\ncysts so frequently found on the side of the tongue. Ptyalin and\\nrhodankalium, however, have never been discovered in the contents of\\na ranula. The absence of these two substances in the contents of a\\nranula is, however, no proof that the cyst is not a dilated duct of a", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0763.jp2"}, "750": {"fulltext": "708 PATHOLOGY AND TREATMENT OF TUMORS.\\nsalivary gland, as the cyst-contents undergo chemical changes which\\nmake it impossible to refer the secretion back to its proper origin by\\nchemical examination.\\nBernard and Weber not only detected the orifice of the duct upon\\nthe wall of a retention-cyst of Wharton s duct, but they succeeded in\\ninserting through the orifice a fine probe into the cyst, thus establish-\\ning beyond all doubt the connection of the cyst with the duct. Neu-\\nmann in a supposed case of ranula excised a part of the cyst-wall,\\nand on examination of sections under the microscope he found the\\ncyst lined with ciliated epithelium. This induced him to regard the\\nforamen cecum as the starting-point of the cyst. Bochdalek showed\\nthat the foramen cecum in some cases does not terminate in a blind\\nsac, but extends in the direction of the median glosso-epiglottic liga-\\nment. The posterior end of this prolongation possesses numerous\\nmucous glands, of which several are situated in the floor of the\\nmouth, on the side of the tongue, and hidden by the genio-glossus\\nmuscle. Recklinghausen is of the opinion that most of the cysts\\nwhich heretofore have been called ranula are cysts which originate\\nfrom Blandin-Nahn s gland in the substance of the tongue. He bases\\nthis opinion upon the form and growth of the cysts as well as the cha-\\nracter of their contents. In multilocular ranula remnants of gland-\\ntissue have been found in the cyst- wall.\\nFrom these remarks it will appear that many of the mucous cysts\\nin the floor of the mouth do not always consist of a dilated duct of\\none of the salivary glands and retained saliva. That retention-cysts of\\nthe salivary ducts occur has been shown by the investigations of\\nBernard and Gurlt. Richet in one case found as the cause of the\\nobstruction a fragment of a grass-blade lodged in the duct, and the\\nduct behind the obstruction was dilated into a cyst.\\nKolliker, Bernard, and Birkett claim that Rivini s duct is as often\\nthe seat of retention-cysts as Wharton s duct. The writer, in several\\ncases of dilatation of Wharton s duct to the size of a walnut, has not\\nonly discovered its orifice upon the wall of the cyst, but by pressure\\nhas been able to empty the cyst through the constricted orifice. In\\nmany cases of ranula the outlet of the duct is not completely closed,\\nbut is contracted. Stenosis and cicatricial obliteration of Wharton s\\nand Rivini s ducts are caused by inflammation and cicatricial con-\\ntraction, producing incomplete or complete obstruction and retention\\nof saliva, which at first constitutes the contents of the cyst, but which\\nundergoes speedy chemical changes.\\nA retention-cyst of the ducts of the salivary glands appears clin-\\nically as a cyst with very thin walls and with mucous contents. The", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0764.jp2"}, "751": {"fulltext": "RETENTION-CYSTS. 709\\ncyst is usually somewhat elongated in the long axis of the tongue\\nit may become so large as to interfere with the free movements of the\\ntongue, and at the same time may appear as a swelling of considerable\\nsize in the submaxillary triangle.\\nThe removal of a ranula by excision is the surest and shortest way\\nto effect a radical cure. The cyst cannot be enucleated, as the cyst-\\nwall is exceedingly delicate and firmly attached. Excision is not\\napplicable in all cases. The second method of treatment is the one\\nusually resorted to this method consists in excision of a large part\\nof the cyst-wall, after which the cavity is packed with iodoform gauze\\nto prevent the healing of the incision. The gauze packing should\\nbe changed daily until the margins of the wound have healed, thus\\nsecuring a free and permanent outlet for the duct.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0765.jp2"}, "752": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0766.jp2"}, "753": {"fulltext": "INDEX\\nAdenoma, 152\\ndiagnosis, 175\\netiology, 155\\nhistory and pathology, 153\\nin animals, 58\\nof digestive tract, 157\\nof Fallopian tubes, 161\\nof kidney, 175\\nof lachrymal gland, 172\\nof liver, 173\\nof mammary gland, 167\\nof nasal cavities, 159\\nof ovaries, 161\\nof parotid gland, 172\\nof prostate gland, 171\\nof skin, 157\\nof testicle, 172\\nof thyroid gland, 162\\nof uterus and its appendages, 159\\nprognosis, 176\\nsebaceum, 157\\nsudoriparum, 157\\ntreatment, 176\\nAkidopeirasty, 98\\nAnastomosis, intestinal, 339\\nAngioma, 448\\nanatomical varieties, 452\\ncomplications, 451\\ndefinition, 448\\nhistogenesis, 449\\nhistology, 449\\nintracranial, 462\\nof bones, 461\\nof deep connective tissue, 459\\nof larynx, 464\\nof liver, 462\\nof mammary gland, 463\\nof muscles, 463\\nof skin and mucous membranes, 458\\nof tongue, 463\\nprognosis, 456\\nsymptoms and diagnosis, 456\\ntreatment, 456\\nAngio-sarcoma, 451\\nAnimals, tumors in, 57\\nApostoli s uterine electrode, 506\\nAtheroma, deep-seated, 183\\nBlepharoplasty, 286\\nBlood-corpuscles, immigration of, into paren-\\nchyma of tumor, in\\nBranchial cysts. See Cysts.\\nBronchocele, 162\\nCarcinoma, 203\\ncylindrical-celled, 214, 252\\ndefinition, 203\\ndiagnosis, 256\\netiology, 231\\nage, 234\\nclimate, 236\\ndiet, 235\\nheredity, 232\\nmental depression, 236\\nmicrobes, 239\\nprolonged irritation and inflammation, 236\\ntraumatism, 233\\ntuberculosis, 236\\nfactors in the production of, 86\\ngeneral infection, 225\\nglandular, 215, 253\\nhistogenesis, 208\\nhistology, 212\\nlocal diffusion, 2 16\\nmalignancy, 215\\nof bladder, 372\\nof cervix uteri, supravaginal amputation for,\\n364\\nof external female genital organs, 370\\nof eye, 372\\nof face, 282\\ndiagnosis, 283\\noperative treatment, 286\\nof internal organs, diagnosis, 263\\nof intestines, 335\\nenterectomy for, 337\\nenterostomy for, 337\\nintestinal anastomosis for, 339\\n711", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0767.jp2"}, "754": {"fulltext": "712\\nINDEX.\\nCarcinoma of intestines, operative treatment\\nof, 337\\nof kidney, 374\\nnephrectomy for, 376\\nof lip, 280\\nclinical course, 280\\ndiagnosis, 281\\noperative treatment, 283\\nof liver, 345\\nof mammary gland, 303\\nacinous variety, 305\\netiology, 307\\nprognosis, 315\\nsymptoms and diagnosis, 308\\ntreatment, 317\\nradical operations, 317\\nof mouth, 289\\nradical operations for, 291\\nof nose, operative treatment, 287\\nof oesophagus, 323\\ndiagnosis of, differential, 324\\ngastrostomy for, 325\\nof ovary, 350\\nof parotid gland, 298\\nextirpation for, 301\\nof penis, 347\\namputation of penis for, 349\\nof rectum, 339\\nextirpation of rectum for, 343\\npalliative operations, 342\\nsymptoms and diagnosis, 341\\nof skin, 275\\ndegeneration of tumor-tissue, 280\\nhistological structure, 275\\nregional infection, 279\\nof stomach, 326\\ngastroenterostomy for, 332\\npylorectomy for, 328\\ntreatment, 328\\nof testicle, 346\\nof thyroid gland, 300\\nof tongue, 292\\nradical operations for, 294\\nof tonsil, 291\\noperative treatment of, 291\\nof urethra, 373\\nof uterus, 353\\netiology, 359\\nhistogenesis and histology, 353\\nsymptoms and diagnosis, 360\\nvaginal hysterectomy for, 366\\n\u00e2\u0080\u00a2origin and nature, 204\\nCarcinoma, pathology, 242\\nprognosis, 264\\nregional infection, 220\\nsecondary, growth of, 222\\nlocal infection of, 223\\nsquamous-celled, 213, 250\\ntreatment, 266\\npalliative operations, 269\\nradical operations, 271\\nulcerating, difficulty in diagnosis of, 261\\nCarcinoma-cells, degenerative changes in, 246\\nCarcinosis, miliary, 229\\nCaustics in treatment of tumors, 120\\nCementomes, 446\\nCervix uteri, supravaginal amputation of, for\\ncarcinoma, 364\\nChassaignac s chain ecraseur, 125\\nCheiloplasty, 286\\nCholesteatoma, 401\\nChondroma, 422\\nbranchiogenes, 432\\ndefinition, 422\\netiology, 426\\nhistology, 424\\nof bone and periosteum, 429\\nof cartilage, 428\\nof connective tissue, 432\\nof joints, 430\\nof ovary, 432\\nof salivary glands, 431\\nof testicle, 432\\norigin, 422\\nprognosis, 427\\nretrogressive metamorphoses, 425\\nsymptoms and diagnosis, 427\\ntreatment, 428\\nClamps, intestinal and stomach, 329\\nColostomy, inguinal, Maydl s, 342\\nComedo, 666\\nCornu cutaneum, 142\\nCystoma, 178\\ndiagnosis, 180\\netiology, 180\\nof bone, 201\\nof broad ligament, 197\\nof eye, 199\\nof mammary gland, 188\\nof ovary, 1 89\\norigin, 194\\ntreatment, 197\\nof parovarium, 195\\nof testicle, 108", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0768.jp2"}, "755": {"fulltext": "INDEX.\\n7*3\\nCystoma of thyroid gland, 187\\nof vagina, 198\\nprognosis, 181\\ntopography, 181\\nCysts, allantoic (urachus), 201\\nbranchial, 623. See also Teratoma.\\nanatomy and embryology, 624\\nantiseptic drainage in treatment of, 635\\natheromatous, 628\\nclassification, 626\\ndiagnosis, 631\\netiology, 630\\nextirpation of, 634\\nhistory, 625\\niodine injections in treatment of, 633\\nmucous, 628\\nprognosis, 631\\nserous, 629\\ntreatment, 632\\ndermoid, 635. See also Teratoma.\\ndefinition, 636\\nhistology, 637\\nhemato-, of branchial clefts, 629\\nmesoblastic, 186\\nmucous, 185\\nof corpus luteum, 195\\nof jaws, 201\\nof vitello-intestinal duct, 199\\novarian, 189\\nretention-. See Retention-cysts.\\nsebaceous, 666\\ntraumatic epithelial, 181\\nDeciduoma maligna, 612\\nDermoid cysts. See Cysts.\\nDesmoid fibroma, 392\\nEcraseur, wire, 126\\nEmbryo, differentiation of tissue in, 23\\ngerminal layers of, origin and disposition,\\n25\\nEmbryonic tissue of post-natal origin, trans-\\nformation of, into malignant tumors, 84\\nEnkatarrhophy, 182\\nEnterectomy, 337\\nEnterostomy, 337\\nEpulis, sarcomatous, 590\\nExostosis, 56\\nExploratory syringe, value of, as an aid in\\ndiagnosis, 101\\nFergusson s percutaneous ligature, 125\\nFibro-chondroma, 424\\nFibroma, 378\\ndefinition, 379\\netiology, 383\\nhistogenesis and histology, 379\\nof abdominal wall, 391\\nof gums, 399\\nof mammary gland, 396\\nof mucous surfaces, 389\\nof nose, 394\\nof ovary, 397\\nof periosteum and bone, 400\\nof serous surfaces, 401\\nof skin, 385\\nof subcutaneous connective tissue, 390\\nof uterus, 397\\nof vulva, 398\\nprognosis, 384\\nretrograde metamorphoses, 382\\nsymptoms and diagnosis, 383\\ntreatment, 385\\nFoetus in fcetu, 621\\nForceps, bowed, 369\\nintestinal, 330\\nGalactocele, 706\\nGastro-enterostomy, Liicke s operation, 333\\nSenn s operation,\\nWolfler s operation, 332\\nGlioma, 554\\nGumma of liver, 104\\nHarpoon, Warren s, 103\\nHegar s forceps, 511\\nHydatids, Morgagni s, 197\\nHydrokolpos, 671\\nHydrometra, 671\\nHydronephrosis, 701\\nHydrops renum cysticus, 699\\nHydrosalpinx, 672\\nHysterectomy, complete abdominal, 514\\nvaginal, for carcinoma of uterus, 366\\nfor myofibroma of uterus, 510\\niNCLUsro fcetalis, 621\\nInfection, general. 76\\nglandular, sarcoma as a cause of, 51\\nlocal, 75\\nmeaning of word as applied to tumors, 74\\nregional, 75\\ncarcinoma as a cause of, 51\\nInflammation, effect of, on tumors, 51", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0769.jp2"}, "756": {"fulltext": "7^4\\nINDEX.\\nKaryokinesis, 30\\nKaryomitosis, 31\\nKeloid scar, 388\\nspontaneous, 386\\nKnaurs, 55\\nKocher s director, 302\\nKoch s syringe, 118\\nKoderick s rosary instrument, 124\\nLaparo-hysterectomy or uterine myofibro-\\nma, 514\\nwith extraperitoneal treatment of the pedi-\\ncle, 516\\nwith intra-abdominal treatment of the pedi-\\ncle, 514\\nLaparo-myomectomy, 512\\nLaparotomy for myofibroma of uterus, 510\\nLeiomyoma, 487\\nhistology and histogenesis, 487\\nLipoma, 404\\nanatomical varieties, 405\\narborescens, 413\\ndefinition, 404\\nhistology, 404\\nin animals, 57\\nintermuscular, 413\\nof broad ligament, 414\\nof eye, 414\\nof eyelids, 41 1\\nof joints, 413\\nof meninges of the brain and spinal cord, 413\\nof periosteum, 413\\nof scrotum, 414\\nof subcutaneous adipose tissue, 408\\nof tendon-sheaths, 414\\nof vulva, 414\\nprognosis, 407\\nregressive metamorphoses, 405\\nsubmucous, 412\\nsubserous, 411\\nsymptoms and diagnosis, 406\\ntreatment, 408\\nLipoxanthoma, 411\\nLiver, carcinoma of, 345\\nLymphangioma, 465\\nanatomical varieties, 465\\ndefinition, 465\\nhistology and histogenesis, 465\\nof lips, 474\\nof neck, 475\\nof subcutaneous and submucous connective\\ntissue, 477\\nLymphangioma of tongue, 474\\nof uterus, 477\\nprognosis, 473\\nregressive metamorphoses, 471\\nsymptoms and diagnosis, 472\\ntreatment, 474\\nLymphatic glands, enlargement of, 51\\nLymphoma, 478\\ndefinition, 478\\nhistology and histogenesis, 480\\nretrograde metamorphoses, 480\\nsymptoms and diagnosis, 481\\ntreatment, 484\\nLympho-sarcoma, 580\\nMacrochilia, 474\\nMacroglossia, 474\\nMaisonneuve s constrictor, 123\\nManec s percutaneous ligation of a tumor, 124\\nMelano-sarcoma, 549\\nof skin, 576\\ntreatment, 576\\nMetastasis during the growth of a malignant\\ntumor, 76\\nMicroscope, value of, as an aid in diagnosis,\\n103\\nMicrotome, freezing, 107\\nMole, 386\\nMorcellement, 508\\nMyofibroma, regressive metamorphoses, 491\\nsymptoms and diagnosis, 49 1\\nMyoma, 485\\ndefinition, 485\\nembryology, 485\\nin animals, 57\\nof alimentary canal, 521\\nof bladder, 522\\nof broad ligament, 519\\nof Fallopian tube, 520\\nof oesophagus, 521\\nof pharynx, 521\\nof rectum, 522\\nof round ligament, 521\\nof small intestines, 521\\nof stomach, 521\\nof uterus, 493\\netiology, 499\\nhistology and histogenesis, 496\\nprognosis, 503\\nregressive metamorphoses, 497\\nsymptoms and diagnosis, 499\\ntreatment, 504", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0770.jp2"}, "757": {"fulltext": "INDEX.\\n715\\nMyoma of uterus, treatment, complete abdom-\\ninal hysterectomy, 514\\ncuretting, 505\\nelectrolysis, 506\\nergot, 505\\nintraperitoneal enucleation, 512\\nlaparo-hysterectomy, 514, 516\\nlaparo-myomectomy, 512\\nlaparotomy, 510\\nsalpingo-oophorectomy, 510\\nvaginal enucleation, 507\\nhysterectomy, 510\\nmyomotomy, 508\\nprognosis, 492\\nregressive metamorphoses, 491\\nsymptoms and diagnosis, 491\\ntreatment, 492\\nMyomotomy, vaginal, 508\\nMyxoma, 415\\ndefinition, 415\\netiology, 417\\nhistology, 416\\nof glands, 421\\nof intermuscular spaces, 418\\nof middle ear, 420\\nof nerve-sheaths, 420\\nof nose, 419\\nof skin, 418\\nprognosis, 417\\nsymptoms and diagnosis, 417\\ntreatment, 418\\nNephrectomy, 376\\nfor carcinoma of kidney, 376\\nNeurofibromata, multiple, 532\\nNeuroma, 524\\ndefinition, 524\\nembryology, 524\\netiology, 530\\nhistology and histogenesis, 524\\nof cranial nerves, 533\\nof lower extremity, 533\\nof prepuce, 535\\nof spinal nerves, 533\\nof upper extremity, 533\\nof vulva, 535\\nplexiform, 534\\nprognosis, 531\\nregressive metamorphoses, 530\\nsymptoms and diagnosis, 530\\ntreatment, 531\\nNeuromata, Virchow s classification of, 525\\nOdontoma, 445\\ndefinition, 445\\nSutton s classification of, 445\\nOdontomes, composite, 447\\ncompound follicular, 446\\nepithelial, 445\\nfibrous, 446\\nfollicular, 445\\nin animals, 57\\nradicular, 446\\nOnychogryphosis, 150\\nOnychoma, 150\\nOnychomycosis, 150\\nOsteoma, 434\\nanatomical varieties, 437\\nat seat of a fracture, 443\\ndefinition, 434\\nhistogenesis, 435\\nhistology, 435\\nin animals, 57\\nof brain, 441\\nof cranial bones, 438\\nof epiphyses of the long bones, 442\\nof external meatus, 441\\nof eye, 444\\nof frontal sinus, 440\\nof jaws, 441\\nof muscles and tendons, 442\\nof orbit, 443\\nprognosis, 437\\nsubungual, 444\\nsymptoms and diagnosis, 437\\ntreatment, 437\\nOvary, glandular cysts of, 193\\nhydrops of follicles of, 194\\npapillary growths of, 192\\nproliferous cysts of, 192\\nsimple cysts of, origin of, 193\\nPacquelin cautery, 1 19\\nPapilloma, 137\\ndiagnosis, 149\\nfibrous, 144\\nhard, 139\\nhistology and pathology, 137\\nof brain, 149\\nof digestive tract, 144\\nof female organs of generation, 146\\nof respiratory tract, 144\\nof skin, 141\\nof urinary organs, 145\\nprognosis, 149", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0771.jp2"}, "758": {"fulltext": "yi6\\nINDEX.\\nPapilloma, soft, 139\\ntopography, 141\\ntreatment, 150\\nPapillomata, transformation of, into malignant\\ntumors, 140\\nParotid gland, extirpation of, 299, 301\\nPean s forceps, 508\\nPozzi s enucleator, 507\\nPsammoma, 556\\nPtyalectasis, 707\\nPtyalocele, 707\\nRanula, 707\\npancreatica, 685\\nRenal region, topography of, 376\\nRetention-cysts, 657\\ndefinition, 657\\netiology, 660\\nhistology, 658\\nhydrokolpos, 671\\nhydrometra, 671\\nhydrosalpinx, 672\\nof appendix vermiformis, 674\\nof bile-ducts, 675\\nof kidney, 699\\ntreatment, 702\\nof mammary glands, 706\\nof mucous membrane, 668\\nof ovary, 665\\nof pancreas, 678\\ndiagnosis, 689\\netiology, 685\\npathology and morbid anatomy, 684\\nprognosis, 694\\ntreatment, 695\\nof salivary glands, 707\\nof sebaceous glands, 184\\nof shin, 666\\nof testicle, 704\\ntreatment, 705\\nof thyroid gland, 665\\nof trachea and bronchial tubes, 674\\nprognosis, 664\\nsymptoms and diagnosis, 661\\ntreatment, 664\\nRhabdomyoma, 486\\nRhinoplasty, 287-289\\nRontgen rays in diagnosis of tumors, 102\\nSalpingo-oophorectomy for myofibroma of\\nuterus, 510\\nSarcoma, 536\\nSarcoma, alveolar, 552\\nbeneficial effects of erysipelas in, 573\\ncapsule of, 562\\ndefinition, 536\\nendotheliomatous, 554\\netiology, 566\\nfascial, 578\\ngiant-celled, 546\\nhistological varieties, 542\\nhistology and histogenesis, 537\\nin animals, 57\\nmetastasis in, 564\\nmixed-cell, 549\\nof bladder, 616\\nof bones, 582\\ngiant-celled or myeloid, 583\\nround-celled, 584\\nspindle-celled, 585\\ntreatment, 595\\nof brain and its envelopes, 616\\nof cranial bones, 587\\nof eye, 616\\nof intestinal canal, 606\\nof jaws, 590\\nof kidney, 607\\ndiagnosis, 607\\ntreatment, 608\\nof long bones, 596\\nof lower jaw, 597\\nof lymphatic glands, 580\\nof mammary gland, 602\\nexcision of, 603\\nof naso-pharynx, 591\\nof nose, 591\\nof omentum, 607\\nof ovary, 612\\nof prostate, 617\\nof salivary glands, 604\\nof skin, 574\\nof submucous connective tissue, 576\\nof testicle, 615\\nof thymus gland, 604\\nof tongue, 606\\nof tonsil, 606\\nof upper jaw, 598\\nexcision of, 599\\nof uterus, 610\\nof vagina, 614\\nof vertebrae, 592\\ndiagnosis, 592\\nof vulva, 615\\nprognosis, 571", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0772.jp2"}, "759": {"fulltext": "INDEX.\\n717\\nSarcoma, regressive metamorphoses, 558\\nround-celled, 542\\nspindle-celled, 544\\nsymptoms and diagnosis, 568\\ntreatment, 571\\ncaustics in, 572\\npalliative, 574\\nSarcoma-cells, morphology of, 541\\nSwellings, infective, 593\\nSyphiloma, 91\\nSyringe, exploratory, Senn s, 100\\nTeratoma, 618\\ndefinition, 618\\ndiagnosis, 640\\nof auricle, 650\\nof eye, 647\\nof face, 644\\nof ovary, 651\\nclinical aspects, 654\\nhistology and histogenesis, 651\\nof palate and pharynx, 645\\nof rectum, 649\\nof scalp and dura mater, 646\\nof scrotum, 655\\nof thorax, 642\\nof tongue, 647\\nof trunk, 641\\norigin, 618\\nprognosis, 641\\nregressive metamorphoses, 639\\ntreatment, 641\\nby antiseptic drainage, 635\\nby extirpation, 634\\nTeratomata, ectogenous, 620\\nendogenous, 620\\nThyroid-dermoids, 649\\nThyroid gland, extirpation of, 165\\npartial, 166\\ninfective swelling of, 163\\ntumors of, differential diagnosis, 164\\ntreatment, 165\\nTongue, amputation of, for carcinoma, 294-\\n298\\nTraumatism, influence of, in transformation of\\nbenign into malignant tumors, 85\\nTumor-cells, degeneration of, amyloid, 45\\ncolloid, 44\\nfatty, 43\\nhyaline, 45\\nmucoid, 44\\nTumors, accidental ulceration in, 52\\nrumors, anatomy of, 34\\nand inflammatory swellings, differences be-\\ntween, 20\\nbenign and malignant, clinical aspects of,\\n71\\nexciting causes effecting a transformation\\ninto malignant, 80, 8$\\nbiology of, 37\\nblood-vessels of, 35\\ncalcification or cretefaction of, 47\\ncapsule of, 51\\ncarcinomatous, location a factor in deter-\\nmining the malignancy of, III\\ncaseation of, 46\\nclassification of, Cohnheim s, 132\\nSenn s, 136\\nVirchow s, 131\\nWilliams s, 133\\ncongenital, etiology of, 60\\nconnection of, with mother-soil, 97\\ndefinition, 19\\ndiagnosis, 88\\nauscultation and percussion in, 102\\nclinical history in, 88\\ncrepitation in, 102\\nexamination of patient, 91\\nof tumor, 94\\nlength of time tumor has existed, 89\\nlocation, 89\\npain, 90\\npulsation, 101\\nrapidity of growth, 89\\ntactile examination, 96\\ntenderness, 90, 101\\neffect of local irritation on, 39\\netiology, 60\\nage, 65\\nclimate, 65\\ncontagion, 70\\nheredity, 61\\ninflammation, 69\\nirritation, 69\\nrace, 64\\nsex, 67\\nsocial status, 68\\ntraumatism, 68\\nfrequency of recurrence after extirpation,\\n78\\ngrafting of a malignant upon a benign, 53\\ngrowth of, 38\\nhemorrhage into, 47\\nhistogenesis, 23", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0773.jp2"}, "760": {"fulltext": "7 i8\\nINDEX.\\nTumors, history, 17\\nin animals, 57\\nadenomata, 58\\ncystic tumors, 59\\nepithelial tumors, 57\\nlipomata, 57\\nmyomata, 57\\nodontomes, 57\\nosteomata, 57\\nsarcomata, 57\\nteratomata, 59\\ninflammation in, 51\\nin plants, 55\\nintrinsic tendency to destroy life, 79\\nlymphatic vessels of, 35\\nmalignant, 74\\nmobility, 73\\nmorphology, 28\\nnerves of, 36\\noperative interference in the treatment of,\\n112\\norigin and nature, 17\\nossification, 47\\nparasitism, 208\\npathology, 42\\nprognosis, 108\\npulsating, 39\\nradical operations for, contra-indications to,\\n129\\nrecurrence of, explanation of, 73\\nrelation of, to adjacent tissues, 40\\nrelative frequency of, in different organs, 71\\nTumors, resistance and consistence of, 98\\nteratoid, origin of, 618\\ntreatment, medical, 113\\npalliative, 129\\nsurgical, 115\\nby avulsion, 126\\nby cauterization, 119\\nwith arsenic, 121\\nwith caustic potash, 120\\nwith chloride of zinc, 121\\nwith chromic acid, 12 1\\nwith nitric acid, 121\\nby ecrasement lineaire, 125\\nby extirpation, 126\\nby galvano-caustic wire, 1 24\\nby galvano-puncture, 116\\nby injection of erysipelas toxines,\\nby ligation of blood-vessels, 116\\nby ligature, 123\\nby parenchymatous injections, 1 17\\ntypical and atypical, 209\\nulceration of, 52\\nTumor-tissue, pathological changes in, 43\\nUlcers, spontaneous, 52\\nVeins, thrombosis of, 50\\nVillous carcinoma of bladder, 372\\nWarren s harpoon, 103\\nXanthoma of eyelids, 41 1\\n118", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0774.jp2"}, "761": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0775.jp2"}, "762": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0776.jp2"}, "763": {"fulltext": "CATALOGUE\\nOF THE\\nMEDICAL PUBLICATIONS\\nOF\\nW- B. SAUNDERS,\\nNo. 925 WALNUT STREET, PHILADELPHIA,\\nArranged Alphabetically and Classified under Subjects*\\nTHE books advertised in this Catalogue as being sold by subscription are usually to be\\nobtained from travelling solicitors, but they will be sent direct from the office of pub-\\nlication (charges of shipment prepaid) upon receipt of the prices given. All the other\\nbooks advertised are commonly for sale by booksellers in all parts of the United States but\\nbooks will be sent to any address, carriage prepaid, on receipt of the published price.\\nMoney may be sent at the risk of the publisher in either of the following ways A post-\\noffice money order, an express money order, a bank check, and in a registered letter. Money\\nsent in any other way is at the risk of the sender.\\nSee pages 30, 3 J, for a List of Contents classified according to subjects*\\nLATEST PUBLICATIONS.\\nInternational Text-Book of Surgery* See page 32.\\nAmerican Text-Book of Surgery Third (Revised) Edition* See page 5*\\nAmerican Text-Book of Dis* of Eye, Ear* Nose* and Throat* Page 3.\\nAmerican Text-Book of Genito-Urinary and Skin Diseases* Page 4.\\nHeisler s Embryology* See page 32.\\nNancrede s Principles of Surgery* See page 32.\\nJackson s Diseases of the Eye* See page 32.\\nKyle on the Nose and Throat* See page J5.\\nPryor s Pelvic Inflammations* See pages J9 and 32.\\nAbbott s Hygiene of Transmissible Diseases* See page 32.\\nAnders Practice of Medicine\u00e2\u0080\u0094 Third (Revised) Edition* See page 6*\\nVierordt s Medical Diagnosis Fourth (Revised) Edition* See page 29*\\nChurch and Peterson s Nervous and Mental Diseases* See page 8.\\nDa Costa s Surgery Revised and Enlarged Edition* See page JO.\\nSaunders Medical Hand-Atlases* See page 2.\\nGriffith on the Baby Revised Edition. See page J2.\\nButler s Materia Medica and Therapeutics\u00e2\u0080\u0094 Third (Revised) Ed* Page 8.\\nDe Schweinitz s Diseases of the Eye Third (Revised) Ed* See page JO.\\nVecki s Sexual Impotence* See page 28.\\nStoney s Materia Medica for Nurses. See page 28.\\nMcFarland s Pathogenic Bacteria\u00e2\u0080\u0094 Revised Edition. See page J7.\\nAmerican Pocket Medical Dictionary\u00e2\u0080\u0094 Second (Revised) Ed. Page JO.\\nStengel s Text-Book of Pathology. Second Edition* See page 26.\\nHirst s Text-Book of Obstetrics* See page J3.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0777.jp2"}, "764": {"fulltext": "SAUNDERS MEDICAL HAND-ATLASES.\\nThe series of books included under this title consists of authorized translations into\\nEnglish of the world-famous Lehmann Medicinische Handatlanten, which for sci-\\nentific accuracy, pictorial beauty, compactness, and cheapness surpass any similar\\nvolumes ever published. Each volume contains from 50 to 100 colored plates, executed\\nby the most skilful German lithographers, besides numerous illustrations in the text. There\\nis a full and appropriate description of each plate, and each book contains a condensed\\nbut adequate outline of the subject to which it is devoted.\\nOne of the most valuable features of these atlases is that they offer a ready and satis-\\nfactory substitute for clinical observation. To those unable to attend important clinics\\nthese books will be absolutely indispensable.\\nIn planning this series of books arrangements were made with representative publishers\\nin the chief medical centers of the world for the publication of translations of the atlases\\ninto nine different languages, the lithographic plates for ail these editions being made in Ger-\\nmany, where work of this kind has been brought to the greatest perfection. The expense of\\nmaking the plates being shared by the various publishers, the cost to each one was materially\\nreduced. Thus by reason of their universal translation and reproduction, the publish-\\ners have been enabled to secure for these atlases the best artistic and professional\\ntalent, to produce them in the most elegant style, and yet to offer them at a price\\nheretofore unapproached in cheapness. The success of the undertaking is demon-\\nstrated by the fact that the volumes have a.ready appeared in nine different languages\\nGerman, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian.\\nIn view of the striking success of these works, Mr. Saunders has contracted with the\\npublisher of the original German edition for one hundred thousand copies of the atlases.\\nIn consideration of this enormous undertaking, the publisher has been enabled to prepare\\nand furnish special additional colored plates, making the series even handsomer and more\\ncomplete than was originally intended.\\nAs an indication of the practical value of the atlases and of the favor with which they\\nhave been received, it should be noted that the Medical Department of the U. S. Army\\nhas adopted the Atlas of Operative Surgery as its standard, and has ordered the book in\\nlarge quantities for distribution to the various regiments and army posts.\\nThe same careful and competent editorial supervision has been secured in the\\nEnglish edition as in the originals, the translations being edited by the leading American\\nspecialists in the different subjects.\\nNOW READY.\\nAtlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited\\nby Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; At-\\ntending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text.\\nCloth, $3.00 net.\\nAtlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter-\\nson, M.D., Clinical Professor of Mental Diseases, Woman s Medical College, New York; Chiei\\nof Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig-\\nures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net.\\nAtlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P.\\nGrayson, M.D., Lecturer on Laryngology and Rhinology in the University of Pennsylvania;\\nPhysician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania.\\nWith 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net.\\nAtlas of Operative Surgery. By Dr. O. Zuckrrkandl, of Vienna. Edited by J. Chalmkrs\\nDaCosta, M.D., Clinical Professor of Surgery, Jetteison Medical College, Philadelphia; Surgeon\\nto the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, $3.00 net.\\nAtlas of Syphilis and tne Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited\\nby L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, University and Believue Hospi-\\ntal Medical College, New York. With 71 colored plates, 16 biack-and-white illustrations, and 122\\npages of text. Cloth, $3.50 net.\\nAtlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E.\\nde Schweinitz, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia.\\nWith 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net.\\nAtlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon,\\nM. D., Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia. 63 colored plates,\\n39 beautiful half-tone illustrations, and 200 pages of text. Cloth, $3.50 net.\\nIN PREPARATION.\\nAtlas of Pathological Histology. Atlas of Operative Gynecology.\\nAtlas of Orthopedic Surgery. Atlas of Psychiatry.\\nAtlas of General Surgery. Atlas of Diseases of the Ear.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0778.jp2"}, "765": {"fulltext": "THE AMERICAN TEXT-BOOK SERIES.\\nAN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS.\\nBy 43 Distinguished Practitioners and Teachers. Edited by James C.\\nWilson, M.D., Professor of the Practice of Medicine and of Clinical\\nMedicine in the Jefferson Medical College, Philadelphia. One hand-\\nsome imperial octavo volume of 1326 pages. Illustrated. Cloth,\\n$7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription.\\nAs a work either for study or reference it will be of great value to the practitioner, as\\nit is virtually an exposition of such clinical therapeutics as experience has taught to be oi\\nthe most value. Taking it all in all, no recent publication on therapeutics can be compared\\nwith this one in practical value to the working physician. Chicago Clinical Review.\\nThe whole field of medicine has been well covered. The work is thoroughly prac-\\ntical, and while it is intended for practitioners and students, it is a better book for the genera]\\npractitioner than for the student. The young practitioner especially will find it extremely\\nsuggestive and helpful. The Indian Lancet.\\nAN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN.\\nSecond Edition, Revised.\\nBy 65 Eminent Contributors. Edited by Louis Starr, M. D., Con-\\nsulting Pediatrist to the Maternity Hospital, etc. assisted by Thomp-\\nson S. Westcott, M. D., Attending Physician to the Dispensary\\nfor Diseases of Children, Hospital of the University of Pennsyl-\\nvania. In one handsome imperial octavo volume of 1244 pages,\\nprofusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco,\\n$8.00 net. Sold by Subscription.\\nThis is far and away the best text-book on children s diseases ever published in the\\nEnglish language, and is certainly the one which is best adapted to American readers.\\nWe congratulate the editor upon the result of his work, and heartily commend it to the\\nattention of every student and practitioner. American Journal of the Medical Sciences.\\nAN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR,\\nNOSE, AND THROAT.\\nBy 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D\\nProfessor of Ophthalmology in the Jefferson Medical College, Phila-\\ndelphia and B. Alexander Randall, M.D., Professor of Diseases\\nof the Ear in the University of Pennsylvania. Imperial octavo, 1251\\npages; 766 illustrations, 59 of them in colors. Cloth, $7.00 net; Sheep\\nor Half Morocco, $8.00 net. Sold by Subscription.\\nIllustrated Catalogue of the American Text-Books sent free upon application.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0779.jp2"}, "766": {"fulltext": "4 Medical Publications of W. B. Saunders.\\nAN AMERICAN TEXT=BOOK OF GENITOURINARY AND SKIN\\nDISEASES.\\nBy 47 Eminent Specialists and Teachers. Edited by L. Bolton\\nBangs, M. D., Professor of Genito- Urinary Surgery, University and\\nBellevue Hospital Medical College, New York and W. A. Hard-\\naway, M. D., Professor of Diseases of the Skin, Missouri Medical\\nCollege. Imperial octavo volume of 1229 pages, with 300 engravings\\nand 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half\\nMorocco, $8.00 net. Sold by Subscription.\\nThis volume is one of the best yet issued of the publisher s series of American Text-\\nBooks. The list of contributors represents an extraordinary array of talent and extended\\nexperience. The book will easily take the place in comprehensiveness and value of the\\nhalf dozen or more costly works on these subjects which have heretofore been necessary to\\na well-equipped library. New York Polyclinic.\\nAN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND\\nSURGICAL. Second Edition, Revised.\\nBy 10 of the Leading Gynecologists of America. Edited by J. M.\\nBaldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic,\\netc. Handsome imperial octavo volume of 718 pages, with 341 illus-\\ntrations in the text, and 38 colored and half-tone plates. Cloth, $6.00\\nnet; Sheep or Half Morocco, $7.00 net. Sold by Subscription.\\nIt is practical from beginning to end. Its descriptions of conditions, its recommen-\\ndations for treatment, and above all the necessary technique of different operations, are\\nclearly and admirably presented. It is well up to the most advanced views of the\\nday, and embodies all the essential points of advanced American gynecology. It is destined\\nto make and hold a place in gynecological literature which will be peculiarly its own.\\nMedical Record, New York.\\nAN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI-\\nCOLOGY.\\nEdited by Frederick Peterson, M.D., Clinical Professor of Mental\\nDiseases in the Woman s Medical College, New York; Chief of Clinic,\\nNervous Department, College of Physicians and Surgeons, New York\\nand Walter S. Haines, M.D., Professor of Chemistry, Pharmacy,\\nand Toxicology in Rush Medical College, Chicago. In Preparation.\\nAN AMERICAN TEXT=BOOK OF OBSTETRICS.\\nBy 15 Eminent American Obstetricians. Edited by Richard C. Nor-\\nris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome\\nimperial octavo volume of 1014 pages, with nearly 900 beautiful colored\\nand half-tone illustrations. Cloth, $7.00 net; Sheep or Half Morocco,\\n$8.00 net. Sold by Subscription.\\nPermit me to say that your American Text-Book of Obstetrics is the most magnificent\\nmedical work that I have ever seen. I congratulate you and thank you for this superb work,\\nwhich alone is sufficient to place you first in the ranks of medical publishers. ALEXANDER\\nJ. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y.\\nThis is the most sumptuously illustrated work on midwifery that has yet appeared. In\\nthe number, the excellence, and the beauty of production of the illustrations it far surpasses\\nevery other book upon the subject. This feature alone makes it a work which no medical\\nlibrary should omit to purchase. British Medical Journal.\\nAs an authority, as a book of reference, as a working book for the student or prac-\\ntitioner, we commend it because we believe there is no better. American Journal of the\\nMedical Sciences.\\nIllustrated Catalogue of the American Text-Books sent free upon application*", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0780.jp2"}, "767": {"fulltext": "Medical Publications of W. B. Saunders. 5\\nAN AMERICAN TEXT=BOOK OF PATHOLOGY.\\nEdited by John Guiteras, M.D., Professor of General Pathology and\\nof Morbid Anatomy in the University of Pennsylvania and David\\nRiesman, M.D., Demonstrator of Pathological Histology in the\\nUniversity of Pennsylvania. In Preparation.\\nAN AMERICAN TEXT=BOOK OF PHYSIOLOGY.\\nBy i o of the Leading Physiologists of America. Edited by William\\nH. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop-\\nkins University, Baltimore, Md. One handsome imperial octavo\\nvolume of 1052 pages. Illustrated. Cloth, $6.00 net; Sheep or Half\\nMorocco, $7.00 net. Sold by Subscription.\\nWe can commend it most heartily, not only to all students of physiology, but to every\\nphysician and pathologist, as a valuable and comprehensive work of reference, written by\\nmen who are of eminent authority in their own special subjects. London Lancet.\\nTo the practitioner of medicine and to the advanced student this volume constitutes,\\nwe believe, the best exposition of the present status of the science of physiology in the\\nEnglish language. American Journal of the Medical Sciences.\\nAN AMERICAN TEXT=BOOK OF SURGERY. Third Edition.\\nBy 11 Eminent Professors of Surgery. Edited by William W. Keen,\\nM.D., LL.D., and J. William White, M.D., Ph.D. Handsome im-\\nperial octavo volume of 1230 pages, with 496 wood-cuts in the text,\\nand 37 colored and half-tone plates. Thoroughly revised and enlarged,\\nwith a section devoted to The Use of the Rontgen Rays in Surgery.\\nCloth, $7.00 net; Sheep or Half Morocco, $8.00 net.\\nPersonally, I should not mind it being called THE Text-Book (instead of A Text-\\nBook) for I know of no single volume which contains so readable and complete an account\\nof the science and art of Surgery as this does. Edmund Owen, F.R.C.S., Member of\\nthe Board of Examiners of the Royal College of Surgeons, England.\\nIf this text-book is a fair reflex of the present position of American surgery, we must\\nadmit it is of a very high order of merit, and that English surgeons will have to look very\\ncarefully to their laurels if they are to preserve a position in the van of surgical practice.\\nLondon Lancet.\\nAN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE\\nOF MEDICINE.\\nBy 12 Distinguished American Practitioners. Edited by William\\nPepper, M.D., LL.D., Professor of the Theory and Practice of Medi-\\ncine and of Clinical Medicine in the University of Pennsylvania. Two\\nhandsome imperial octavo volumes of about 1000 pages each. Illus-\\ntrated. Prices per volume Cloth, $5.00 net Sheep or Half Morocco,\\n$6.00 net. Sold by Subscription.\\nI am quite sure it will commend itself both to practitioners and students of medicine,\\nand become one of our most popular text-books. Alfred Loomis, M.D., LL.D., Pro-\\nfessor of Pathology and Practice of Medicine, University of the City of New York.\\nWe reviewed the first volume of this work, and said It is undoubtedly one of the\\nbest text-books on the practice of medicine which we possess. A consideration of the\\nsecond and last volume leads us to modify that verdict and to say that the completed work\\nis in our opinion the best of its kind it has ever been our fortune to see. New York Medical\\nJournal.\\nIllustrated Catalogue of the American Text-Books n sent free upon application*", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0781.jp2"}, "768": {"fulltext": "6 Medical Publications of W. B. Saunders.\\nAN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY.\\nA Yearly Digest of Scientific Progress and Authoritative Opinion in all\\nbranches of Medicine and Surgery, drawn from journals, monographs,\\nand text-books of the leading American and Foreign authors and\\ninvestigators. Collected and arranged, with critical editorial com-\\nments, by eminent American specialists and teachers, under the general\\neditorial charge of George M. Gould, M.D. One handsome imperial\\noctavo volume of about 1200 pages. Uniform in style, size, and\\ngeneral make-up with the American Text-Book Series. Cloth,\\n$6.50 net; Half Morocco, $7.50 net. Sold by Subscription.\\nIt is difficult to know which to admire most the research and industry of the distin-\\nguished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the\\nwealth and abundance of the contributions to every department of science that have been\\ndeemed worthy of analysis. It is much more than a mere compilation of abstracts,\\nfor, as each section is entrusted to experienced and able contributors, the reader has the\\nadvantage of certain critical commentaries and expositions proceeding from writers\\nfully qualified to perform these tasks. It is emphatically a book which should find\\na place in every medical library, and is in several respects more useful than the famous\\nJahrbiicher of Germany. London Lancet.\\nTHE AMERICAN POCKET MEDICAL DICTIONARY.\\n[See Dorland s Pocket Dictionary, page 10.]\\nANDERS PRACTICE OF MEDICINE. Third Revised Edition.\\nA Text-Book of the Practice of Medicine. By James M. Anders,\\nM.D., Ph.D., LL.D., Professor of the Practice of Medicine and of\\nClinical Medicine, Medico-Chirurgical College, Philadelphia. In one\\nhandsome octavo volume of 1292 pages, fully illustrated. Cloth,\\n$5.50 net; Sheep or Half Morocco, $6.50 net.\\nIt is an excellent book, concise, comprehensive, thorough, and up to date. It is a\\ncredit to you but, more than that, it is a credit to the profession of Philadelphia to us.\\nJames C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson\\nMedical College, Philadelphia.\\nASHTON S OBSTETRICS. Fourth Edition, Revised.\\nEssentials of Obstetrics. By W. Easterly Ashton, M.D., Pro.\\nfessor of Gynecology in the Medico-Chirurgical College, Philadelphia.\\nCrown octavo, 252 pages; 75 illustrations. Cloth, $1. 00; interleaved\\nfor notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nEmbodies the whole subject in a nut-shell. We cordially recommend it to our read*\\ngrs. Chicago Medical Times.\\nBALL S BACTERIOLOGY. Third Edition, Revised.\\nEssentials of Bacteriology a Concise and Systematic Introduction\\nto the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol-\\nogist to St. Agnes Hospital, Philadelphia, etc. Crown octavo, 218\\npages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00;\\ninterleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nThe student or practitioner can readily obtain a knowledge of the subject from a perusal\\nof this book. The illustrations are clear and satisfactory. Medical Record, New York.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0782.jp2"}, "769": {"fulltext": "Medical Publications of W. B. Saunders. 7\\nBASTINS BOTANY.\\nLaboratory Exercises in Botany. By Edson S. Bastin, M.A.,\\nlate Professor of Materia Medica and Botany, Philadelphia College of\\nPharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.50.\\nIt is unquestionably the best text-book on the subject that has yet appeared. The\\nwork is eminently a practical one. We regard the issuance of this book as an important\\nevent in the history of pharmaceutical teaching in this country, and predict for it an unquali-\\nfied success. Alumni Report to the Philadelphia College of Pharmacy.\\nThere is no work like it in the pharmaceutical or botanical literature of this country,\\nand we predict for it a wide circulation. American Journal of Pharmacy.\\nBECK S SURGICAL ASEPSIS.\\nA Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to\\nSt. Mark s Hospital and the New York German Poliklinik, etc. 306\\npages; 65 text-illustrations, and 12 full-page plates. Cloth, #1.25 net.\\nAn excellent exposition of the very latest in the treatment of wounds as practised\\nby leading German and American surgeons. Birmingham (Eng.) Medical Review.\\nThis little volume can be recommended to any who are desirous of learning the details\\nof asepsis in surgery, for it will serve as a trustworthy guide. London Lancet.\\nBOISLINIERE S OBSTETRIC ACCIDENTS, EMERGENCIES, AND\\nOPERATIONS.\\nObstetric Accidents, Emergencies, and Operations. By L. Ch.\\nBoisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis\\nMedical College. 381 pages, handsomely illustrated. Cloth, $2.00 net.\\nIt is clearly and concisely written, and is evidently the work of a teacher and practi-\\ntioner of large experience. British Medical Journal.\\nA manual so useful to the student or the general practitioner has not been brought to\\nour notice in a long time. The field embraced in the title is covered in a terse, interesting\\nway. Yale Medical Journal.\\nBROCKWAY S MEDICAL PHYSICS. Second Edition, Revised.\\nEssentials of Medical Physics. By Fred J. Brockway, M.D.,\\nAssistant Demonstrator of Anatomy in the College of Physicians and\\nSurgeons, New York. Crown octavo, 330 pages 155 fine illustrations.\\nCloth, $1.00 net interleaved for notes, $1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nThe student who is well versed in these pages will certainly prove qualified to com\u00c2\u00ab\\nprehend with ease and pleasure the great majority of questions involving physical principles\\nlikely to be met with in his medical studies. American Practitioner and News.\\nWe know of no manual that affords the medical student a better or more concise\\nexposition of physics, and the book may be commended as a most satisfactory presentation\\nof those essentials that are requisite in a course in medicine. New York Medical Journal.\\nIt contains all that one need know on the subject, is well written, and is copiously\\nillustrated. Medical Record, New York.\\nBURR ON NERVOUS DISEASES.\\nA Manual of Nervous Diseases. By Charles W. Burr, M.D.,\\nClinical Professor of Nervous Diseases, Medico-Chirurgical College,\\nPhiladelphia; Pathologist to the Orthopedic Hospital and Infirmary\\nfor Nervous Diseases; Visiting Physician to St. Joseph s Hospital, etc.\\nJn Preparation.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0783.jp2"}, "770": {"fulltext": "8 Medical Publications of W. B. Saunders.\\nBUTLER S MATERIA MEDICA, THERAPEUTICS, AND PHAR-\\nMACOLOGY. Third Edition, Revised.\\nA Text=Book of Materia Medica, Therapeutics, and Pharma-\\ncology. By George F. Butler, Ph.G., M.D., Professor of Materia\\nMedica and of Clinical Medicine in the College of Physicians and\\nSurgeons, Chicago Professor of Materia Medica and Therapeutics,\\nNorthwestern University, Woman s Medical School, etc. Octavo, 874\\npages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net.\\nTaken as a whole, the book may fairly be considered as one of the most satisfactory\\nof any single-volume works on materia medica in the market, Journal of the American\\nMedical Association.\\nCERNA ON THE NEWER REMEDIES. Second Edition, Revised.\\nNotes on the Newer Remedies, their Therapeutic Applications\\nand Modes of Administration. By David Cerna, M.D., Ph.D.,\\nformerly Demonstrator of and Lecturer on Experimental Therapeutics\\nin the University of Pennsylvania Demonstrator of Physiology in the\\nMedical Department of the University of Texas. Rewritten and\\ngreatly enlarged. Post-octavo, 253 pages. Cloth, $1.25.\\nThe appearance of this new edition of Dr. Cerna s very valuable work shows that it\\nis properly appreciated. The book ought to be in the possession of every practising physi-\\ncian. New York Medical Journal.\\nCHAPIN ON INSANITY.\\nA Compendium of Insanity. By John B. Chapin, M.D., LL.D.,\\nPhysician-in-Chief, Pennsylvania Hospital for the Insane late Physi-\\ncian-Superintendent of the Willard State Hospital, New York Hon-\\norary Member of the Medico-Psychological Society of Great Britain,\\nof the Society of Mental Medicine of Belgium. i2mo, 234 pages,\\nillustrated. Cloth, $1.25 net.\\nThe practical parts of Dr. Chapin s book are what constitute its distinctive merit. We\\ndesire especially to call attention to the fact that on the subject of therapeutics of insanity\\nthe work is exceedingly valuable. It is not a made book, but a genuine condensed thesis,\\nwhich has all the value of ripe opinion and all the charm of a vigorous and natural style.\\nPhiladelphia Medical Journal.\\nCHAPMAN S MEDICAL JURISPRUDENCE AND TOXICOLOGY.\\nSecond Edition, Revised.\\nMedical Jurisprudence and Toxicology. By Henry C. Chapman,\\nM.D., Professor of Institutes of Medicine and Medical Jurisprudence\\nin the Jefferson Medical College of Philadelphia. 254 pages, with 55\\nillustrations and 3 full-page plates in colors. Cloth, $1.50 net.\\nThe best book of its class for the undergraduate that we know of. New York\\nMedical Times.\\nCHURCH AND PETERSON S NERVOUS AND MENTAL DISEASES.\\nNervous and Mental Diseases. By Archibald Church, M. D.,\\nProfessor of Mental Diseases and Medical Jurisprudence in the North-\\nwestern University Medical School, Chicago and Frederick Peter-\\nson, M. D., Clinical Professor of Mental Diseases, Woman s Medical\\nCollege, N. Y.; Chief of Clinic, Nervous Dept., College of Physi-\\ncians and Surgeons, N. Y. Handsome octavo volume of 843 pages,\\nprofusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0784.jp2"}, "771": {"fulltext": "Medical Publications of W. B. Saunders. 9\\nCLARKSON S HISTOLOGY.\\nA Text=Book of Histology, Descriptive and Practical. By\\nArthur Clarkson, M.B., CM. Edin., formerly Demonstrator of\\nPhysiology in the Owen s College, Manchester; late Demonstrator of\\nPhysiology in Yorkshire College, Leeds. Large octavo, 554 pages;\\n22 engravings in the text, and 174 beautifully colored original illustra-\\ntions. Cloth, strongly bound, $4.00 net.\\nThe work must be considered a valuable addition to the list of available text- books,\\nand is to be highly recommended. New York Medical Journal.\\nThis is one of the best works for students we have ever noticed. We predict that the\\nbook will attain a well-deserved popularity among our students. Chicago Medical Recorder.\\nCLIMATOLOGY.\\nTransactions of the Eighth Annual Meeting of the American\\nClimatological Association, held in Washington, September 22-25,\\n1 89 1. Forming a handsome octavo volume of 276 pages, uniform with\\nremainder of series. (A limited quantity only.) Cloth, $1.50.\\nCOHEN AND ESHNER S DIAGNOSIS.\\nEssentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro-\\nfessor of Clinical Medicine and Applied Therapeutics in the Philadel-\\nphia Polyclinic and Augustus A. Eshner, M.D., Professor of Clinical\\nMedicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55\\nillustrations. Cloth, $1.50 net.\\n[See Saunders Question- Compends, page 21.]\\nWe can heartily commend the book to all those who contemplate purchasing a com-\\npend. It is modern and complete, and will give more satisfaction than many other works\\nwhich are perhaps too prolix as well as behind the times. Medical Review, St. Louis.\\nCORWIN S PHYSICAL DIAGNOSIS. Third Edition, Revised.\\nEssentials of Physical Diagnosis of the Thorax. By Arthur\\nM. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush\\nMedical College, Chicago Attending Physician to Central Free Dis-\\npensary, Department of Rhinology, Laryngology, and Diseases of the\\nChest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net.\\nIt is excellent. The student who shall use it as his guide to the careful study of\\nphysical exploration upon normal and abnormal subjects can scarcely fail to acquire a good\\nworking knowledge of the subject. Philadelphia Polyclinic.\\nA most excellent little work. It brightens the memory of the differential diagnostic\\nsigns, and it arranges orderly and in sequence the various objective phenomena to logical\\nsolution of a careful diagnosis. \u00e2\u0080\u0094Journal oj Nervous and Mental Diseases.\\nCRAGIN S GYNAECOLOGY. Fourth Edition, Revised.\\nEssentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer\\nin Obstetrics, College of Physicians and Surgeons, New York. Crown\\noctavo, 200 pages; 62 illustrations. Cloth, $1.00 interleaved for notes,\\n$1.25.\\n[See Saunders 1 Question- Compends, page 21.]\\nA handy volume, and a distinct improvement on students compends in general. No\\nauthor who was not himself a practical gynecologist could have consulted the student s needs\\nso thoroughly as Dr. Cragin has done. Medical Record, New York.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0785.jp2"}, "772": {"fulltext": "10 Medical Publications of W. B. Saunders.\\nCROOKSHANK S BACTERIOLOGY. Fourth Edition, Revised.\\nA Text=Book of Bacteriology. By Edgar M. Crookshank, M.B.,\\nProfessor of Comparative Pathology and Bacteriology, King s College,\\nLondon. Octavo volume of 700 pages, with 273 engravings and 22\\noriginal colored plates. Cloth, $6.5.0 net; Half Morocco, $7.50 net.\\nTo the student who wishes to obtain a good resume of what has been done in bacteri-\\nology, or who wishes an accurate account of the various methods of research, the book may\\nbe recommended with confidence that he will find there what he requires. London Lancet.\\nDa COSTA S SURGERY. Second Ed., Revised and Greatly Enlarged.\\nModern Surgery, General and Operative. By John Chalmers\\nDaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical\\nCollege, Philadelphia Surgeon to the Philadelphia Hospital, etc.\\nHandsome octavo volume of 900 pages, profusely illustrated. Cloth,\\n$4.00 net; Half Morocco, $5.00 net.\\nWe know of no small work on surgery in the English language which so well fulfils\\nthe requirements of the modern student. Medico- Chirttrgical Journal, Bristol, England.\\nDE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition,\\nRevised.\\nDiseases of the Eye. A Handbook of Ophthalmic Practice.\\nBy G. E. de Schweinitz, M.D., Professor of Ophthalmology in the\\nJefferson Medical College, Philadelphia, etc. Handsome royal octavo\\nvolume of 696 pages, with 256 fine illustrations and 2 chromo-litho-\\ngraphic plates. Cloth, $4.00 net Sheep or Half Morocco, $5.00 net.\\nA clearly written, comprehensive manual. One which we can commend to students\\nas a reliable text-book, written with an evident knowledge of the wants of those entering\\nupon the study of this special branch of medical science. British Medical Journal.\\nA work that will meet the requirements not only of the specialist, but of the general\\npractitioner in a rare degree. I am satisfied that unusual success awaits it. William\\nPepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine\\nUniversity of Pennsylvania.\\nDORLAND S DICTIONARY. Second Edition, Revised.\\nThe American Pocket Medical Dictionary. Containing the Pro-\\nnunciation and Definition of all the principal words and phrases, and a\\nlarge number of useful tables. Edited by W. A. Newman Dorland,\\nM. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania\\nFellow of the American Academy of Medicine. 518 pages handsomely\\nbound in full leather, limp, with gilt edges and patent index. Price,\\n#1.00 net; with thumb index, #1.25 net.\\nDORLAND S OBSTETRICS.\\nA Manual of Obstetrics. By W. A. Newman Dorland, M.D.,\\nAssistant Demonstrator of Obstetrics, University of Pennsylvania;\\nInstructor in Gynecology in the Philadelphia Polyclinic. 760 pages;\\n163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net.\\nBy far the best book on this subject that has ever come to our notice. American\\nMedical Review.\\nIt has rarely been our duty to review a book which has given us more pleasure in its\\nperusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge,\\na gold mine of practical, concise thoughts. American Medico- Surgical Bulletin.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0786.jp2"}, "773": {"fulltext": "Medical Publications of W. B. Saunders. 11\\nFROTHINGHAM S GUIDE FOR THE BACTERIOLOGIST.\\nLaboratory Guide for the Bacteriologist. By Langdon Froth-\\ningham, M.D.V., Assistant in Bacteriology and Veterinary Science,\\nSheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts.\\nIt is a convenient and useful little work, and will more than repay the outlay neces-\\nsary for its purchase in the saving of time which would otherwise be consumed in looking\\nup the various points of technique so clearly and concisely laid down in its pages. Ameri-\\ncan Medico- Surgical Bulletin.\\nGARRIGUES DISEASES OF WOMEN. Second Edition, Revised.\\nDiseases of Women. By Henry J. Garrigues, A.M., M.D., Pro-\\nfessor of Gynecology in the New York School of Clinical Medicine\\nGynecologist to St. Mark s Hospital and to the German Dispensary,\\nNew York City, etc. Handsome octavo volume of 728 pages, illus-\\ntrated by 335 engravings and colored plates. Cloth, $4.00 net;\\nSheep or Half Morocco, $5.00 net.\\nOne of the best text-books for students and practitioners which has been published in\\nthe English language; it is condensed, clear, and comprehensive. The profound learning\\nand great clinical experience of the distinguished author find expression in this book in a\\nmost attractive and instructive form. Young practitioners to whom experienced consultants\\nmay not be available will find in this book invaluable counsel and help. Thad. A.\\nReamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio.\\nGLEASON S DISEASES OF THE EAR. Second Edition, Revised.\\nEssentials of Diseases of the Ear. By E. B. Gleason, S.B.,\\nM.D., Clinical Professor of Otology, Medico-Chirurgical College,\\nPhiladelphia Surgeon-in-Charge of the Nose, Throat, and Ear Depart-\\nment of the Northern Dispensary, Philadelphia. 208 pages, with\\n114 illustrations. Cloth, $1. 00; interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nIt is just the book to put into the hands of a student, and cannot fail to give him a\\nuseful introduction to ear-affections while the style of question and answer which is adopted\\nthroughout the book is, we believe, the best method of impressing facts permanently on the\\nmind. Liverpool Medico- Chirurgical fournal.\\nGOULD AND PYLE S CURIOSITIES OF MEDICINE.\\nAnomalies and Curiosities of Medicine. By George M. Gould,\\nM.D., and Walter L. Pyle, M.D. An encyclopedic collection of\\nrare and extraordinary cases and of the most striking instances of\\nabnormality in all branches of Medicine and Surgery, derived from an\\nexhaustive research of medical literature from its origin to the present\\nday, abstracted, classified, annotated, and indexed. Handsome im-\\nperial octavo volume of 968 pages, with 295 engravings in the text,\\nand 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net.\\nSold by Subscription.\\nOne of the most valuable contributions ever made to medical literature. It is, so far\\nas we know, absolutely unique, and every page is as fascinating as a novel. Not alone for\\nthe medical profession has this volume value it will serve as a book of reference for all who\\nare interested in general scientific, sociologic, or medico-legal topics. Brooklyn Medical\\nJournal.\\nThis is certainly a most remarkable and interesting volume. It stands alone among\\nmedical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in\\nmedical literature. It is a book full of revelations from its first to its last page, and cannot\\nbut interest and sometimes almost horrify its readers. American Medico- Surgical Bulletin*", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0787.jp2"}, "774": {"fulltext": "12 Medical Publications of W. B. Saunders.\\nGRAFSTROM S MECHANOTHERAPY.\\nA Text=Book of Mechanotherapy (Massage and Medical Gym=\\nnasties). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in\\nthe Royal Swedish Army late House Physician City Hospital, Black-\\nwell s Island, New York. i2mo. 139 pages, illustrated. Cloth, $1.00 net.\\nGRIFFITH ON THE BABY. Second Edition, Revised.\\nThe Care of the Baby. By J. P. Crozer Griffith, M.D., Clini-\\ncal Professor of Diseases of Children, University of Pennsylvania\\nPhysician to the Children s Hospital, Philadelphia, etc. i2mo, 404\\npages, with 67 illustrations in the text, and 5 plates. Cloth, #1.50.\\nThe best book for the use of the young mother with which we are acquainted.\\nThere are very few general practitioners who could not read the book through with advan-\\ntage. Archives of Pediatrics.\\nThe whole book is characterized by rare good sense, and is evidently written by a\\nmaster hand. It can be read with benefit not only by mothers but by medical students and\\nby any practitioners who have not had large opportunities for observing children. Ameri-\\ncan Journal of Obstetrics.\\nGRIFFITH S WEIGHT CHART.\\nInfant s Weight Chart. Designed by J. P. Crozer Griffith, M.D.,\\nClinical Professor of Diseases of Children in the University of Penn-\\nsylvania, etc. 25 charts in each pad. Per pad, 50 cents net.\\nA convenient blank for keeping a record of the child s weight during the first two years\\nof life. Printed on each chart is a curve representing the average weight of a healthy infant,\\nso that any deviation from the normal can readily be detected.\\nGROSS, SAMUEL D., AUTOBIOGRAPHY OF.\\nAutobiography of Samuel D. Gross, M.D., Emeritus Professor of\\nSurgery in the Jefferson Medical College, Philadelphia, with Remi-\\nniscences of His Times and Contemporaries. Edited by his Sons,\\nSamuel W. Gross, M.D., LL.D., late Professor of Principles of Sur-\\ngery and of Clinical Surgery in the Jefferson Medical College, and\\nA. Hauler Gross, A.M., of the Philadelphia Bar. Preceded by a\\nMemoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In\\ntwo handsome volumes, each containing over 400 pages, demy octavo,\\nextra cloth, gilt tops, with fine Frontispiece engraved on steel. Price\\nper volume, $2.50 net.\\nDr. Gross was perhaps the most eminent exponent of medical science that America\\nhas yet produced. His Autobiography, related as it is with a fulness and completeness\\nseldom to be found in such works, is an interesting and valuable book. He comments on\\nmany things, especially, of course, on medical men and medical practice, in a very interest-\\ning way. The Spectator, London, England.\\nHAMPTON S NURSING. Second Edition, Revised and Enlarged.\\nNursing Its Principles and Practice. By Isabel Adams Hamp-\\nton, Graduate of the New York Training School for Nurses attached\\nto Bellevue Hospital late Superintendent of Nurses and Principal of\\nthe Training School for Nurses, Johns Hopkins Hospital, Baltimore,\\nMd. 12 mo, 512 pages, illustrated. Cloth, $2.00 net.\\nSeldom have we perused a book upon the subject that has given us so much pleasure\\nas the one before us. We would strongly urge upon the members of our own profession the\\nneed of a book like this, for it will enable each of us to become a training school in him-\\nself. Ontario Medical Journal.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0788.jp2"}, "775": {"fulltext": "Medical Publications of W. B. Saunders. 13\\nHARE S PHYSIOLOGY. Fourth Edition, Revised.\\nEssentials of Physiology. By H. A. Hare, M.D., Professor of\\nTherapeutics and Materia Medica in the Jefferson Medical College of\\nPhiladelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter-\\nleaved for notes, #1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nThe best condensation of physiological knowledge we have yet seen. Medical\\nRecord, New York.\\nHARTS DIET IN SICKNESS AND IN HEALTH.\\nDiet in Sickness and in Health. By Mrs. Ernest Hart, formerly\\nStudent of the Faculty of Medicine of Paris and of the London School\\nof Medicine for Women with an Introduction by Sir Hendry\\nThompson, F.R.C.S., M.D., London. 220 pages. Cloth, $1.50.\\nWe recommend it cordially to the attention of all practitioners both to them and to\\ntheir patients it may be of the greatest service. New York Medical Journal.\\nHAYNES ANATOMY.\\nA Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct\\nProfessor of Anatomy and Demonstrator of Anatomy, Medical Depart-\\nment of the New York University, etc. 680 pages, illustrated with 42\\ndiagrams in the text, and 134 full-page half-tone illustrations from\\noriginal photographs of the author s dissections. Cloth, $2.50 net.\\nThis book is the work of a practical instructor one who knows by experience the\\nrequirements of the average student, and is able to meet these requirements in a very satis-\\nfactory way. The book is one that can be commended. Medical Record, New York.\\nHEISLERS EMBRYOLOGY.\\nA Text=Book of Embryology. By John C. Heisler, M.D., Pro-\\nfessor of Anatomy in the Medico- Chirurgical College, Philadelphia. Oc-\\ntavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net.\\nHIRST S OBSTETRICS.\\nA Text=Book of Obstetrics. By Barton Cooke Hirst, M. D.,\\nProfessor of Obstetrics in the University of Pennsylvania. Handsome\\noctavo volume of 848 pages, with 618 illustrations, and 7 colored\\nplates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net.\\nThe illustrations are numerous and are works of art, many of them appearing for the\\nfirst time. The arrangement of the subject-matter, the foot-notes, and index are beyond\\ncriticism. As a true model of what a modern text-book on obstetrics should be, we feel\\njustified in affirming that Dr. Hirst s book is without a rival. New York Medical Record.\\nHYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL\\nDISEASES.\\nSyphilis and the Venereal Diseases. By James Nevins Hyde,\\nM.D., Professor of Skin and Venereal Diseases, and Frank H. Mont-\\ngomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases\\nin Rush Medical College, Chicago, 111. 618 pages, profusely illustrated.\\nCloth, $2.50 net.\\nWe can commend this manual to the student as a help to him in his study of venereal\\ndiseases. Liverpool Medico- Chirurgical Journal.\\nThe best student s manual which has appeared on the subject. St. Louis Medical\\nand Surgical Journal.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0789.jp2"}, "776": {"fulltext": "14 Medical Publications of W. B. Saunders.\\nJACKSON AND GLEASON S DISEASES OF THE EYE, NOSE, AND\\nTHROAT. Second Edition, Revised.\\nEssentials of Refraction and Diseases of the Eye. By Edward\\nJackson, A.M., M.D., Professor of Diseases of the Eye in the Phila-\\ndelphia Polyclinic and College for Graduates in Medicine and\\nEssentials of Diseases of the Nose and Throat. By E. Bald-\\nwin Gleason, M.D., Surgeon-in- Charge of the Nose, Throat, and\\nEar Department of the Northern Dispensary of Philadelphia. Two\\nvolumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth,\\n$1.00; interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nOf great value to the beginner in these branches. The authors are both capable men,\\nand know what a student most needs. Medical Record, New York.\\nKEATING S DICTIONARY. Second Edition, Revised.\\nA New Pronouncing Dictionary of Medicine, with Phonetic\\nPronunciation, Accentuation, Etymology, etc. By John M.\\nKeating, M.D., LL.D., Fellow of the College of Physicians of Phila-\\ndelphia; Vice-President of the American Pediatric Society; Editor\\nCyclopaedia of the Diseases of Children, etc.; and Henry\\nHamilton, Author of A New Translation of Virgil s ^Eneid into\\nEnglish Rhyme, etc.; with the collaboration of J. Chalmers Da-\\nCosta, M.D., and Frederick A. Packard, M.D. With an Appendix\\ncontaining Tables of Bacilli, Micrococci, Leucomaines, Ptomaines;\\nDrugs and Materials used in Antiseptic Surgery; Poisons and their\\nAntidotes Weights and Measures Thermometric Scales New\\nOfficial and Unofficial Drugs, etc. One volume of over 800 pages.\\nPrices, with Denison s Patent Ready-Reference Index: Cloth, $5.00\\nnet; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net.\\nWithout Patent Index: Cloth, $4.00 net; Sheep or Half Morocco,\\n$5.00 net.\\nI am much pleased with Keating s Dictionary, and shall take pleasure in recommend-\\ning it to my classes. Henry M. Lyman, M.D., Professor of the Principles and Practice\\nof Medicine, Rush Medical College, Chicago, III.\\nI am convinced that it will be a very valuable adjunct to my study-table, convenient\\nin size and sufficiently full for ordinary use. C. A. Lindsley, M.D., Professor of the\\nTheory and Practice of Medicine, Medical Dept. Yale University.\\nKEATING S LIFE INSURANCE.\\nHow to Examine for Life Insurance. By John M. Keating,\\nM. D., Fellow of the College of Physicians of Philadelphia; Vice-\\nPresident of the American Pediatric Society; Ex- President of the\\nAssociation of Life Insurance Medical Directors. Royal octavo, 21 j\\npages with two large half-tone illustrations, and a plate prepared by\\nDr. McClellan from special dissections also, numerous other illustra-\\ntions. Cloth, $2.00 net.\\nThis is by far the most useful book which has yet appeared on insurance examination,\\na subject of growing interest and importance. Not the least valuable portion of the volume\\nis Part II., which consists of instructions issued to their examining physicians by twenty-four\\nrepresentative companies of this country. If for these alone, the book should be at the right\\nhand of every physician interested in this special branch of medical science. The Medical\\nNews.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0790.jp2"}, "777": {"fulltext": "Medical Publications of W. B. Saunders. 15\\nKEEN ON THE SURGERY OF TYPHOID FEVER.\\nThe Surgical Complications and Sequels of Typhoid Fever.\\nBy Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-\\ngery and of Clinical Surgery, Jefferson Medical College, Philadelphia;\\nCorresponding Member of the Societe de Chirurgie, Paris Honorary\\nMember of the Societe Beige de Chirurgie, etc. Octavo volume of\\n386 pages, illustrated. Cloth, $3.00 net.\\nThis is probably the first and only work in the English language that gives the reader\\na clear view of what typhoid fever really is, and what it does and can do to the human\\norganism. This book should be in the possession of every medical man in America.\\nAmerican Medico-Surgical Bulletin.\\nKEEN S OPERATION BLANK. Second Edition, Revised Form.\\nAn Operation Blank, with Lists of Instruments, etc. Required\\nin Various Operations. Prepared by W. W. Keen, M.D., LL.D.,\\nProfessor of the Principles of Surgery in Jefferson Medical College,\\nPhiladelphia. Price per pad, containing blanks for fifty operations,\\n50 cents net.\\nKYLE ON THE NOSE AND THROAT.\\nDiseases of the Nose and Throat. By D. Braden Kyle, M.D.,\\nClinical Professor of Laryngology and Rhinology, Jefferson Medical\\nCollege, Philadelphia Consulting Laryngologist, Rhinologist, and\\nOtologist, St. Agnes Hospital. Handsome octavo volume of about\\n630 pages, with over 150 illustrations and 6 lithographic plates. Price,\\nCloth, $4.00 net; Half Morocco, $5.00 net.\\nLAINE S TEMPERATURE CHART.\\nTemperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^\\ninches. A conveniently arranged Chart for recording Temperature,\\nwith columns for daily amounts of Urinary and Fecal Excretions,\\nFood, Remarks, etc. On the back of each chart is given in full the\\nmethod of Brand in the treatment of Typhoid Fever. Price, per pad\\nof 25 charts, 50 cents net.\\nTo the busy practitioner this chart will be found of great value in fever cases, and\\nespecially for cases of typhoid. Indian Lancet, Calcutta.\\nLOCKWOOD S PRACTICE OF MEDICINE.\\nA Manual of the Practice of Medicine. By George Roe Lock-\\nwood, M.D., Professor of Practice in the Woman s Medical College\\nof the New York Infirmary, etc. 935 pages, with 75 illustrations in\\nthe text, and 22 full-page plates. Cloth, $2.50 net.\\nGives in a most concise manner the points essential to treatment usually enumerated\\nin the most elaborate works. Massachusetts Medical Journal.\\nLONGS SYLLABUS OF GYNECOLOGY.\\nA Syllabus of Gynecology, arranged in Conformity with An\\nAmerican Text=Book of Gynecology. By J. W. Long, M.D.,\\nProfessor of Diseases of Women and Children, Medical College of\\nVirginia, etc. Cloth, interleaved, $1.00 net.\\nThe book is certainly an admirable resume of what every gynecological student and\\npractitioner should know, and will prove of value not only to those who have the American\\nText-Book of Gynecology, but to others as well. Brooklyn Medical Journal.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0791.jp2"}, "778": {"fulltext": "16 Medical Publications of W. B. Saunders.\\nMACDONALD S SURGICAL DIAGNOSIS AND TREATMENT.\\nSurgical Diagnosis and Treatment. By J. W. Macdonald, M.D.\\nEdin., F.R.C.S., Edin., Professor of the Practice of Surgery and of\\nClinical Surgery in Hamline University Visiting Surgeon to St.\\nBarnabas Hospital, Minneapolis, etc. Handsome octavo volume of\\n800 pages, profusely illustrated. Cloth, #5.00 net; Half Morocco,\\n$6.00 net.\\nA thorough and complete work on Surgical diagnosis and treatment, free from pad-\\nding, full of valuable material, and in accord with the surgical teaching of the day. The\\nMedical Nezvs, New York.\\nThe work is brimful of just the kind of practical information that is useful alike to\\nstudents and practitioners. It is a pleasure to commend the bock because of its intrinsic\\nvalue to the medical practitioner. Cincinnati Lancet- Clinic\\nMALLORY AND WRIGHTS PATHOLOGICAL TECHNIQUE.\\nPathological Technique. A Practical Manual for Laboratory Work\\nin Pathology, Bacteriology, and Morbid Anatomy, with chapters on\\nPost-Mortem Technique and the Performance of Autopsies. By Frank\\nB. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvarn\\nUniversity Medical School, Boston; and James H. Wright, A.M.,\\nM.D., Instructor in Pathology, Harvard University Medical School,\\nBoston. Octavo volume of 396 pages, handsomely illustrated. Cloth,\\n$2.50 net.\\nI have been looking forward to the publication of this book, and I am glad to say that\\nI find it to be a most useful laboratory and post-mortem guide, full of practical, information,\\nand well up to date. William H. Welch, Professor of Pathology, Johns Hopkins Uni-\\nversity, Baltimore, Md.\\nMARTIN S MINOR SURGERY, BANDAGING, AND VENEREAL\\nDISEASES. Second Edition, Revised.\\nEssentials of Minor Surgery, Bandaging, and Venereal\\nDiseases. By Edward Martin, A.M., M.D., Clinical Professor of\\nGenito-Urinary Diseases, University of Pennsylvania, etc. Cr@wn\\noctavo, 166 pages, with 78 illustrations. Cloth, $1.00 interleaved for\\nnotes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nA very practical and systematic study of the subjects, and shows the author s famil-\\niarity with the needs of students. Therapeutic Gazette.\\nMARTIN S SURGERY. Sixth Edition, Revised.\\nEssentials of Surgery. Containing also Venereal Diseases, Surgi-\\ncal Landmarks, Minor and Operative Surgery, and a complete de-\\nscription, with illustrations, of the Handkerchief and Roller Bandages.\\nBy Edward Martin, A.M., M.D., Clinical Professor of Genito-\\nUrinary Diseases, University of Pennsylvania, etc. Crown octavo, 338\\npages, illustrated. With an Appendix containing full directions for the\\npreparation of the materials used in Antiseptic Surgery, etc. Cloth,\\n$1.00; interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nContains all necessary essentials of modern surgery in a comparatively small space.\\nIts style is interesting, and its illustrations are admirable. Medical and Surgical Reporter.\\nc", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0792.jp2"}, "779": {"fulltext": "Medical Publications of W. B. Saunders. 17\\nMcFARLAND S PATHOGENIC BACTERIA. Second Edition, Re=\\nvised and Greatly Enlarged.\\nText=Book upon the Pathogenic Bacteria. By Joseph McFar-\\nland, M. D. Professor of Pathology and Bacteriology in the Medico-\\nChirurgical College of Philadelphia, etc. Octavo volume of 497 pages,\\nfinely illustrated. Cloth, $2.50 net.\\nDr. McFarland has treated the subject in ysteraatic manner, and has succeeded in\\npresenting in a concise and readable form the essentials of bacteriology up to date. Alto-\\ngether, the book is a satisfactory one, and I shall take pleasure in recommending it to the\\nstudents of Trinity College. H. B. Anderson, M.D., Professor of Pathology and Bac-\\nteriology, Trinity Medical College, Toronto.\\nMEIGS ON FEEDING IN INFANCY.\\nFeeding in Early Infancy. By Arthur V. Meigs, M.D. Bound\\nin limp cloth, flush edges, 25 cents net.\\nThis pamphlet is worth many times over its price to the physician. The author s\\nexperiments, and conclusions are original, and have been the means of doing much good.\\nMedical Bulletin.\\nMOORE S ORTHOPEDIC SURGERY.\\nA Manual of Orthopedic Surgery. By James E. Moore, M.D.,\\nProfessor of Orthopedics and Adjunct Professor of Clinical Surgery,\\nUniversity of Minnesota, College of Medicine and Surgery. Octavo\\nvolume of 356 pages, handsomely illustrated. Cloth, $2.50 net.\\nA most attractive work. The illustrations and the care with which the book is adapted\\nto the wants of the general practitioner and the student are worthy of great praise. Chicago\\nMedical Recorder.\\nA very demonstrative work, every illustration of which conveys a lesson. The work is\\na most excellent and commendable one, which we can certainly endorse with pleasure.\\nSt. Louis Medical and Surgical Journal,\\nMORRIS S MATERIA MEDICA AND THERAPEUTICS. Fifth\\nEdition, Revised.\\nEssentials of Materia Medica, Therapeutics, and Prescription\\nWriting. By Henry Morris, M.D., late Demonstrator of Thera-\\npeutics, Jefferson Medical College, Philadelphia; Fellow of the College\\nof Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth,\\n$1.00 interleaved for notes, $1.25.\\n[See Saunders 7 Question- Compends, page 21.]\\nThis work, already excellent in the old edition, has been largely improved by revi-\\nsion. American Practitioner and News.\\nMORRIS, WOLFF, AND POWELL S PRACTICE OF MEDICINE.\\nThird Edition, Revised.\\nEssentials of the Practice of Medicine. By Henry Morris, M.D.,\\nlate Demonstrator of Therapeutics, Jefferson Medical College, Phila-\\ndelphia with an Appendix on the Clinical and Microscopic Examina-\\ntion of Urine, by Lawrence Wolff, M.D. Demonstrator of Chemistry,\\nJefferson Medical College, Philadelphia. Enlarged by some 300 essen-\\ntial formulae collected and arranged by William M. Powell, M.D.\\nPost-octavo, 488 pages. Cloth, $2.00.\\n[See Saunders Question- Co?npends, page 21.]\\nThe teaching is sound, the presentation graphic matter full as can be desired, and\\nstyle attractive. American Practitioner and News.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0793.jp2"}, "780": {"fulltext": "18 Medical Publications of W. B. Saunders.\\nMORTEN S NURSES DICTIONARY.\\nNurse s Dictionary of Medical Terms and Nursing Treat-\\nment. Containing Definitions of the Principal Medical and Nursing\\nTerms and Abbreviations of the Instruments, Drugs, Diseases, Acci-\\ndents, Treatments, Operations, Foods, Appliances, etc. encountered\\nin the ward or in the sick-room. By Honnor Morten, author of\\nHow to Become a Nurse, etc. 161110, 140 pages. Cloth, $1.00.\\nA handy, compact little volume, containing a large amount of general information, all\\nof which is arranged in dictionary or encyclopedic form, thus facilitating quick reference.\\nIt is certainly of value to those for whose use it is published. Chicago Clinical Review.\\nNANCREDE S ANATOMY. Sixth Edition, Thoroughly Revised.\\nEssentials of Anatomy, including the Anatomy of the Viscera.\\nBy Charles B. Nancrede, M.D., LL.D., Professor of Surgery and\\nof Clinical Surgery in the University of Michigan, Ann Arbor. Crown\\noctavo, 420 pages; 151 illustrations. Based upon Gray s Anatomy.\\nCloth, $1.00 net; interleaved for notes, $1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nFor self-quizzing and keeping fresh in mind the knowledge of anatomy gained at\\nschool, it would not be easy to speak of it in terms too favorable. American Practitioner.\\nNANCREDE S ANATOMY AND DISSECTION. Fourth Edition.\\nEssentials of Anatomy and Manual of Practical Dissection.\\nBy Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of\\nClinical Surgery, University of Michigan, Ann Arbor. Post-octavo\\n500 pages, with full-page lithographic plates in colors, and nearly 200\\nillustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net.\\nIt may in many respects be considered an epitome of Gray s popular work on general\\nanatomy, at the same time having some distinguishing characteristics of its own to commend\\nit. The plates are of more than ordinary excellence, and are of especial value to students\\nin their work in the dissecting room. Journal of the American Medical Association.\\nNORRIS S SYLLABUS OF OBSTETRICS. Third Edition, Revised.\\nSyllabus of Obstetrical Lectures in the Medical Department\\nof the University of Pennsylvania. By Richard C. Norris,\\nA.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania.\\nCrown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net.\\nThis work is so far superior to others on the same subject that we take pleasure in\\ncalling attention briefly to its excellent features. It covers the subject thoroughly, and will\\nprove invaluable both to the student and the practitioner. Medical Record, New York.\\nPENROSE S DISEASES OF WOMEN. Second Edition, Revised.\\nA Text=Book of Diseases of Women. By Charles B. Penrose,\\nM.D., Ph.D., Professor of Gynecology in the University of Pennsyl-\\nvania Surgeon to the Gynecean Hospital, Philadelphia. Octavo\\nvolume of 529 pages, handsomely illustrated. Cloth, $3.50 net.\\nI shall value very highly the copy of Penrose s Diseases of Women received.\\nI have already recommended it to my class as THE BEST book. Howard A. Kelly,\\nProfessor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md.\\nThe book is to be commended without reserve, not only to the student but to the\\ngeneral practitioner who wishes to have the latest and best modes of treatment explained\\nwith absolute clearness. Therapeutic Gazette.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0794.jp2"}, "781": {"fulltext": "Medical Publications of W. B. Saunders. 19\\nPOWELL S DISEASES OF CHILDREN. Second Edition.\\nEssentials of Diseases of Children. By William M. Powell,\\nM.D., Attending Physician to the Mercer House for Invalid Women\\nat Atlantic City, N. J. late Physician to the Clinic for the Diseases of\\nChildren in the Hospital of the University of Pennsylvania. Crown\\noctavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nContains the gist of all the best works in the department to which it relates.\\nAmerican Practitioner and News.\\nPRINGLE S SKIN DISEASES AND SYPHILITIC AFFECTIONS.\\nPictorial Atlas of Skin Diseases and Syphilitic Affections\\n(American Edition). Translation from the French. Edited by\\nJ. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex\\nHospital, London. Photo-lithochromes from the famous models in\\nthe Museum of the Saint-Louis Hospital, Paris, with explanatory wood-\\ncuts and text. In 12 Parts. Price per Part, $3.00. Complete in\\none volume, Half Morocco binding, $40.00 net.\\nI strongly recommend this Atlas. The plates are exceedingly well executed, and\\nwill be of great value to all studying dermatology. Stephen Mackenzie, M.D.\\nThe introduction of explanatory wood-cuts in the text is a novel and most important\\nfeature which greatly furthers the easier understanding of the excellent plates, than which\\nnothing, we venture to say, has been seen better in point of correctness, beauty, and general\\nmerit. New York Medical Journal.\\nPRYOR\u00e2\u0080\u0094 PELVIC INFLAMMATIONS.\\nThe Treatment of Pelvic Inflammations through the Vagina.\\nBy W. R. Pryor, M.D., Professor of Gynecology in New York Poly-\\nclinic. i2mo, 248 pages, handsomely illustrated. Cloth, $2.00 net.\\nThis subject, which has recently been so thoroughly canvassed in high gynecological\\ncircles, is made available in this volume to the general practitioner and student. Nothing is\\ntoo minute for mention and nothing is taken for granted consequently the book is of the utmost\\nvalue. The illustrations and the technique are beyond criticism. Chicago Medical Recorder.\\nPYE S BANDAGING.\\nElementary Bandaging and Surgical Dressing. With Direc-\\ntions concerning the Immediate Treatment of Cases of Emergency.\\nFor the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late\\nSurgeon to St. Mary s Hospital, London. Small i2mo, with over 80\\nillustrations. Cloth, flexible covers, 75 cents net.\\nThe directions are clear and the illustrations are good. London Lancet.\\nThe author writes well, the diagrams are clear, and the book itself is small and port-\\nable, although the paper and type are good. British Medical Journal.\\nRAYMOND S PHYSIOLOGY.\\nA Manual of Physiology. By Joseph H. Raymond, A.M., M.D.,\\nProfessor of Physiology and Hygiene and Lecturer on Gynecology in\\nthe Long Island College Hospital Director of Physiology in the\\nHoagland Laboratory, etc. 382 pages, with 102 illustrations in the\\n.text, and 4 full-page colored plates. Cloth, $1.25 net.\\nExtremely well gotten up, and the illustrations have been selected with care The\\ntext is fully abreast with modern physiology. \u00e2\u0080\u0094British Medical Journal.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0795.jp2"}, "782": {"fulltext": "\u00e2\u0096\u00baAUNDERS\\nQuestion\\nArranged in Question and\\nAnswer Form*\\nHTHE MOST COMPLETE AND BEST\\nPn^IDnMnc illustrated series of\\nV^UlVlX\\\\ClN.Uo COMPENDS EVER ISSUED.\\nNow the Standard Authorities in Medical Literature\\nwith Students and Practitioners in every City of the United States and Canada.\\no-\\no-\\nOVER 175,000 COPIES SOLD.\\nTHE REASON WHY.\\nThey are the advance guard of Student s Helps that DO HELP. They are the\\nleaders in their special line, well and authoritatively written by able men, who, as teachers in\\nthe large colleges, know exactly what is wanted by a student preparing for his examinations.\\nThe judgment exercised in the selection of authors is fully demonstrated by their professional\\nstanding. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of\\nthem have become Professors and Lecturers in their respective colleges.\\nEach book is of convenient size (5x7 inches) containing on an average 250 pages,\\nprofusely illustrated, and elegantly printed in clear, readable type, on fine paper.\\nThe entire series, numbering twenty-three volumes, has been kept thoroughly revised\\nand enlarged when necessary, many of the books being in their fifth and sixth editions.\\nTO SUM UP.\\nAlthough there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of\\nthem approach the Blue Series of Question Compends; and the claim is made for the\\nfollowing points of excellence\\n1. Professional distinction and reputation of authors.\\n2. Conciseness, clearness, and soundness of treatment.\\n3. Quality of illustrations, paper, printing, and binding.\\nAny cf these Compends will be mailed on receipt of price (see next page for List).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0796.jp2"}, "783": {"fulltext": "Saunders Question-Compend Oeries,\\nPrice, Cloth, $J.OO per copy, except when otherwise noted.\\nWhere the work of preparing students manuals is to end we cannot say, but the\\nSaunders Series, in our opinion, bears off the palm at present. New York Medical Record.\\n1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition,\\nrevised and enlarged. ($1.00 net.)\\n2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition,\\nrevised, with an Appendix on Antiseptic Surgery.\\n3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Sixth\\nedition, thoroughly revised and enlarged. ($i.oo net.)\\n4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.\\nBy Lawrence Wolff, M.D. Fifth edition, revised. ($i.oo net.)\\n5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth\\nedition, revised and enlarged.\\n6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.\\nArmand Semple, M.D.\\n7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-\\nSCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised.\\n8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris,\\nM.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D.\\nThird edition, enlarged by some 300 Essential Formulae, selected from eminent\\nauthorities, by Wm. M. Powell, M.D. (Double number, $2.00.)\\n10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth\\nedition, revised.\\n1 1 ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon,\\nM.D. Fourth edition, revised and enlarged. ($1.00 net.)\\n12. ESSENTIALS OF MINOR SURGERY, BANDAGiNG, AND VENEREAL\\nDISEASES. By Edward Martin, M.D. Second ed., revised and enlarged.\\n13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.\\nBy C. E. Armand Semple, M.D.\\n14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT.\\nBy Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised.\\n15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell,\\nM.D. Second edition.\\n16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff,\\nM.D. Colored Vogel Scale. (75 cents.)\\n17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner,\\nM.D. ($1.50 net.)\\n18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre.\\nSecond edition, revised and enlarged.\\n20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition,\\nrevised.\\n21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C.\\nShaw, M. D. Third edition, revised.\\n22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.\\nSecond edition, revised. ($1.00 net.)\\n23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,\\nand Edward S. Lawrance, M.D.\\n24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D.\\nSecond edition, revised and greatly enlarged.\\nPamphlet containing specimen pages, etc. sent free upon application.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0797.jp2"}, "784": {"fulltext": "Saunders\\nfor Students\\nNew Series and\\nof Manuals Practitioners\\n^T^HAT there exists a need for thoroughly reliable hand-books on the leading branches\\nof Medicine and Surgery is a fact amply demonstrated by the favor with which\\nthe SAUNDERS NEW SERIES OF MANUALS have been received by medical\\nstudents and practitioners and by the Medical Press. These manuals are not merely\\ncondensations from present literature, but are ably written by well-known authors\\nand practitioners, most of them being teachers in representative American colleges.\\nEach volume is concisely and authoritatively written and exhaustive in detail, without\\nbeing encumbered with the introduction of cases, which so largely expand the\\nordinary text-book. These manuals will therefore form an admirable collection of\\nadvanced lectures, useful alike to the medical student and the practitioner: to the\\nlatter, too busy to search through page after page of elaborate treatises for what he\\nwants to know, they will prove of inestimable value to the former they will afford\\nsafe guides to the essential points of study.\\nThe SAUNDERS NEW SERIES OF MANUALS are conceded to be superior\\nto any similar books now on the market. No other manuals afford so much infor-\\nmation in such a concise and available form. A liberal expenditure has enabled the\\npublisher to render the mechanical portion of the work worthy of the high literary\\nstandard attained by these books.\\nAny of these Manuals will be mailed on receipt of price (see next page for List).", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0798.jp2"}, "785": {"fulltext": "Saunders New Series of Manuals*\\nVOLUMES PUBLISHED.\\nPHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology\\nand Hygiene and Lecturer on Gynecology in the Long Island College Hospital\\nDirector of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net.\\nSURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini-\\ncal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the\\nPhiladelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged.\\nOctavo, 911 pages, profusely illustrated. Cloth, $4.00 net Half Morocco, $5.00 net.\\nDOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q.\\nThornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-\\ndelphia. Illustrated. Cloth, $1.25 net.\\nSURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark s Hospital and\\nto the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net.\\nMEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti-\\ntutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila-\\ndelphia. Illustrated. Cloth, $1.50 net.\\nSYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,\\nProfessor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D.,\\nLecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College,\\nChicago. Profusely illustrated. Cloth, $2.50 net.\\nPRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of\\nPractice in the Woman s Medical College of the New York Infirmary Instructor in\\nPhysical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.\\nCloth, $2.50 net.\\nMANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of\\nAnatomy and Demonstrator of Anatomy, Medical Department of the New York\\nUniversity, etc. Beautifully illustrated. Cloth, $2.50 net.\\nMANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant\\nDemonstrator of Obstetrics, University of Pennsylvania Chief of Gynecological Dis-\\npensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net.\\nDISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to\\nMiddlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E.\\nGiles, M.D. B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital,\\nLondon. Handsomely illustrated. Cloth, $2.50 net.\\nVOLUMES IN PREPARATION.\\nNERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous\\nDiseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic\\nHospital and Infirmary for Nervous Diseases Visiting Physician to the St. Joseph\\nHospital, etc.\\nThere will be published in the same series, at short intervals, carefully-prepared works\\non various subjects by prominent specialists.\\nPamphlet containing specimen pages, etc. sent free upon application*", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0799.jp2"}, "786": {"fulltext": "24 Medical Publications of W. B. Saunders,\\nSAUNDBY S RENAL AND URINARY DISEASES.\\nLectures on Renal and Urinary Diseases. By Robert Saundby,\\nM.D. Edin., Fellow of the Royal College of Physicians, London, and\\nof the Royal Medico-Chirurgical Society Physician to the General\\nHospital Consulting Physician to the Eye Hospital and to the Hos-\\npital for Diseases of Women Professor of Medicine in Mason College,\\nBirmingham, etc. Octavo volume of 434 pages, with numerous illus-\\ntrations and 4 colored plates. Cloth, $2.50 net.\\nThe volume makes a favorable impression at once. The style is clear and succinct.\\nWe cannot find any part of the subject in which the views expressed are not carefully thought\\nout and fortified by evidence drawn from the most recent sources. The book may be cordially\\nrecommended. British Medical Journal.\\nSAUNDERS MEDICAL HAND=ATLASES.\\nThis series of books consists of authorized translations into English of\\nthe world-famous Lehmann Medicinische Handatlanten. Each\\nvolume contains from 50 to 100 colored lithographic plates, besides\\nnumerous illustrations in the text. There is a full description of each-\\nplate, and each book contains a condensed but adequate outline of the\\nsubject to which it is devoted. For full description of this series, with\\nlist of volumes and prices, see page 2.\\nLehmann Medicinische Handatlanten belong to that class of books that are too good\\nto be appropriated by any one nation. Journal of Eye, Ear, and Throat Diseases.\\nThe appearance of these works marks a new era in illustrated English medical\\nworks. The Canadian Practitioner.\\nSAUNDERS POCKET MEDICAL FORMULARY. Fifth Edition,\\nRevised.\\nBy William M. Powell, M.D., Attending Physician to the Mercer\\nHouse for Invalid Women at Atlantic City, N. J. Containing 1800\\nformulae selected from the best-known authorities. With an Appen-\\ndix containing Posological Table, Formulae and Doses for Hypo-\\ndermic Medication, Poisons and their Antidotes, Diameters of the\\nFemale Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various\\nDiseases, Materials and Drugs used in Antiseptic Surgery, Treatment\\nof Asphyxia from Drowning, Surgical Remembrancer, Tables of\\nIncompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-\\nsomely bound in flexible morocco, with side index, wallet, and flap.\\n$1.75 net.\\nThis little book, that can be conveniently carried in the pocket, contains an immense\\namount of material. It is very useful, and, as the name of the author of each prescription\\nis given, is unusually reliable. Medical Record, New York.\\nSAYRE S PHARMACY. Second Edition, Revised.\\nEssentials of the Practice of Pharmacy. By Lucius E. Sayre,\\nM.D., Professor of Pharmacy and Materia Medica in the University of\\nKansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for\\nnotes, $1.25.\\n[See Saunders 1 Question- Compends, page 21.]\\nThe topics are treated in a simple, practical manner, and the work forms a very useful\\nStudent s manual. Boston Medical and Surgical Journal.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0800.jp2"}, "787": {"fulltext": "Medical Publications of W. B. Saunders. 25\\nSEMPLE S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.\\nEssentials of Legal Medicine, Toxicology, and Hygiene. By\\nC. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond.,\\nPhysician to the Northeastern Hospital for Children, Hackney, etc.\\nCrown octavo, 2 1 2 pages 130 illustrations. Cloth, $1.00; interleaved\\nfor notes, #1.25.\\n[See Saunders Question- Compends, page 21.]\\nNo general practitioner or student can afford to be without this valuable work. The\\nsubjects are dealt with by a masterly hand. London Hospital Gazette.\\nSEMPLE S PATHOLOGY AND MORBID ANATOMY.\\nEssentials of Pathology and Morbid Anatomy. By C. E.\\nArmand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to\\nthe Northeastern Hospital for Children, Hackney, etc. Crown octavo,\\n174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nShould take its place among the standard volumes on the bookshelf of both student\\nand practitioner. London Hospital Gazette.\\nSENN S GENITOURINARY TUBERCULOSIS.\\nTuberculosis of the Genito=Urinary Organs, Male and Female.\\nBy Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of\\nSurgery and of Clinical Surgery, Rush Medical College, Chicago.\\nHandsome octavo volume of 320 pages, illustrated. Cloth, $3. 00 net.\\nAn important book upon an important subject, and written by a man of mature judg-\\nment and wide experience. The author has given us an instructive book upon one of the\\nmost important subjects of the day. Clinical Reporter.\\nA work which adds another to the many obligations the profession owes the talented\\nauthor. Chicago Medical Recorder.\\nSENN S SYLLABUS OF SURGERY.\\nA Syllabus of Lectures on the Practice of Surgery, arranged\\nin conformity with An American Text=Book of Surgery. By\\nNicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and\\nof Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00.\\nThis syllabus will be found of service by the teacher as well as the student, the work\\nbeing superbly done. There is no praise too high for it. No surgeon should be without\\nit. New York Medical Times.\\nSENN S TUMORS.\\nPathology and Surgical Treatment of Tumors. By N. Senn,\\nM.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery,\\nRush Medical College Professor of Surgery, Chicago Polyclinic\\nAttending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St.\\nJoseph s Hospital, Chicago. Octavo volume of 710 pages, with 515\\nengravings, including full-page colored plates. New and Revised Edi-\\ntion in Preparation.\\nThe most exhaustive of any recent book in English on this subject. It is well illus-\\ntrated, and will doubtless remain as the principal monograph on the subject in our language\\nfor some years. The book is handsomely illustrated and printed, and the author has given a\\nnotable and lasting contribution to surgery. Journal of the American Medical Association.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0801.jp2"}, "788": {"fulltext": "26 Medical Publications of W. B. Saunders.\\nSHAW S NERVOUS DISEASES AND INSANITY. Third Edition,\\nRevised.\\nEssentials of Nervous Diseases and Insanity. By John C.\\nShaw, M.D., Clinical Professor of Diseases of the Mind and Nervous\\nSystem, Long Island College Hospital Medical School Consulting\\nNeurologist to St. Catherine s Hospital and to the Long Island College\\nHospital. Crown octavo, 186 pages; 48 original illustrations. Cloth,\\n#1.00 interleaved for notes, $1.25.\\n[See Saunders Question- Compends, page 21.]\\nClearly and intelligently written. Boston Medical and Surgical Journal.\\nThere is a mass of valuable material crowded into this small compass. American\\nMedico- Surgical Bulletin.\\nSTARR S DIETS FOR INFANTS AND CHILDREN.\\nDiets for Infants and Children in Health and in Disease. By\\nLouis Starr, M.D., Editor of An American Text-Book of the\\nDiseases of Children. 230 blanks (pocket-book size), perforated\\nand neatly bound in flexible morocco. $1.25 net.\\nThe first series of blanks are prepared for the first seven months of infant life each\\nblank indicates the ingredients, but not the quantities, of the food, the latter directions being\\nleft for the physician. After the seventh month, modifications being less necessary, the diet\\nlists are printed in full. Formulae for the preparation of diluents and foods- are appended.\\nSTELW AGON S DISEASES OF THE SKIN. Fourth Ed., Revised.\\nEssentials of Diseases of the Skin. By Henry W. Stelwagon,\\nM.D., Clinical Professor of Dermatology in the Jefferson Medical\\nCollege, Philadelphia Dermatologist to the Philadelphia Hospital\\nPhysician to the Skin Department of the Howard Hospital, etc.\\nCrown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter-\\nleaved for notes, $1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nThe best student s manual on skin diseases we have yet seen. Times and Register.\\nSTENGEL S PATHOLOGY. Second Edition.\\nA Text=Book of Pathology. By Alfred Stengel, M.D., Professor\\nof Clinical Medicine in the University of Pennsylvania Physician to\\nthe Philadelphia Hospital Physician to the Children s Hospital, etc.\\nHandsome octavo volume of 848 pages, with nearly 400 illustrations,\\nmany of them in colors. Cloth, $4.00 net; Half Morocco, $5.00\\nnet.\\nSTEVENS MATERIA MEDICA AND THERAPEUTICS. Second\\nEdition, Revised.\\nA Manual of Materia Medica and Therapeutics. By A. A.\\nStevens, A.M., M.D., Lecturer on Terminology and Instructor in\\nPhysical Diagnosis in the University of Pennsylvania; Professor of\\nPathology in the Woman s Medical College of Pennsylvania. Post-\\noctavo, 445 pages. Flexible leather, $2.25.\\nThe author has faithfully presented modern therapeutics in a comprehensive work,\\nand, while intended particularly for the use of students, it will be found a reliable guide and\\nsufficiently comprehensive for the physician in practice. University Medical Magazine.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0802.jp2"}, "789": {"fulltext": "Medical Publications of W. B. Saunders. 27\\nSTEVENS PRACTICE OF MEDICINE. Fifth Edition, Revised.\\nA Manual of the Practice of Medicine. By A. A. Stevens, A. M.,\\nM. D., Lecturer on Terminology and Instructor in Physical Diagnosis\\nin the University of Pennsylvania Professor of Pathology in the\\nWoman s Medical College of Pennsylvania. Specially intended for\\nstudents preparing for graduation and hospital examinations. Post-\\noctavo, 519 pages; illustrated. Flexible leather, $2.00 net.\\nThe frequency with which new editions of this manual are demanded bespeaks its\\npopularity. It is an excellent condensation of the essentials of medical practice for the\\nstudent, and maybe found also an excellent reminder for the busy physician. Buffalo\\nMedical Journal.\\nSTEWART S PHYSIOLOGY. Third Edition, Revised.\\nA Manual of Physiology, with Practical Exercises. For\\nStudents and Practitioners. By G. N. Stewart, M.A., M.D.,\\nD.Sc, lately Examiner in Physiology, University of Aberdeen, and\\nof the New Museums, Cambridge University Professor of Physiology\\nin the Western Reserve University, Cleveland, Ohio. Octavo volume\\nof 848 pages; 300 illustrations in the text, and 5 colored plates.\\nCloth, $3.75 net.\\nIt will make its way by sheer force of merit, and amply deserves to do so. It is one\\nof the very best English text-books on the subject. London Lancet.\\nOf the many text-books of physiology published, we do not know of one that so\\nnearly comes up to the ideal as does Prof. Stewart s volume. British Medical Journal.\\nSTEWART AND LAWRANCE S MEDICAL ELECTRICITY.\\nEssentials of Medical Electricity. By D. D. Stewart, M.D.,\\nDemonstrator of Diseases of the Nervous System and Chief of the\\nNeurological Clinic in the Jefferson Medical College; and E. S.\\nLawrance, M.D., Chief of the Electrical Clinic and Assistant Demon-\\nstrator of Diseases of the Nervous System in the Jefferson Medical\\nCollege, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,\\n1 1. 00; interleaved for notes, $1.25.\\n[See Saunders 1 Question- Compends, page 21.]\\nThroughout the whole brief space at their command the authors show a discriminating\\nknowledge of their subject. Medical News.\\nSTONEY S NURSING. Second Edition, Revised.\\nPractical Points in Nursing. For Nurses in Private Practice.\\nBy Emily A. M. Stoney, Graduate of the Training-School for Nurses,\\nLawrence, Mass.; late Superintendent of the Training-School for\\nNurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated\\nwith 73 engravings in the text, and 8 colored and half-tone plates.\\nCloth, $1.75 net.\\nThere are few books intended for non-profess-ional readers which can be so cordially\\nendorsed by a medical journal as can this one. Therapeutic Gazette.\\nThis is a well-written, eminently practical volume, which covers the entire range of\\nprivate nursing as distinguished from hospital nursing, and instructs the nurse how best to\\nmeet the various emergencies which may arise, and how to prepare everything ordinarily\\nneeded in the illness of her patient. American Journal of Obstetrics and Diseases of\\nWomen and Children.\\nIt is a work that the physician can place in the hands of his private nurses with the\\nassurance of benefit. Ohio Medical Journal,", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0803.jp2"}, "790": {"fulltext": "28 Medical Publications of W. B. Saunders.\\nSTONEY S MATERIA MEDICA FOR NURSES.\\nMateria Medica for Nurses. By Emily A. M. Stoney, Graduate of\\nthe Training-School for Nurses, Lawrence, Mass. late Superintendent\\nof the Training-School for Nurses, Carney Hospital, South Boston, Mass.\\nHandsome octavo volume of 306 pages. Cloth, $1.50 net.\\nThe present book differs from other similar works in several features, all of which are\\nintended to render it more practical and generally useful. The general plan of the contents\\nfollows the lines laid down in training-schools for nurses, but the book contains much use-\\nful matter not usually included in works of this character, such as Poison-emergencies,\\nReady Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms\\nused in Materia Medica, and describing all the latest drugs and remedies, which have been\\ngenerally neglected by other books of the kind.\\nSUTTON AND GILES DISEASES OF WOMEN.\\nDiseases of Women. By J. Bland Sutton, F.R.C.S., Assistant\\nSurgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital,\\nLondon; and Arthur E. Giles, M.D., B.Sc. Lond. F.R.C.S. Edin.,\\nAssistant Surgeon to Chelsea Hospital, London. 436 pages, hand-\\nsomely illustrated. Cloth, #2.50 net.\\nThe text has been carefully prepared. Nothing essential has been omitted, and its\\nteachings are those recommended by the leading authorities of the day. Journal of the\\nAmerican Medical Association.\\nTHOMAS S DIET LISTS AND SICK=ROOM DIETARY.\\nDiet Lists and Sick=Room Dietary. By Jerome B. Thomas,\\nM.D., Visiting Physician to the Home for Friendless Women and\\nChildren and to the Newsboys Home Assistant Visiting Physician\\nto the Kings County Hospital. Cloth, $1.50. Send for sample sheet.\\nTHORNTON S DOSE=BOOK AND PRESCRIPTION=WRITING.\\nDose=Book and Manual of Prescription=Writing. By E. Q.\\nThornton, M.D., Demonstrator of Therapeutics, Jefferson Medical\\nCollege, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net.\\nFull of practical suggestions; will take its place in the front rank of works of this\\nsort. Medical Record, New York.\\nVAN VALZAH AND NISBET S DISEASES OF THE STOMACH.\\nDiseases of the Stomach. By William W. Van Valzah, M.D.,\\nProfessor of General Medicine and Diseases of the Digestive System\\nand the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D.,\\nAdjunct Professor of General Medicine and Diseases of the Digestive\\nSystem and the Blood, New York Polyclinic. Octavo volume of 674\\npages, illustrated. Cloth, $3.50 net.\\nIts chief claim lies in its clearness and general adaptability to the practical needs of\\nthe general practitioner or student. In these relations it is probably the best of the recent\\nspecial works on diseases of the stomach. Chicago Clinical Review.\\nVECKI S SEXUAL IMPOTENCE.\\nThe Pathology and Treatment of Sexual Impotence. By Victor\\nG. Vecki, M.D. From the second German edition, revised and en-\\nlarged. Demi-octavo, about 300 pages. Cloth, $2.00 net.\\nThe subject of impotence has seldom been treated in this country in the truly scientific\\nspirit that it deserves. Dr. Vecki s work has long been favorably known, and the German\\nbook has received the highest consideration. This edition is more than a mere translation,\\nfor, although based on the German edition, it has been entirely rewritten in English.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0804.jp2"}, "791": {"fulltext": "Medical Publications of W. B. Saunders. 29\\nVIERORDT S MEDICAL DIAGNOSIS. Fourth Edition, Revised.\\nMedical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi-\\ncine at the University of Heidelberg. Translated, with additions,\\nfrom the fifth enlarged German edition, with the author s permission,\\nby Francis H. Stuart, A. M., M. D. Handsome royal octavo volume\\nof 603 pages; 194 fine wood-cuts in text, many of them in colors.\\nCloth, $4.00 net; Sheep or Half Morocco, $5.00 net.\\nA treasury of practical information which will be found of daily use to every busy\\npractitioner who will consult it. C. A. LiNDSLEY, M.D., Professor of the Theory and\\nPractice of Medicine, Yale University.\\nRarely is a book published with which a reviewer can find so little fault as with the\\nvolume before us. Each particular item in the consideration of an organ or apparatus, which\\nis necessary to determine a diagnosis of any disease of that organ, is mentioned nothing\\nseems forgotten. The chapters on diseases of the circulatory and digestive apparatus and\\nnervous system are especially full and valuable. The reviewer would repeat that the book is\\none of the best probably the best which has fallen into his hands. University Medical\\nMagazine.\\nWARREN S SURGICAL PATHOLOGY AND THERAPEUTICS.\\nSurgical Pathology and Therapeutics. By John Collins Warren,\\nM.D., LL.D., Professor of Surgery, Medical Department Harvard\\nUniversity; Surgeon to the Massachusetts General Hospital, etc.\\nHandsome octavo volume of 832 pages; 136 relief and lithographic\\nillustrations, 33 of which are printed in colors, and all of which were\\ndrawn by William J. Kaula from original specimens. Revised and\\nEnlarged Edition in Preparation.\\nThere is the work of Dr. Warren, which I think is the most creditable book on\\nSurgical Pathology, and the most beautiful medical illustration of the bookmaker s art, that\\nhas ever been issued from the American press. Dr. Roswell Park, in the Harvard\\nGraduate Magazine.\\nThe handsomest specimen of bookmaking that has ever been issued from the American\\nmedical press. American Journal of the Medical Sciences.\\nA most striking and very excellent feature of this book is its illustrations. Without\\nexception, from the point of accuracy and artistic merit, they are the best ever seen in a work\\nof this kind. Many of those representing microscopic pictures are so perfect in their coloring\\nand detail as almost to give the beholder the impression that he is looking down the barrel\\nof a microscope at a well-mounted section. Annals of Surgery.\\nWOLFF ON EXAMINATION OF URINE.\\nEssentials of Examination of Urine. By Lawrence Wolff, M.D.,\\nDemonstrator of Chemistry, Jefferson Medical College, Philadelphia,\\netc. Colored (Vogel) urine scale and numerous illustrations. Crown\\noctavo. Cloth, 75 cents.\\n[See Saunders Question- Comf ends, page 21.]\\nA very good work of its kind very well suited to its purpose. Times and Register.\\nWOLFF S MEDICAL CHEMISTRY. Fifth Edition, Revised.\\nEssentials of Medical Chemistry, Organic and Inorganic.\\nContaining also Questions on Medical Physics, Chemical Physiology,\\nAnalytical Processes, Urinalysis, and Toxicology. By Lawrence\\nWolff, M.D., Demonstrator of Chemistry, Jefferson Medical College,\\nPhiladelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter-\\nleaved for notes, $1.25 net.\\n[See Saunders Question- Comf ends, page 21.]\\nThe scope of this work is certainly equal to that of the best course o\\\\ lectures on\\nMedical Chemistry. Pharmaceutical Era.", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0805.jp2"}, "792": {"fulltext": "CLASSIFIED LIST\\nMedical Publications\\nOF\\nW. B, SAUNDERS,\\n925 Walnut Street, Philadelphia.\\nANATOMY, EMBRYOLOGY,\\nHISTOLOGY.\\nClarkson A Text-Book of Histology, 9\\nHaynes A Manual of Anatomy, 13\\nHeisler A Text- Book of Embryology, 13\\nNancrede Essentials of Anatomy, 18\\nNancrede Essentials of Anatomy and\\nManual of Practical Dissection, 18\\nSemple Essentials of Pathology and\\nMorbid Anatomy, 25\\nBACTERIOLOGY.\\nBall Essentials of Bacteriology, 6\\nCrookshank A Text- Book of Bacteri-\\nology, 10\\nFrothingham\u00e2\u0080\u0094 Laboratory Guide, II\\nMallory and Wright Pathological\\nTechnique, 16\\nMcFarland Pathogenic Bacteria, 17\\nCHARTS, DIET-LISTS, ETC.\\nGriffith Infant s Weight Chart, 12\\nHart Diet in Sickness and in Health, 13\\nKeen Operation Blank, 15\\nLaine Temperature Chart 15\\nMeigs Feeding in Early Infancy, 17\\nStarr Diets for Infants and Children, 26\\nThomas Diet-Lists and Sick-Room\\nDietary, 28\\nCHEMISTRY AND PHYSICS.\\nBrockway Essentials of Medical Phys-\\nics, 7\\nWolff Essentials of Medical Chemistry, 29\\nCHILDREN.\\nAn American Text-Book of Diseases\\nof Children, 3\\nGriffith Care of the Baby, 12\\nGriffith Infant s Weight Chart, 12\\nMeigs Feeding in Early Infancy, 17\\nPowell\u00e2\u0080\u0094 Essentials of Dis. of Children, 19\\nStarr Diets for Infants and Children, 26\\nDIAGNOSIS.\\nCohen and Eshner\u00e2\u0080\u0094 Essentials of Di-\\nagnosis, 9\\nCorwin Physical Diagnosis, 9\\nMacdonald Surgical Diagnosis and\\nTreatment, 16\\nVierordt Medical Diagnosis, 29\\nDICTIONARIES.\\nDorland Pocket Dictionary, 10\\nKeating Pronouncing Dictionary, 14\\nMorten Nurse s Dictionary, 18\\nEYE, EAR, NOSE, AND THROAT.\\nAn American Text- Book of Diseases\\nof the Eye, Ear, Nose, and Throat, 3\\nDe Schweinitz Diseases of the Eye, 10\\nGleason Essentials of Dis. of the Ear, 1 1\\nJackson Manual of Diseases of Eye, 32\\nJackson and Gleason Essentials of\\nDiseases of the Eye, Nose, and Throat, 14\\nKyle Diseases of the Nose and Throat, 15\\nGENITOURINARY.\\nAn American Text-Book of Genito-\\nurinary and Skin Diseases, 4\\nHyde and Montgomery Syphilis and\\nthe Venereal Diseases, 13\\nMartin Essentials of Minor Surgery,\\nBandaging, and Venereal Diseases, 16\\nSaundby Renal and Urinary Diseases, 24\\nSenn Genito-Urinary Tuberculosis, 25\\nVecki Sexual Impotence, 28\\nGYNECOLOGY.\\nAmerican Text- Book of Gynecology, 4\\nCragin Essentials of Gynecology, 9\\nGarrigues Diseases of Women, 11\\nLong Syllabus of Gynecology, 15\\nPenrose\u00e2\u0080\u0094 Diseases of Women, 18\\nPryor Pelvic Inflammations, 32\\nSutton and Giles Diseases of Women, 28\\nMATERIA MEDICA, PHARMACOL-\\nOGY, AND THERAPEUTICS.\\nAn American Text-Book of Applied\\nTherapeutics, 3\\nButler Text-Book of Materia Medica,\\nTherapeutics and Pharmacology, 8\\nCerna Notes on the Newer Remedies, 8\\nGriffin Materia Med. and Therapeutics, 12\\nMorris Essentials of Materia Medica\\nand Therapeutics, 17\\nSaunders Pocket Medical Formulary, 24\\nSayre Essentials of Pharmacy, 24\\nStevens Essentials of Materia Medica\\nand Therapeutics, 26\\nStoney Materia Medica for Nurses, 28\\nThornton Dose- Book and Manual of\\nPrescription-Writing, 28\\nMEDICAL JURISPRUDENCE AND\\nTOXICOLOGY.\\nChapman Medical Jurisprudence and\\nToxicology, 8\\nSemple Essentials of Legal Medicine,\\nToxicology, and Hygiene, 25", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0806.jp2"}, "793": {"fulltext": "Medical Publications of W. B. Saunders.\\n31\\nNERVOUS AND MENTAL\\nDISEASES, ETC.\\nBurr Nervous Diseases,\\nChapin Compendium of Insanity,\\nChurch and Peterson\u00e2\u0080\u0094 Nervous and\\nMental Diseases,\\nShaw\u00e2\u0080\u0094 Essentials of Nervous Diseases\\nand Insanity,\\nNURSING.\\nAn American Text-Book of Nursing,\\nGriffith\u00e2\u0080\u0094 The Care of the Baby,\\nHampton\u00e2\u0080\u0094 Nursing,\\nHart Diet in Sickness and in Health,\\nMeigs\u00e2\u0080\u0094 Feeding in Early Infancy,\\nMorten\u00e2\u0080\u0094 Nurse s Dictionary\\nStoney Materia Medica for Nurses,\\nStoney Practical Points in Nursing,\\nOBSTETRICS.\\nAn American Text-Book of Obstetrics,\\nAshton\u00e2\u0080\u0094 Essentials of Obstetrics,\\nBoisliniere Obstetric Accidents,\\nDorland\u00e2\u0080\u0094 Manual of Obstetrics,\\nHirst Text- Book of Obstetrics,\\nNorris Syllabus of Obstetrics,\\n26\\n29\\n12\\n12\\n13\\n17\\n18\\n28\\n27\\nPATHOLOGY.\\nAn American Text-Book of Pathology, 5\\nMallory and Wright Pathological\\nTechnique, 16\\nSemple Essentials of Pathology and\\nMorbid Anatomy, 25\\nSenn Pathology and Surgical Treat-\\nment of Tumors, 25\\nStengel Text-Book of Pathology, 26\\nWarren Surgical Pathology and Thera-\\npeutics, 29\\nPHYSIOLOGY.\\nAn American Text-Book of Physi-\\nology, 5\\nHare Essentials of Physiology, 13\\nRaymond Manual of Physiology, 19\\nStewart Manual of Physiology, 27\\nPRACTICE OF MEDICINE.\\nAn American Text-Book of the The-\\nory and Practice of Medicine, 5\\nAn American Year-Book of Medicine\\nand Surgery, 6\\nAnders Text-Book of the Practice of\\nMedicine, 6\\nLockwood Manual of the Practice of\\nMedicine, 15\\nMorris Essentials of the Practice of\\nMedicine, 17\\nStevens Manual of the Practice of\\nMedicine, 27\\nSKIN AND VENEREAL.\\nAn American Text-Book of Genito-\\nurinary and Skin Diseases, 3\\nHyde and Montgomery Syphilis and\\nthe Venereal Diseases, 13\\nMartin Essentials of Minor Surgery,\\nBandaging, and Venereal Diseases, 16\\nPringle Pictorial Atlas of Skin Dis-\\neases and Syphilitic Affections, 19\\nStelwagon Essentials of Diseases of\\nthe Skin, 26\\nSURGERY.\\nAn American Text-Book of Surgery, 5\\nAn American Year-Book of Medicine\\nand Surgery, 6\\nBeck Manual of Surgical Asepsis, 7\\nDaCosta Manual of Surgery, 10\\nInternational Text-Book of Surgery, 32\\nKeen Operation Blank, 15\\nKeen The Surgical Complications and\\nSequels of Typhoid Fever, 15\\nMacdonald Surgical Diagnosis and\\nTreatment, 16\\nMartin Essentials of Minor Surgery,\\nBandaging, and Venereal Diseases, 16\\nMartin Essentials of Surgery, 16\\nMoore Orthopedic Surgery, 17\\nNancrede Principles of Surgery, 32\\nPye Bandaging and Surgical Dressing, 19\\nRowland and Hedley\u00e2\u0080\u0094 Archives of\\nthe Roentgen Ray, 19\\nSenn Genito-Urinary Tuberculosis, 25\\nSenn Syllabus of Surgery, 25\\nSenn Pathology and Surgical Treat-\\nment of Tumors, 25\\nWarren Surgical Pathology and Ther-\\napeutics, 29\\nURINE AND URINARY DISEASES.\\nSaundby Renal and Urinary Diseases, 24\\nWolff\u00e2\u0080\u0094 Essentials of Examination of\\nUrine, 29\\nMISCELLANEOUS.\\nAbbott Hygiene of Transmissible Dis-\\neases, 32\\nBastin Laboratory Exercises in Bot-\\nany, 7\\nGould and Pyle Anomalies and Curi-\\nosities of Medicine, 11\\nGrafstrom Massage, 12\\nKeating How to Examine for Life\\nInsurance, 14\\nRowland and Hedley Archives of\\nthe Roentgen Ray, 19\\nSaunders Medical Hand-Atlases, 2\\nSaunders New Series of Manuals, 22, 23\\nSaunders Pocket Medical Formulary, 24\\nSaunders Question-Compends, 20, 21\\nSenn Pathology and Surgical Treat-\\nment of Tumors, .25\\nStewart and Lawrance Essentials of\\nMedical Electricity, 27\\nThornton Dose-Book and Manual of\\nPrescription-Writing, 2S\\nVan Valzah and Nisbet\u00e2\u0080\u0094 Diseases of\\nthe Stomach, 28", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0807.jp2"}, "794": {"fulltext": "JUST ISSUED.\\nTHE INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes.\\nBy American and British authors. Edited by J. Collins Warren, M. D., LL.D.,\\nProfessor of Surgery, Harvard Medical School, Boston Surgeon to the Massachusetts\\nGeneral Hospital; and A. Pearce Gould, M S., F. R. C. S., Eng., Lecturer on\\nPractical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical\\nSchool; Surgeon to the Middlesex Hospital, London, England. Vol. I. General\\nSurgery. Handsome octavo volume of 947 pages, with 458 beautiful illustrations in\\nthe text and 9 lithographic plates. Vol. II. Special or Regional Surgery is now in\\npress, and will be ready Jan. 1, 1900. Prices per volume: Cloth, $5.00 net; Half\\nMorocco, $6.00 net.\\nKYLE ON THE NOSE AND THROAT.\\nDiseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro-\\nfessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia Con-\\nsulting Laryngologist, Rhinologist, and Otologist, St. Agnes Hospital. Octavo volume\\nof 646 pages, with over 150 illustrations and 6 lithographic plates. Prices Cloth, $4.00\\nnet; Half Morocco, $5.00 net.\\nPRYOR\u00e2\u0080\u0094 PELVIC INFLAMMATIONS.\\nThe Treatment of Pelvic Inflammations through the Vagina. By W. R.\\nPryor, M. D., Professor of Gynecology in the New York Polyclinic. i2mo volume\\nof 248 pages, handsomely illustrated. Cloth, $2.00 net.\\nABBOTT ON TRANSMISSIBLE DISEASES.\\nThe Hygiene of Transmissible Diseases their Causation, Modes of\\nDissemination, and Methods of Prevention. By C. Abbott, M. D., Pro\\nfessor of Hygiene in the University of Pennsylvania Director of the Laboratory of\\nHygiene. Octavo volume of 311 pages, containing a numbc of charts and maps, and\\nnumerous illustrations. Cloth, $2.00 net.\\nHEISLER S EMBRYOLOGY.\\nA Text=Book of Embryology. By John C. Heis er, M. D., Professor of\\nAnatomy in the Medico-Chirurgical College, Philadelphia. Octavo volume of 405\\npages, with 190 illustrations, 26 in colors. Cloth, $2.50 net.\\nJACKSON\u00e2\u0080\u0094 DISEASES OF THE EYE.\\nA Manual of Diseases of the Eye. By Edward Jacks n, A. M., M. D., some-\\ntime Professor of Diseases of the Eye in the Philadelphia Po. clinic and College for\\nGraduates in Medicine. i2mo volume of over 535 pages, witn 178 beautiful illustra-\\ntions, mostly from drawings by the author.\\nNANCREDE-PRINCIPLES OF SURGERY.\\nLectures on the Principles of Surgery. By Chas. B. Nai crede, M.D., LL.D.,\\nProfessor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor.\\nOctavo volume of 398 pages, illustrated. Cloth, $2.50 net.\\nIN PREPARATION FOR EARLY PUBLICATION.\\nOGDEN\u00e2\u0080\u0094 URINARY ANALYSIS.\\nA Manual of Urinary Analysis. By J. Bergen Ogd*\\\\ t M. D., Assistant in\\nChemistry, Harvard University Medical School.\\nSTONEY\u00e2\u0080\u0094 SURGICAL TECHNIQUE FOR NURSES.\\nSurgical Technique for Nurses. By Emily A. M. Stoney, Graduate of Training\\nSchool for Nurses, Lawrence, Mass.-, late Superintendent 01 Training School for Nurses,\\nCarney Hospital, South Boston, Mass.\\nLRBJL78-", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0808.jp2"}, "795": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0809.jp2"}, "796": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0810.jp2"}, "797": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0811.jp2"}, "798": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0812.jp2"}, "799": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0813.jp2"}, "800": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0814.jp2"}, "801": {"fulltext": "", "height": "4324", "width": "2624", "jp2-path": "pathologysurgic00senn_0815.jp2"}, "802": {"fulltext": "LIBRARY OF CONGRESS\\n111\\n027 325 138 8\\ni3B!B\\nHI\\n^H\\nv;\\n1\\n\u00e2\u0096\u00a0I", "height": "4530", "width": "2964", "jp2-path": "pathologysurgic00senn_0816.jp2"}}