VOL. X. [NEW SERIES.]

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

A REGIONAL STUDY OF TUMORS.*
BY W. L. RODMAN, M. D.
Demonstrator of Surgery, University of Louisville.

My subject, “A Regional Study of Tumors," is certainly a practical one, and one which at times is of interest to all physicians and surgeons.

Important as it is, there is not, it is strange to say, a treatise upon the subject in any language. I wrote to all the publishers of this country for such a book, if there was one, and received the same answer from all of them. I have not, after diligent search, been able to find even so much as an article in a medical journal upon the subject.

If writers would give the same attention to all of the important surgical regions as Dr. S. W. Gross gave to one of them—the mammary gland-order would in time soon come out of what is now little more than chaos. This short paper is simply written in the hope that some one worthier than I, feeling the same interest in the subject, will give it proper elaboration. Statistics are yet to be made. If the recordbooks of all hospitals and college clinics contained a full history of tumors, and the diag tained a full history of tumors, and the diag nosis in each instance, confirmed by a competent microscopist, it would not be long before we could in nearly all instances determine the nature of the neoplasm by the age of the patient, the situation of the growth, etc., before its removal.

Read at the May (1890) meeting of the Kentucky State Medical Society.

No. 3.

Such knowledge would be a blessing to those surgeons who, while skillful with the knife, are not microscopists, and are oftentimes so situated that the aid of one can not be invoked.

The patient is entitled to a reasonably accurate prognosis-the relations often demand it; and no surgeon at all jealous of his reputation will give one, in the majority of instances, without availing himself of every means of diagnosis at hand. One may blindly predict that a tumor of the scalp is a sebaceous cyst, that one growing from the inner condyle of the femur is a sarcoma, and nearly always he will turn out right. The same would, to a less extent, be true of other regions prolific in morbid growths, if proper attention was given them. I begin with the

SCALP.

By far the most common tumors of the scalp are the three forms of cystic tumors, viz., (1) cutaneous sebaceous cysts, (2) congenital dermoid cysts, (3) serous cysts.

1. Of these the first is much the commonest, and is popularly called a "wen." They are single or multiple. Prof. Gross saw a man with more than two hundred. They vary in size from a buckshot to an orange. They are more common in women than in men, 70 out of 107 consecutive cases reported by Bryant being in women. Unquestionably they are hereditary. Sir James Paget says "they are more commonly hereditary than any forms of cancer.” They are more common after thirty years of

age. The scalp over these tumors is either partially or wholly bald. Three fourths of all sebaceous tumors are on the head and face.

2. Congenital dermoid cysts are sufficiently often met with to be of interest. Its favorite site is about the eyebrow, at the outer angle of the orbit; it is also found over the frontal bone,

behind the ear, and over the anterior fontanelle. In the last situation a cyst of this kind has been mistaken for a meningocele cut off from the cranial cavity. They are deeply placed, usually attached to the periosteum, and by prolonged pressure may indent or even perforate the bone. This is especially true of those situated at the outer angle of the orbit.

3. Serous cysts are extremely uncommon. They are, according to Treves, "either (1) congenital, (2) formed from extravasated blood, (3) formed from a meningocele whose connection with the cranial cavity has been cut off." They are unusually small and situated over the occipital region. Billroth saw a cyst of this kind as large as the patient's head.

Vascular Tumors. Next in frequency to the cystic are the various forms of the vascular tumors or nevi. They are by far more common here than in any other situation. According to Haineke arterial angiomata are found only in this region.

Another interesting but rare form of vascular tumor is the venous, which communicates at times by one, again by several openings through the skull with the superior longitudinal sinus. Fortunately, they are extremely rare, and will be found in the middle line over the longitudinal sinus. Surgical interference is out of the question, unless it be to make systematic compression.

Before leaving soft tumors of the scalp the occasional existence of a meningocele or encephalocele is not to be forgotten. The most common situation is at the point where the four centers of ossification of the occipital bone come together. They also occur at the anterior fontanelle, above the nose, and in the parietal regions.

Solid tumors of the scalp are uncommon. They are lipoma, fibroma, general or circumscribed hypertrophy of the scalp, elephantiasis or, as some call it, pachydermatocele, and sarcoma and carcinoma.

Lipoma, fibroma, and pachydermatocele are all very uncommon. I have never seen an instance of either, nor are there many cases on record.

Sarcoma and carcinoma occur more frequently, but they too must be classed as rare affec

tions. I have witnessed two examples of each. Both of the carcinomas were of the epithelial variety. This is the usual form of cancer. I find one case of scirrhus reported.

The bones of the skull may be the seat of ivory exostoses, ordinary or syphilitic. The former are more likely to occur on the outer and the latter on the inner table.

Sarcomata also grow from the bones, but, as a rule, begin in the pericranium.

PAROTID GLAND.

Tumors of the parotid are not uncommon. Gross gives the record of ninety-five cases collected by Billroth, Bruns, and Weber, the diagnosis in all instances being confirmed by the microscope. Adding to these two cases in my own practice, one of which was an enchondroma larger than a fist, removed four years ago from a man still living in Cloverport, Ky., the other a cyst, removed from a middle-aged man from Knoxville, Tenn., who presented himself at the University clinic, we have 29 enchondromas, 20 fibro-myxo-chondromas, 26 carcinomas, 9 of which were encephaloid, 10 epithelial, and 7 scirrhus, 6 fibromas, 6 cystomas, 4 melanotic adeno-sarcomas, 3 sarcomas, and 3 myxomas.

Taking the 29 pure chondromas, and 20 fibromyxo-chondromas, and we have 49 or 50.51 per cent of all tumors of this gland of a cartilaginous nature. The cancerous tumors are next in frequency, comprising 26.78 per cent. Specimens of mixed neoplasms are very frequent in this situation.

The benign tumors, which comprise 67.04 per cent, are movable, grow in early and middle life; the skin over them is not discolored, have little tendency to cause pain, and do not cause paralysis of the facial nerve. The converse is true of the malignant growths.

Sir William Ferguson, whose experience with these tumors has been larger than any other surgeon, says: "If it were evident that the tumor slid freely over the subjacent textures, I should not hesitate about using the knife, whatever might be the bulk of the disease; . . . but if the tumor seemed fixed, its limits not clearly defined, or an attempt to move it caused pain, I should not readily be induced to use the knife, however small the mass might be."

The tumors occurring in this situation are the fibro-elastic or keloid, fatty, sebaceous, hematoma auris, nevus, sarcoma, and epithelioma. Of these by far the most common is the first, or fibro-elastic tumor. It grows from the lobule of the ear, varies in size from a pea to a hen's egg, is hard and dense, and of slow very growth. It is most common in negresses, and is undoubtedly, in most instances, due to the irritation of heavy and irritating ear-rings. For this reason it is uncommon in men. Fatty tumor is very rare, though it has been found. The same may be said of sebaceous cysts, and also of sarcoma.

A very interesting tumor is the hematoma. It usually begins in the concha and spreads over the auricle. Dr. Hun finds that it is almost peculiar to the insane. In 24 cases 23 were in insane persons. Nevus is very rare. Epithelioma may occur in elderly persons.

LIPS.

Tumors of the lips are common. The most frequent is the small mucous cyst which is almost peculiar to the lower lip.

Next in frequency are the different forms of vascular tumors, and they are almost entirely limited to the upper lip.

Epithelioma is common enough. It is an interesting fact that this affection is nearly always situated in the lower lip. Of 560 analyzed by Gross, only 20, or 3.5 per cent, appeared in the upper lip.

In 150 of his own cases, Gross only saw it in the upper lip twice. Bryant places the relative frequency of the disease in the two lips as 25 to 1. I have never seen it in the upper lip. Epithelioma is by far more frequent in males than in females, the proportion being 17 to 1. It is rarely seen under forty-five, being pre-emiThe nently an affection of advanced age. theory so long fashionable, that it is caused by smoking short-stem pipes, is perhaps untenable. The majority of authors are against this opinion.

MAMMARY GLAND.

If tumors in other regions of the body had. been studied and classified with the same care as those of the mammary gland, there would be little left to be desired.

S. W. Gross, who has written the best work in any language upon the subject, has made the simplest, and at the same time the most rational classification of these neoplasms, based as it is upon a sound anatomical and clinical foundation.

Of benign tumors of the mamma we find fibroma, myxoma, adenoma, and cysts, retension, and of new formation. While lipoma and enchondroma both occur in the para-mammary tissue, they do not occur in the gland itself, and will not be considered. Of malignant growths there are sarcomata and carcinomata.

The statistics collected by Gross show that of 649 cases of mammary tumors 530 were cancers, 57 sarcomas, 48 fibromas, 2 adenomas, and 12 cysts. So we have 81.66 per cent cancerous, 8.75 per cent sarcomas, 7.38 per cent fibromas, 0.30 per cent adenomas, and 1.84 per cent cysts, or over 90 per cent malignant, and 9.52 per cent benign.

Age has a most potent influence in determining the nature of a mammary growth. S. W. Gross says: "The non-carcinomatous growths occur, on an average, at the thirty-third year;

The above tabular statement of 777 cases is copied from S. W. Gross's work on Tumors of Mammary Gland, page 34.

The only tumors we find before the sixteenth year are the fibromas and sarcomas, the former occurring six times as frequently as the latter.

In conclusion, to quote still further from Gross, "Structural perfection of the mamma renders it most obnoxious to fibroma, sarcoma, and adenoma, while atrophy or decay predisposes it to myxoma and carcinoma."

A word as to the part of the gland which is invaded by the neoplasm. Carcinomas are usually situated at the upper and outer margin of the gland, and about the nipple. Noncarcinomatous growths are generally situated at the upper and inner margin of the breast, and but rarely grow around the nipple.

AXILLA.

Before enumerating the neoplasms which have their origin in the axilla, it should be borne in mind that abscesses both acute and chronic are frequently situated in this locality, also tuberculosis of the lymphatic glands. Aneurisms are not uncommon, and such surgeons as Syme, Dupuytren, Desault, and Ferraud have mistaken them for neoplasms. The result was fatal in every instance save one. Then again, the subclavian has been ligated

for a supposed aneurism, when the real trouble was a pulsating sarcoma.

The tumors met with in this situation are fatty, cystic, sarcomatous, and carcinomatous. The malignant are more common than the benign. Fatty tumors sometimes attain an enormous size; perhaps the largest on record being reported by Dr. A. H. Scott, of Arkansas. It reached below the ilium, was pyriform in shape, and when removed weighed twenty-one pounds.

Cystic tumors are frequently congenital, contents serous and coagulable. Notwithstanding the abundance of hairs in this situation, sebaceous cysts are almost if not entirely unknown.

Sarcomas originate in the connective tissues and also from the lymphatic glands. At first freely movable they soon become fixed. The superficial veins are prominent-tendency to ulceration is marked.

Gross claims "that carcinoma of the axilla is always the result of secondary involvement in connection with carcinoma of the breast." Erichsen recognizes the fact that scirrhous cancer may begin as a primary affection under the pectoral muscle or in the axilla.

I myself have seen a well-marked example of a scirrhous tumor in the axilla of a man beyond sixty years of age. The tumor was removed, but reappeared in three months. The patient lived in an adjoining State, and the subsequent history is unknown to me.

In the removal of malignant tumors in this situation the fact is not to be lost sight of that the attachments are deep, and that not infrequently the sheaths of the blood-vessels are adherent to the growth.

SHOULDER.

Tumors in the region of the shoulder may be divided into two classes, those beginning in the soft tissues around the joint, and those growing from the humerus, scapula, and clavicle. The former are almost invariably benign, the latter as certainly malignant.

Of the benign tumors growing in the soft tissues around the joint, we most generally find chondromas, fibromas, and lipomas. The former acquire an enormous size, often weighing twenty-five pounds, and, in rare instances, fifty.

Fatty tumors are common. They also may attain considerable volume. They are not so easily enucleated as in other situations, being at times quite adherent to the surrounding tissues. Two years ago I removed a large lipoma from over the shoulder of a middle-aged man. It was quite adherent to the surrounding tissues, requiring a tedious dissection for its removal. Cysts and erectile tumors are very rare, the latter, when they occur, are aneurismal or venous.

The one tumor which often springs from the bones of the shoulder is the small, round-celled or encephaloid sarcoma. It is exceedingly malignant. The points of diagnosis are rapid growth, apparent fluctuation, and prominence of the superficial veins. Of this frightful disease I have seen two instances, both in females. One a widow, twenty-two years of age, who fell upon the ice, striking her shoulder a severe blow. This was the starting-point of the sarcoma, which began in the head of the humerus. A spontaneous fracture of the bone occurred a few weeks before the limb was amputated at the shoulder-joint. This is not uncommon. The second case was in the person of a married woman, about forty-five years of age, whom I saw in consultation with my cousin, Dr. W. B. Rodman. This lady moved away from Frankfort, where she was then living, but I heard from her frequently. She survived less than a year. Enchondroma sometimes grows from the upper end of the humerus, beginning either centrally or subperiosteally. This, in fact, is one of the favorite seats of the chondroma. is likely to undergo sarcomatous degeneration.

ABDOMINAL WALLS.

It

Tumors of the abdominal wall are usually of a fatty, fibroid, cystic, or sarcomatous nature. They may be superficial to or beneath the muscle-rarely between them.

Those superficial to the muscles are, as a rule, fatty. Sometimes these tumors, when situated near the middle line, may communicate by a small opening with the abdominal cavity. The possibility of this should be remembered. The slow and painless growth, lobulation, etc., render the diagnosis sufficiently easy.

In 1862 Nélaton described a fibrous tumor which he had in fifteen instances found growing

in the iliac fossa. The tumor was dense and inelastic, usually situated just above Poupart's ligament, and attached to the anterior superior spinous process of the ilium, or thereabouts, by a dense fibrous band. They are beneath the muscles, between the peritoneum and the iliac fascia.

Cystic tumors in this situation are rare. When existing they are deeply placed just external to the peritoneum. They are supposed to develop from the fetal urachus. They contain a serous fluid and attain a large size. They may simulate ascites.

Sarcoma is uncommon. In the few cases where it has been observed it is rather deeply placed, either between the planes of muscles or beneath them. Being malignant in character, they frequently form adhesions to the abdominal viscera.

In the removal of all tumors of the abdominal wall, more especially the deeper ones, as small an incision as practicable should be made, the muscles carefully stitched so as to prevent ventral hernia.

BACK.

Tumors of the back are benign and malignant-most usually benign. Fatty and fibrous are more frequent than others. Cystic tumors are rare. The peculiarity of both fatty and fibrous tumors of the back is that they are large and pendulous. The former grow from the superficial connective tissues, the latter from the deeper ones beneath the muscles. A fatty tumor weighing twenty-five pounds was removed from the back by Dover.

Sarcomas are rather uncommon, and when they do occur are apt to grow in the interscapular region.

Cancer is still more uncommon. When it exists it is of the epitheliomatous nature, and may spread over a large extent of surface.

GROIN.

Of tumors liable to occur in this interesting surgical region, the fatty, fibrous, cystic, and sarcomatous are the most common. Varix of the saphenous vein at its opening into the femoral may also occur. So may aneurisms of different kinds.

The fatty tumor of this situation may begin