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The Clinical use of Prisms and the Decentering of Lenses. By ERNEST E.
Manual of the Diseases peculiar to Women. By JAMES OLIVER, M.D. Edin.,
Dissections Illustrated; a Graphic Handbook for Students of Human
Syphilis; its Treatment by Intra-muscular Injections of Soluble Mercurial Salts. By EDWARD COTTERELL, F R.C.S., Surgeon to out-patients, London Lock Hospital. London: John Ball and Sons.
The Student's Handbook of Gynecology specially designed to assist those commencing the study of Diseases of Women. Illustrated with forty-nine engravings. Edinburgh: E. and S. Livingstone. 1893.
Sciatic Neuritis; its Pathology and Treatment.
By ROBERT SIMPSON,
LR.C.P., L. R.C.S. Bristol: John Wright and Co. Handbook of Public Health and Demography. By EDWD. F. Willoughby, M.D. Lond. London: Macmillan and Co. 1893.
Tumours, Innocent and Malignant; their Clinical Features and Appropriate
Pyogenic Infective Diseases of the Brain and
Spinal Cord. Meningitis, By WILLIAM MACEWEN, 1893.
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BIRMINGHAM MEDICAL REVIEW.
(CANCEROUS AND QUASI-CANCEROUS GROWTHS OF
BY HERBERT SNOW, M.D. LOND., ETC.
NO ONE who attempts a comprehensive classification of the various diseases laying claim to the title of "malignant," or 'cancerous," can fail to be struck by the appearance of certain obscure and strangely-constituted tumours which refuse to fall into any of the recognised groups. They materially differ from one another in histological composition and in clinical career: while the most conspicuous examples prove assuredly fatal, with metastatic deposits, the minor but occasionally display these cancer-features; all, however, agree in being the offspring of fœtal structures obsolete in extra-uterine life. The cases are numerically small, and have hitherto served mainly as pathological curiosities, designated by sundry polysyllabic names; but in no way linked together. I venture to think that a clearer perception of their true affinities will cast much light upon a hitherto obscure corner of pathology, and in order to facilitate discussion, have placed them in a single group under the title of Blastoma (Bλaστos, germ).
Cohnheim ascribed all malignant new-growths to the persistence of embryonic residua which should normally have become obliterated. His theory entirely fails to obtain any evidence in support, among the average cancer-developments of the adult; on the other hand, it very accurately accounts for the raison d'être and clinical manifestations of the tumourformations now in question-i.e., whenever the latter display the symptoms recognised as "malignant," which is commonly, but not invariably, the case. The most striking, though by no means the most common, exemplar of the blastoma in its most malignant form is that new-growth of the infantile kidney long recognised as rhabdo-myoma. The disease may begin in utero ; it often synchronously attacks both organs. Among eleven cases cited by Dr. Bertram Windle (Journal of Anatomy and Physiology, xviii., 166), the most advanced age at which it was first recognisable was 34 years. The development appears wholly spontaneous. Huge masses, containing striped muscle blended with ordinary sarcoma-tissue, grow rapidly; and prove fatal with metastases in lungs, liver, heart, peritoneum, etc. There are a large number of cases, exactly similar in clinical history, only not ranked as rhabdo-myoma, because striated muscle-fibres are absent.
These rare formations exemplify a general tendency pervading all the organs derived from the Wolffian bodies, Müllerian ducts, and germinal epithelium. Of such the most important are the kidneys, uterine appendages, testes with their gubernacula, vesiculæ seminales, epididymes, prostate, vasa deferentia, and cortical part of the adrenals. The organ of Giraldés, vas aberrans of Haller, hydatids of Morgagni, parovarium, are less conspicuous obsolete relics of the embryonic structures alluded to.
In association with every one of the viscera above named do we find a marked proclivity to the development in childhood or adolescence, of tumours, clinically bearing an exact correspondence to the cancerous lesions of the adult, giving rise to distal metastases, progressively advancing, and terminating surely in
death; yet conspicuously differing from the sarcoma or carcinoma of the "cancer-age" in the absence of any discernible exciting cause.
Congenital tumours of the ovary, long familiarly known as "Dermoids," are sufficiently common in their more conspicuous forms. According, however, to Mr. Greig Smith (Abdominal Surgery, p. 14), they are much more prevalent than has been hitherto supposed, about one in ten of so-called "Ovarian Cysts" being wholly or partially dermoid. Several striking
cases which illustrate the cancerous character of these newgrowths are cited by Mr. Bland Sutton (Surgical Diseases of the Ovaries). A woman of 28 had a huge dermoid cyst, of ten years' apparent duration. It contained hair and teeth. To the main cyst smaller were attached by pedicles; others lay perfectly loose. The largest of the latter was as big as a hen's egg. It lay among adhesions of the small intestines, which completely parted it from the parent cyst. There was another (fixed) in the great omentum; two near the right broad ligament; many small ones adhered to the mesentery or pelvic peritoneum. In Mr. Jessop's case, quoted by Sutton, there were secondary metastases in the liver, right adrenal, and the mesenteric lymph-glands. In Kolaczek's (Virchow's Archiv, Bd, lxxv., s. 399), the peritoneum was dotted over by numerous small yellow knots, many of which contained fine hairs. The primary growth was an ordinary ovarian dermoid in a woman of 40. In Fraenkel's (Wien. Med. Woch., 1883, p. 865) a woman, aged 37, fell and ruptured a dermoid, noticed two years. Autoinoculation of its cell-contents to the peritoneal surface followed, with the result of very numerous small pedunculated cysts growing from that membrane; larger ditto from the liver, diaphragm, and meso-colon; and hairs sprouting from the omentum. See also cases by Grawitz (Virchow's Archiv, Bd. c.), Matthews Duncan (Obst. Trans., xxiv.), Moore (Path. Trans., xviii.), and Hulke (Path. Trans., xxiv.). On the proneness to recurrence of ovarian dermoids after operative removal, see case by Knowsley Thornton in the Med. Times and Gazette, ii., 235;
Alban Doran (Diseases of the Ovaries, p. 89); Bland Sutton (Op. cit.).*
The composition of these malignant dermoids (which pass through a variable period of latency, often not displaying cancerous phenomena until puberty, or even later) is peculiarly complex and puzzling, insomuch that Mr. Bland Sutton has found it necessary to coin for them a special term "Oophoroma." A peculiarly interesting feature is a marked variation in their structure at different ages. Cell-elements with little organisation or regular arrangement prevail in the öophoromata of fœtuses. or very young children; towards puberty a higher organisation is found, the cells being grouped in alveoli, and various formed tissues being present; later on are large cysts with the usual heterogeneous contents.
Before passing to other derivatives of the Wolffian body, the kidney must be again referred to. Although, as above stated, the presence of striped muscle has conferred upon a rare form of renal tumour a special title, numerous cases occur in which that feature is absent, yet which must necessarily be referred to the operation of the same pathological principle. The elaborate tables published by Dr. Bertram Windle (Journal of Anatomy and Physiology, xviii, 166) are of great value in proving the congenital origin of many so-called "sarcomata" or cystic sarcomata " of the kidney; as also in demonstrating that admixture of heterogeneous tissues which is the most distinctive character of a Blastoma. He gives 61 cases in all, including the Rhabdo-myomata. Of 12"mainly round-celled," 5 appeared in both organs, the fact almost certainly indicating a foetal source; 7 appeared in children under the age of six. Of 8
* It may in this connection be pointed out that the familiar "ovarian cyst" of later life, in which there is no manifest indication of an embryonic source, is often a cancerous growth; with its cell-elements cast into the shade by the exuberant cyst-formation. Thus of 600 ovariotomies in Schroeder's klinik, only 195 per cent. of the complete operations remained free from disease for more than a year; 100 of these shewed obvious signs of malignancy on an exploratory incision. Leopold, of 110 complete ovariotomies, found cancer in 20; while six others were left unfinished on this account: 22'4 per cent. of malignant cases.