glance at Figures 38, 39, and 40. All these illustrations represent in the foreground embryonic connective tissue with a very scanty stroma. Without knowing anything about the clinical aspects, it will readily be seen that it would be exceedingly difficult to distinguish between a small round-celled sarcoma, young granulation-tissue, and a gumma. It is in just such cases that we seek additional light from a microscopic examination.

To illustrate still further the danger which may follow the use of the microscope as an exclusive and only means of diagnosis, the writer will relate a case which recently came under his observation. During the World's Fair held in Chicago he was consulted by a Russian gentleman concerning several tumors which had developed in the scar of an operation-wound. He gave the following history: Age, forty; married; the father of several healthy children; merchant by occupation. In 1890 he noticed a swelling in the skin at a point corresponding to the supraspinatus fossa of the right scapula. The tumor was movable and painless, but increased quite rapidly in size. He consulted his family physician in Russia, who pronounced the tumor a sarcoma of the skin and sent him to one of the most prominent surgeons in Berlin for operation. The Berlin surgeon made a diagnosis of gumma, placed the patient on specific treatment, and removed the tumor, more for the purpose of allaying the fears of the patient than with the expectation of any benefit being derived from the operation. The patient followed the treatment faithfully, but in the course of six months a tumor returned in the scar. He consulted the same surgeon, who at the patient's special request removed the tumor a second time, still claiming that it was not malignant. It was now decided to leave the diagnosis in the hands of the most competent pathologists. The surgeon sent a part of the tumor to an eminent Berlin pathologist, and the patient sent the balance to the foremost Paris pathologist. The specimens were subjected to microscopic examination, and each pathologist sent in a written report to the effect that the tumor was a gumma, and not a sarcoma. The patient was now placed on vigorous antisyphilitic treatment, including mercurial inunctions, baths, and the internal use of corrosive sublimate and potassic iodide in large doses. The wound after both operations healed by primary intention. The patient is not aware that he ever contracted syphilis, and never showed evidences of secondary or tertiary manifestations. When the writer examined the patient none of the remote consequences of syphilis were discovered. The pale, large scar following the last operation was occupied by four tumors, covered by intact scar-tissue and varying in size from that of a hazelnut to that

was one.

H

of a walnut, all of them perfectly movable, and with no attachments to the scapula. If ever a case of sarcoma of the skin was seen, this Under the circumstances it was deemed prudent to advise the patient to return to his surgeon for a third operation. The writer does not wish to under-estimate the value of the microscope as an aid in the diagnosis of doubtful tumors, but he must insist that it cannot be relied upon in differentiating between a small round-celled sarcoma and some of the granulomata under circumstances such as those detailed above. In doubtful tumors of accessible surfaces tumor-tissue can be selected and removed for microscopic examination. Sections of such specimens are better adapted for diagnosis by means of the microscope than fragments taken from the depths of tumors through the skin with the different forms of harpoons. Another course is sometimes necessary when the surgeon has decided to remove the growth and is in doubt as to its nature. Here the microscope is employed during the operation as an aid in diagnosis. As soon as the tumor is reached, when doubt still remains as to its character, a piece is removed and sections are made with a freezing microtome (Fig. 41) for microscopic examination. The freezing microtome can be purchased at a small expense, and should have a place in the operating-room of every hospital. The result of such an examination frequently settles all doubt as to the nature of the tumor, and serves as a valuable guide to the surgeon in the performance of the operation. The microscope is an invaluable aid in the diagnosis of tumors, but the conclusions based upon the results of the examination are not infallible; hence the importance of a careful study of the clinical aspects of the tumor, followed by a thorough examination of the patient, of the tumor, and of its environments.

X. PROGNOSIS OF TUMORS.

A RELIABLE prognosis presupposes a correct diagnosis. To predict correctly the probable termination of a tumor requires an accurate knowledge of its life-history and of its relations to its neighborhood and to the entire organism. The prognosis must therefore rest largely upon a careful study of the clinical history of the tumor, its anatomical location, its influence upon the adjacent tissues, and the general condition of the patient. It is when we are called upon to foretell the future behavior of a tumor that we realize most keenly the necessity of making a searching examination of the patient as well as of the tumor. From a prognostic standpoint it is absolutely necessary to divide all tumors into the two great clinical divisions (1) benign and (2) malignant. If we are able in the diagnosis to exclude inflammatory swellings, the next duty that presents itself is to differentiate between benign and malignant tumors. This task is easy in some cases, difficult or impossible in others. A carcinoma that has advanced to the stage of ulceration with regional glandular infection is recognized at sight; a rapidly-growing tumor in bone or in periosteum in localities predisposed to sarcoma is readily identified as such. Under other less obvious circumstances the question as to whether the tumor is benign or is malignant is not so easily decided. Carcinoma of some of the internal organs is often diagnosed only in the post-mortem room. Carcinoma and sarcoma of accessible organs are frequently recognized as such only after their clinical behavior has given unmistakable evidence of their malignant character. It is evident that the surgeon who regards his own reputation and the welfare of his patient must be cautious in rendering his verdict as to the probable course the tumor will pursue in the future and the ultimate fate of his patient. The prognosis should be postponed until repeated examinations-and, if necessary, the microscopic examination of tissue from the tumor-have furnished conclusive evidence of the nature of the tumor. It is most humiliating to a surgeon to make a diagnosis of malignant disease, and to render a prognosis in accordance with his views of the nature of the tumor, and to find later, by its clinical course, that it was either a benign tumor or an inflammatory swelling. It is a disregard of a duty imposed upon a surgeon to pronounce a malignant tumor non-malig

nant upon a superficial, hasty examination, as the loss of time may weigh heavily in the balance of failure of a too-long-postponed radical operation. It must be apparent to the student that an intelligent, reliable prognosis must necessarily rest on a correct diagnosis, and that a prognosis should consequently be withheld from the patient and his friends until the nature of the tumor has been ascertained by conclusive evidence. A correct diagnosis having been made, the next question that presents itself to the conscientious surgeon is, To what extent should the knowledge gained as to the nature of the tumor be communicated to the patient and his friends? The prognosis in cases of benign tumors should be freely and candidly expressed to the patient, including the possible risks of an operation and its probable result. A different course should be pursued if the tumor is malignant. Under ordinary circumstances the writer regards it in the light of a cruelty to inform a patient directly that he is suffering from a malignant tumor. The public appreciates our shortcomings in the treatment of malignant tumors, and with few exceptions an intelligent patient regards such a diagnosis as his death-sentence. The mental depression following such a declaration not only destroys all happiness on the part of the patient, but has a disastrous effect on the disease, and is an important factor in detracting from the immediate and remote results of an operation. The surgeon is often placed in a very unenviable position when importuned by the patient in reference to the nature of the growth. The question, "Have I a cancer?" is often squarely put to him, and the reply will either inspire hope or cause a despondency from which the patient will never recover completely. It has been an invariable rule with the writer to inform the relatives as to the true nature of the tumor, and to discuss with them the propriety of an operation as well as its probable immediate and remote results. The patient is informed that he is suffering from a tumor, and this statement will prove satisfactory in the majority of cases. If asked as to the possibility of a recurrence, the facts are placed as gently as possible before the patient. If "ignorance is bliss," this adage has a special significance in the case of a patient suffering from a malignant tumor. If the patient is not aware that he is suffering from what is regarded almost universally as a fatal malady, an operation inspires hope, and, in place of the despondency often bordering on desperation that attends a knowledge of the true nature of the tumor, the patient looks forward to a complete and permanent recovery. The surgeon should communicate to the patient's nearest relatives or friends the true nature of the tumor and the probable results of an operation, but such information should be withheld from the patient himself under ordinary

circumstances. There are exceptions to every rule, and circumstances may arise which make it imperative on the part of the surgeon to tell the patient the whole truth.

From an anatomical standpoint every tumor is benign in proportion to its degree of isolation from the adjacent tissues and from the organism. Benign tumors, as a rule, are encapsulated; consequently they remain permanently as local affections having no connection whatever with the organism. The encapsulation of some forms of sarcoma is more apparent than real, as the capsule does not afford protection to the surrounding tissues against invasion by tumor-cells; yet when a capsule is present it imparts to the tumor a certain degree of benignancy which is not observed in malignant tumors entirely devoid of a capsule, as is the case in carcinoma and in the most malignant varieties of sarcoma. For reasons that have been explained, the soft, vascular tumors belonging to the malignant type of tumors manifest the greatest degree of malignancy. In tumors of this kind the stroma, which always acts more or less as a barrier to local and general dissemination, is always scanty and sometimes is nearly wanting. The cells remain in their embryonic state, possess ameboid movements, and are reproduced with great rapidity. Such tumors resemble inflammation. very closely, and the surgeon is familiar with the well-known clinical

FIG. 42.-Carcinoma of mammary gland, showing numerous leucocytes between tumor-cells and along the course of blood-vessels (Surgical Clinic, Rush Medical College): a, carcinoma-cells; b, stroma; c, brownish granules of blood-pigment; d, area of new proliferation; e, leucocytes.