myxo-carcinoma, myxo-sarcoma, etc. The most frequent combination is myxoma with lipoma, lipoma myxomatodes. Etiology. Congenital myxomata have been reported by C. O. Weber, Schuh, and others. No age is exempt, but they are met with most frequently in young adults. The most potent exciting causes are chronic irritation and inflammation. The formation of nasal myxomata is frequently preceded by chronic catarrhal inflammation. Myxomatous polypi of the external auditory meatus are most always associated with chronic inflammation of the external ear. Symptoms and Diagnosis.—A myxoma is a soft, gelatinous, translucent, interstitial, sessile or pedunculated growth. It is of slow growth, and as a surface tumor it does not attain large size. Its growth is unlimited if it receives its blood-supply from the entire periphery, as is the case in interstitial myxoma. The diagnosis is not attended by any difficulties if the tumor is accessible to sight and touch. Its color and consistence distinguish it from fibroma, adenoma, and the malignant tumors. Fluctuation is a constant sign, owing to the softness of the tumor-tissue. The transition of a myxoma into a sarcoma should be suspected when the tumor without any obvious cause begins to grow rapidly. In such cases an examination of the tumor-tissue under the microscope should be made before an operation is undertaken, as a correct diagnosis is of paramount importance in planning and executing an operation of sufficient thoroughness to remove all the infected tissues in case the tumor has become malignant. If the microscope is to be relied upon in ascertaining whether or not malignant transition has taken place, tissue from the new part of the tumor must be obtained for examination. Serious blunders in practice have arisen from the examination of old portions of the tumor, in which portions no traces of malignant transition could be seen. Wherever possible, tissue from the base of the tumor should be taken for microscopic examination, as it is here that malignant transition is most frequently initiated. Prognosis. A pure myxoma is a benign, local, encapsulated tumor. Myxoma has received an unenviable reputation from a prognostic standpoint from the fact that it has been so often confounded with malignant tumors that had undergone myxomatous degeneration, and from the frequency with which it undergoes transformation into sarcoma. A pure myxoma does not give rise to local, regional, or general infection. The implication of adjacent tissues, regional infection, and general dissemination are positive proofs either that the primary tumor was malignant and had undergone myxomatous degeneration or that the tumor is no longer a myxoma, but is a sarcoma produced in consequence of transformation of a benign into a malignant tumor. In rendering a prognosis in cases of myxoma the aptitude of such a tumor to undergo malignant transition must be remembered. The greater liability of myxoma than of fibroma to become transformed into a sarcoma is due to the more lowly organized cells of which its matrix is composed. Treatment. Remembering the liability of myxoma to transition from a benign tumor into a sarcoma, it is necessary to emphasize the importance of early and thorough removal. Imperfect removal by operation or incomplete destruction by caustics has frequently been followed by a sarcomatous recurrence. The irritation incident to such imperfect treatment has proved sufficient to bring about a transition of the remnant of the tumor into sarcoma. The writer has more than once seen such a transformation follow incomplete removal of nasal polypi with the snare. It is especially necessary to remove the base of the tumor; complete removal is seldom accomplished with the snare or by torsion. A hyaline myxoma of a mucous surface is so friable that its complete removal cannot be effected by avulsion. If the tumor is so located that its base cannot be reached for its removal by the snare or by avulsion, these procedures should be followed by cauterization with the Pacquelin cautery, in order to destroy every remaining vestige of the tumor. The removal of an intermuscular myxoma must be done with the utmost care, as the tumor usually has prolongations into the loose connective tissue surrounding it; these prolongations might be overlooked, and if not removed would become the source of a certain and early recurrence. TOPOGRAPHY. Skin. Myxoma of the skin occurs as a sessile or pedunculated tumor, but is rare as compared with fibroma or with papilloma. Myxomatous tumors of the skin are most frequent in the neighborhood of the perineum and the labia in women. In young persons these tumors possess a regular, usually oval, outline. Later in life they shrink, and the surface of the tumor assumes a lobulated appearance. These tumors ordinarily occur in the labium majus, although they may be found in the nymphæ or in the perineum. Sessile myxornata are very prone to recur after removal, unless especial care is taken to carry the incisions beyond the limits of the capsule. Enucleation is often attended by rupture of the capsule; consequently this method of operating cannot be relied upon for complete removal of the tumor unless its capsule is unusually firm. Intermuscular Spaces.-Myxoma, like lipoma, is sometimes found to occupy the intermuscular spaces, and in this locality frequently exists in combination with lipoma. The favorite locality, as has been pointed out by Lücke, is the space between the external and internal hamstring muscles, below the gluteal fold. These tumors are of slow growth and may reach great size. The writer has seen a myxoma the size of an adult's head between the adductor muscles of the thigh. In the excision of deep-seated myxoma it is often necessary to excise some of the connective tissue around it in order to remove all the myxomatous tissue. Nose.-Unmixed myxoma occurs more frequently in the submucous tissue of the nasal cavities than in any other locality. It starts usually in the mucous membrane overlying the turbinated bones, and only in exceptional cases in the frontal sinus or in the antrum of Highmore. The tumor is usually multiple, often from three to six being found in one nasal cavity. Frequently both nasal cavities are simultaneously affected. The growths may project anteriorly or in the direction of the pharynx. During moist weather the tumors absorb moisture, swell, and produce more obstruction than during dry weather. If numerous and large, they distend the nose; and when located in the frontal sinus bulging at the inner angle of the orbit takes place, like that produced by hydrops or by empyema of this cavity. FIG. 288-Myxoma of nose (Surgical Clinic, Rush Medical College, Chicago): a, delicate connective-tissue stroma; b, granular amorphous myxomatous material, non-staining; c, nuclei; d, blood-vessels. A nasal myxoma appears as a jelly-like, translucent mass which moulds itself to the cavity of the nose. It is covered by mucous membrane paved with columnar or stratified epithelium. Under the microscope the tumor-tissue appears like very oedematous connective tissue. The great mass of the tumor is composed of myxomatous tissue in the meshes of the reticulum of connective tissue and parenchyma-cells (Fig. 288). The blood-vessels traversing the connective tissue stroma are usually quite large with very thin vessel-walls. Nasal myxoma occurs most frequently in persons from the age of puberty to that of fifty years. The removal of nasal myxomata is by no means an easy operation. Avulsion with the different kinds of forceps devised for this purpose is usually followed by recurrence owing to incomplete removal of the tumor; the use of the snare gives better results, but recurrence is by no means infrequent. In cases in which a permanent cure followed these procedures, usually a part of the turbinated bone to which the tumor was attached was removed with the tumor. König's operation should be resorted to if snaring and avulsion have not resulted satisfactorily. This operation consists in cutting through the ala of the nose on the side of the septum from within outward as far as the bony framework, thus rendering the base of the tumor more accessible. After locating the attachment of the tumor the index finger should be inserted into the nasal passage from the pharynx, and with it the tumor is pushed forward, when it may be removed with the snare or, what is perhaps better, the sharp spoon. If the tumor is attached far back, a temporary resection of the nose may become necessary to effect complete removal. This preliminary operation becomes absolutely necessary in the removal of polypoid tumors of the nose that have undergone malignant transformation. Middle Ear.-Myxomatous tumors in the external meatus are frequently preceded by chronic or acute inflammation of the middle ear and by perforation of the drum. These tumors usually spring from the mucous lining of the tympanum, filling this cavity and projecting into the external meatus through a perforation in the drum, causing deafness. Jacobson suggests that myxoma of the middle ear may in some instances arise from vestiges of connective tissue in this locality— an opinion which will be sustained by all who adhere to Cohnheim's theory regarding the origin of tumors. The operative treatment of aural myxomata should be consigned to skilled aural surgeons, as the reckless use of instruments and of caustics in the middle ear is calculated not only to destroy hearing, but may even be followed by fatal cerebral complications. Nerve-sheaths.-Myxomatous tumors are not infrequently found in the central nervous system, the brain and the spinal cord. Myxoma of the sheaths of peripheral nerves is called neuroma myxomatosum. The tumors often occur multiple, and they have been found in connection. with diffused nerves (Fig. 289). They often produce serious functional disturbances in the form of neuralgia or paralysis. The most frequent seat of myxomatous tumors of the nerve-sheaths is the optic nerve. |