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the case of Maas just quoted admits of another and more satisfactory explanation. In the repair of the vessel-wounds inflicted by the sabrecut the angioblasts must necessarily have taken an active part. In the event of the new cells failing to undergo the necessary developmental stages requisite in the ideal healing of an injured part, they would, according to our position, become available as tumor-forming elements, and their histogenetic origin would determine the production of a vascular tumor of more active tendencies than the primary tumor. The writer therefore believes that the trauma, instead of acting only as an exciting cause, in this case furnished also the necessary tumor-matrix. The relationship of irritation to tumor-formation has recently increased in prominence. As is well known, the psoriasis lingualis, laryngis, nasalis, and præputialis, and the seborrhoea senilis of Richard Volkmann, have engaged, and still engage, very considerable attention. Schuchardt in 1885, Rudolph Volkmann in 1889, and others have brought together a very considerable number of surface tumors which were preceded by long-standing sources of irritation and inflammation, such as, for example, those originating from soot-sifting, tar- and paraffin-working, chronic sinuses, and lupoid and syphilitic ulceration. Cases in which there existed a combination between syphilis and carcinoma have been reported by Lang and Doutrelepont. In 1859, O. Weber showed the etiological relations of lupus to carcinoma, and cases substantiating the correctness of his observations were reported later by von Esmarch, Hebra, Lang, and others. Neisser reminds us that "one ought not to forget that complications of carcinoma and lupus occur, and in these cases, owing to lack of resistance, in part, of the lupus tissue against the encroaching cancer papillæ, it is advisable to adopt early therapeutic measures." Lesser commits himself on this subject as follows: "Occasionally pathological changes in tissue are the seat of epithelial carcinomata which are in no way directly responsible for the origin of tumors, such as ulcers of the leg, syphilitic ulcerations, lupus, etc." E. Friend of Chicago, under the tutorship of Kaposi made a very careful study of the microscopic picture of tissue representing a combination of lupus and carcinoma. Friend saw three cases of lupus vulgaris of the face complicated by carcinoma in Kaposi's clinic (Fig. 32). The probabilities are that the atypical proliferation of the epithelial cells in the inflamed tissues, and the diminished physiological resistance of the tissues in their immediate vicinity, are the important factors in the production of carcinoma in lupoid tissue as well as in other pathological conditions representing embryonic epithelial cells with a similar environment. The writer has seen a number of instances in which a carcinoma developed on the surface of a chronic ulcer of the leg. In such cases the islets of embryonic

epithelial cells become the starting-point of a carcinoma when the causes which maintain the ulceration have succeeded in diminishing the physiological resistance of the tissues in their vicinity sufficiently to permit the

[graphic]

FIG. 32.-Carcinoma in lupoid tissue (after Friend). Isolated tissue-masses, called by Leloir "lupoma," lie irregularly and at different depths in the corium. Upper and papillary layer and rete Malpighii appear normal. Below and interspersed in these nodules are round and elliptical bodies with nests of epithelial cells. Section from lupus vulgaris of face complicated by carcinoma. (Zeiss, A., ocular No. 3.)

embryonic epithelial cells to migrate into the surrounding tissues. We must therefore admit that the transformation of a benign growth and of a matrix of embryonic cells of post-natal origin into a malignant tumor is not only possible but probable when the embryonic cells, under the influences of local or general causes, assume active tissue-proliferation, and their migration is permitted by a diminished physiological resistance on the part of the adjacent tissues.

IX. DIAGNOSIS OF TUMORS.

THE diagnosis of tumors is a science and an art-a science, because the accurate anatomical localization of a tumor and the correct appreciation of its character and tendencies presuppose a thorough knowledge of anatomy, physiology, and pathology; an art, because the determination of the exact location and character of a tumor often requires delicate manipulation and the most intelligent application of all known diagnostic resources. The accurate eye and the trained sense of touch, the tactus eruditus, are always at hand, and, as a rule, can be more relied upon than can the use of complicated instruments in ascertaining the location, extent, and pathological characteristics of a tumor. Practical instruction at the bedside and examination of patients under supervision of the teacher will accomplish more in rendering the student familiar with the means of diagnosis than will the most painstaking didactic teaching. An abundance of clinical material and thorough and systematic examination by the students of the cases presented are absolutely necessary in acquiring the necessary diagnostic skill. The writer knows of no department of surgery more difficult to teach and to comprehend. The interest of the student can be awakened and his senses be trained properly only by bringing him in contact with patients and by encouraging him in making thorough and systematic examinations. Oncology is usually imperfectly taught in our medical colleges; this fact will go far in explaining the lack of interest of our students in this, to them, perplexing subject.

Clinical History. In each case of suspected tumor the clinical history should be investigated carefully. A failure to carry out properly this, the initial, part of the diagnostic work has led many a distinguished surgeon astray in making a distinction between an inflammatory swelling and a tumor. Every surgeon inquires almost instinctively into heredity as a possible factor in the production of a tumor. It is not only necessary to ascertain the existence of an hereditary influence in the parents, but the investigation must be carried farther back, as we have seen that this element may not assert itself in the offspring, but may appear again in the second, third, or fourth generation. It is also necessary to determine the existence of heredity in more distant members of the family-uncles, aunts, cousins, and nephews-as heredity

does not descend on all members of a family in the same degree, as is shown by the statistics quoted on this subject. The existence of tumors in different members of the family and in related families of two or more generations should be noted in estimating heredity as a possible etiological factor.

Length of Time Tumor has Existed. This part of the clinical history is often indefinite and misleading. A tumor has often existed for years before being accidentally discovered by the patient or the physician. Patients generally fix as the date when the tumor appeared the time when it was accidentally discovered. By relying on the patient's statement in regard to the time the tumor commenced the surgeon is liable to mistake a benign tumor for a malignant tumor or an inflammatory affection. Due allowance must therefore be made in reference to the statements made by patients or their friends as to the length of time a tumor has existed.

Location of Tumor.-In eliciting from the patient the clinical history it is very important to ascertain from him, so far as possible, the exact location of the tumor when it was first noticed. The student should be made to appreciate the importance of the questions put to the patient to elicit this part of the clinical history. In investigating the probable starting-point of a large abdominal tumor it is quite important for us to ascertain from the patient whether the tumor was first noticed above the pelvis or about the pelvic brim, and on which side. In a rapidly-growing ulcerating tumor of the neck the patient's statements will often render material aid in making a differential diagnosis between secondary glandular carcinoma and lympho-sarcoma. In the absence of an appreciable source of carcinomatous infection the patient, upon questioning him properly, will probably make the statement that the first thing he noticed was a movable, painless tumor under the skin. This information alone from an intelligent patient will exclude a surface carcinoma. An epiblastic surface tumor commences in the skin, and the patient's statement will often impart valuable information in differentiating between an ulcerating malignant tumor of the epiblast and one of the mesoblast. The relation of the skin or the mucous membrane to the tumor in its early stages must be ascertained from the patient for the purpose of enabling the surgeon to connect the tumor with its matrix, derived from the different germinal layers, in all cases in which any doubt remains as to the histogenetic source of the tumor.

Rapidity of Growth of Tumor.-The rapidity with which a tumor has increased in size should be taken carefully into account in the dif ferential diagnosis between a tumor and an inflammatory swelling and between a benign and a malignant tumor. We know how unreliable

the statements of patients are in ascertaining the previous clinical course of a tumor. The patient must be requested to compare the size of the tumor when first discovered with objects familiar to him, such as a hempseed, a pea, a bean, a hazelnut, a walnut, a hen's egg, a plum, an apple, an orange, a cocoanut, a child's head, an adult's head, etc. By comparing the size of the tumor when first discovered with its present size and estimating the time that has elapsed we are in possession of facts which enable us to judge, at least in an approximately correct way, the rapidity of growth of the tumor. As a rule, a benign tumor grows slowly, a malignant tumor rapidly; the clinical behavior of a tumor is therefore very important in making a differential diagnosis between benign and malignant growths.

Pain. Spontaneous pain was regarded for a long time as one of the most distinctive clinical witnesses of carcinoma as compared with benign growths. The idea that carcinoma is an exceedingly painful, torturing disease is deeply rooted among the people of all nations. A peculiar lancinating, paroxysmal pain with nocturnal exacerbations has been described since the time of Hippocrates as characteristic of carcinoma. Physicians and surgeons have placed too much stress upon the diagnostic value of this symptom. A lancinating pain at variable intervals and only of a moment's duration is described by many patients suffering from carcinoma of the breast and epithelioma of the lip, but is by no means a constant symptom. The writer is sure that clinical observations will bear him out in making the statement that adenoma of the breast causes more suffering than does carcinoma of the same organ and of the same size. He has known of numerous cases of carcinoma of internal organs in which the disease was painless from the beginning to the end. Sarcoma, as a rule, causes less pain than carcinoma. Benign tumors, with the exception of tumors of the nerves or of their sheaths, produce pain only when, from their location or their size, they cause compression of a sensitive nerve. A small osteoma in the bony canal through which pass certain sensitive nerves will occasion excruciating pain, while a lipoma in the panniculus adiposus, of immense size and meeting with no resistance to its outward growth, will remain a painless affection throughout life.

Tenderness. The pain produced by pressure results from compression of a sensitive nerve subjected to the pressure. Tumors of the nerves or of the nerve-sheaths most frequently give rise to pain on pressure. The subcutaneous painful tubercle is well known as the most sensitive tumor. Tumors of the nerve-sheaths of the terminal nerves in the subcutaneous tissue, described by Recklinghausen, are not painful on pressure, owing to the looseness of the structures in

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