of the third nerve, paralysis of the facial nerve and of both trigeminal nerves. After this he developed weakness in certain muscles of the right arm. There was a history of rheumatism in the parents, and of alcoholism in the patient. About one year ago there was a purulent discharge from the left ear, which lasted for several months. One year ago the right eye was struck by a piece of hoop from a barrel. Shortly afterward he began to complain of double vision, and saliva drivelled from the right angle of the mouth. There had been at no time pain in the hand or forearm. Under the administration of iodide the patient had regained some control of the movement of the eye-muscles and right eyelid. The physical examination, on November 26, 1895, showed the man to be small and fairly nourished, with lateral curvature of the spine, and considerable deformity of the thorax. There was slight ptosis on the right side. The right internal rectus was extremely weak, and there was paresis of the superior and inferior recti. There was sufficient power in the internal rectus to maintain binocular vision, but not sufficient to preserve convergence. The reaction to accommodation was greatly impaired. R. V. was 20/50, and L. V. 20/40. Both optic disks were found to be distinctly paler than normal, and the vessels slightly narrowed. Near the right disk were two patches of slight choroidal atrophy. All the movements of the face were well performed, and there was no drivelling of saliva. Reaction of the facial muscles to faradism was well preserved. The temperature-sense and tactile sense presented fairly welldefined areas. Sensation was preserved over the eyelids, and was only moderately impaired over the nose. Near the lips sensations of pain and touch were slightly impaired. The uvula deviated to the left. The sense of taste did not seem to be distinctly impaired. There was some loss of power in both arms, but this was more marked on the right side. The flexors of the right wrist were weak, and those of the fingers were wholly paralyzed. The power of the pronators and supinators was normal. All the paretic and paralyzed muscles were wasted. All the paralyzed muscles showed the reaction of degeneration to a greater or less degree. The ulnar area of the right hand and lower two-thirds of the forearm showed loss of sensibility to pain, temperature, and touch. In the left hand and forearms there was a moderate loss of power in the flexors of the fingers. There was no wasting of the left forearm or any change in sensibility or electrical reaction. In both arms there was slight and rather coarse tremor when the arms were extended. There was no loss of power in the legs, and sensibility was not impaired. Both knee-jerks were absent, but the plantar and cremasteric reflexes were present. There was considerable oscillation on standing with the feet together and the eyes closed. The patient urinated without straining. There was frequent pain in the right hypogastric region, but no "girdle" pain. There had evidently been marked improvement during the past month under the use of iodide. The conditions present in this patient were undoubtedly due to the lesions of cerebro-spinal syphilis. The fifth nerve had been more damaged than the others. The speaker said that the two points upon which he desired further information were: (1) The exact location of the lesions at the base; and (2) as to whether or not the patient has locomotor ataxia. DR. W. M. LESZYNSKY said that he recalled having seen a man, aged about fifty-eight years, with very marked exophthalmos and goitre, associated with marked oedema of the eyelids. This oedema, however, had been absent in one eyelid for a time, and it had gradually disappeared. DR. B. SACHS said that within the last few years he had seen upward of thirty cases of Basedow's disease, and yet he had never observed such oedema in any of these cases. DR. J. ARTHUR BOOTH said that he had been unable to find any mention of more than one case of the kind in English literature. It was interesting that no exophthalmos had been noticed until a few weeks ago. It had been suggested that the cedema was due to paralysis of the orbicularis. DR. SACHS said that he agreed to the diagnosis of cerebro-spinal syphilis in Dr. Herter's case, but would prefer to have it called multiple cerebro-spinal syphilis. The involvement of a large number of cranial nerves and imperfect involvement of some of these nerves were especially characteristic features. He had made the diagnosis of cerebro-spinal syphilis several years ago in a case in which there had been complete trophic paralysis of the upper and lower extremities, with ptosis. One critic had looked upon this case as one of neuritis rather than of central disturbance. This view he did not accept, for we had only to suppose that the specific meningitis had extended along the ventral surface of the cord instead of laterally to explain the symptoms. The fact that there had been improvement in some of the symptoms under the use of iodide was, of course, very significant. In his opinion there was no one symptom of greater value than the complete immobility of the pupil to accommodation and light, or the equal impairment of both of these functions. This was very different from the Argyll-Robertson pupil. If in addition to this there was a multiplicity of lesions, the probability of syphilis was very strong. He would not think of making the diagnosis of tabes in this case, because there was absence of the Argyll-Robertson pupil, little or no pain, and no involvement of the bladder. DR. HIRSCH said that he did not think we could exclude general paresis of syphilitic character. The expression of the face, the tremor, and slight deviation of the tongue, all pointed toward this condition, and the diagnosis could not be made without further knowledge of the psychical symptoms. DR. HERTER said that from his short acquaintance with the patient he felt that the psychical symptoms usually observed in general paresis were not present. His mental condition and memory were quite good, and his slight imperfection in articulation seemed to be due to an imperfect co-ordination of the lower speech-mechanism. The expression of the face appeared to be due to the ptosis. THE PRESIDENT said that he would certainly agree with the diagnosis of cerebro-spinal syphilis, and also regarding the points of localization at the base of the brain. DR. IRA VAN GIESON said that he wished to indorse the term "multiple" cerebro-spinal syphilis from a pathological standpoint. Syphilis of the nervous system should be considered in three forms: (1) The multiple variety appearing in the form of plaques; (2) the form in which there were discrete gummata; and (3) the form in which there were less tangible lesions of the bloodvessels and interference with the nutrition of the bloodvessels. DR. SACHS said that through recent researches the endarteritis of the spinal cord had been very definitely established. The specific endarteritis of the cerebral vessels had been recognized for a long time, but more recently it had been very definitely established in some of the cases of spinal syphilis that there was a specific endarteritis of the vessels of the spinal cord with areas of softening in the cord. The speaker said that a few years ago he had been inclined to consider these cases as examples of meningeal infiltration, extending in gradually through the entire cross-section of the cord. THE PRESIDENT said that most of the symptoms of general paresis were of later origin than those present in the case under discussion. This patient had already shown improvement, therefore the symptoms must be due to specific infiltration at the base of the brain, and also possibly to softening in the cord from an endarteritis -a condition shown to exist many years ago. This was essentially different from the chronic condition present in general paresis. DR. A. WIENER presented a | ffected about the face. The deltoid muscle showed simple atrophy of the muscular fibres, with cell-infiltration in the muscle and between the fibres. No hypertrophy of the fibres could be found, and there was no evidence of fatty deposit. The small bloodvessels were filled with blood, and the walls with round cells. The lack of all sensory disturbances left no doubt that this was a case of the myopathic type. No improvement was noticed under the usual tonics and electrical treatment, so it was decided to try the effect on physical culture carried on daily to the point of exhaustion. From half an hour to one hour was devoted to exercises with dumb-bells, Indian clubs, and the use of a health-lift machine. There was evidence of a very marked improvement in every way. Quite lately he had been able to ride forty miles in one day on a bicycle. Some of the muscles still showed atrophy. The improvement was especially marked in the muscular movements and in the partial return of the contour of the parts. The speaker said he did not think such treatment would be efficacious in cases developing in infancy, but where there had been a good development prior to the appearance of the disease this plan of treatment offered a good prospect of success. DR. G. M. HAMMOND said that the heart-symptoms in this man were very much like those seen in individuals who had received too much physical exercise at a time when the heart was feeble. This man's heart was dilated and hypertrophied, and it was possible that this was due to a loss of muscular tissue as a part of his disease. He asked if Dr. Wiener thought the arrest of the atrophy might not have been spontaneous and independent of the physical exercise. He had himself seen one or two less extensive cases of dystrophy in which the atrophy was recovered from without any treatment. In one of these cases the atrophy was limited to the muscles of the thumb in both hands. DR. C. L. DANA said that he thought there was a class of cases of progressive muscular dystrophy brought on by excessive muscular work when the person was immature. This form of dystrophy seemed to him to have a different course from the ordinary types of dystrophies. He had seen cases in which he believed the lesion was in the muscles, and in which the course and clinical symptoms were those of dystrophies occurring in acrobats and gymnasts. In these cases the symptoms usu with the idea of showing that such a case could be improved by treatment. From a review of the literature, he said that it was apparent that the tendency now was to bring the disease formerly divided into spinal and myopathic forms under one head. The patient to be presented this evening, he said, had been exhibited two years ago before this Society. At that time he was twenty years old, and had been perfectly healthy up to May, 1892, and had not experienced the slightest difficulty in performing any muscular movement. The first indication of difficulty was in May, 1892, when he began to suffer from vague pains in the region of the spleen and liver on considerable muscular exertion. Shortly after this, difficulty in going up stairs and walking was observed, and soon atrophy of the lower extremities and back followed. Finally, the muscles of the neck and face became involved. The patient denied alcoholism or syphilis, and stated that his health had been excellent. He had noticed while engaged in athletically progressed steadily up to a certain point, and then sports that the muscles of the upper extremities quickly became fatigued. In 1893 there was no distinct abnormality about the formation of the skull. His general appearance was that of a person very much emaciated, and there was great difficulty in walking and lifting the limbs. On attempting to stand upright he exhibited a marked lordosis. When lying down it was impossible for him to turn over. The muscles were soft and covered with redundant skin. No vasomotor or trophic disturbances were discovered. The deep reflexes were absent on both sides. The spinal column was in no way tender on percussion. Examination of the muscles showed a marked paresis. The muscles of the forearm and hand appeared normal. Mechanical excitability was very much diminished. Electrical examination gave quantitative changes, but no reaction of degeneration. The abdominal muscles were only slightly affected. The orbicularis oris and palpebrarum were the ones chiefly there was an arrest of the process, and sometimes a very decided improvement. This clinical distinction should be borne in mind in estimating the value of the treatment pursued in this case. He doubted very much if such treatment would have much effect on the more usual form of atrophies. In the cases to which he had referred the upper arm, shoulder, and back were usually affected. DR. B. SACHS said that the case seemed to him of great importance. He was perfectly familiar with the class of cases referred to by the last speaker-the localized atrophies and those due to excessive muscular exercise. The case under discussion, however, did not belong to this category. When first presented to the Society, two years ago, the involvement of the facial muscles was a prominent feature, and the improvement observed had been in the muscles other than the facial There was, of course, room for doubt as to the ones. value of this particular treatment, yet it should be remembered that no improvement had been observed under other methods, and yet was prompt and decided under physical exercise systematically carried out. The original diagnosis of progressive muscular dystrophy was without doubt correct, and the result of treatment was certainly unique. DR. JOSEPH COLLINS said that where the proton was diseased it should be evident that no amount of mechanical treatment would be of service, but if the form of progressive muscular atrophy were acquired, then treatment, including exercise, should be of some advantage. He thought, therefore, the case was very instructive. It was begging the question to infer that the improvement was independent of the treatment. He believed this to be a case of progressive muscular dystrophy of the acquired type, no evidence having been brought forward to show that it was heredity, and that the improvement was due to the treatment. DR. G. M. HAMMOND said that the man had been an athlete and a runner, and yet had developed the muscular dystrophy; hence he could not understand why if the muscular atrophy had developed during exercise, it should be arrested and improved by a resumption of systematic exercises. DR. C. HERTER said that the case was evidently one of the familiar form of progressive muscular dystrophy, and he felt that the systematic exercise must have had a beneficial effect in bringing about this change. One should not, however, draw too positive conclusions from one or two cases. The case was a most interesting example of what could be done by modifying favorably the nutrition of a part. The PRESIDENT said that as far as the distribution of the dystrophy was concerned we certainly found cases in which it was exactly similar, and yet we could not trace the exact etiological factor. Where the hereditary element was not present it was possible that there was a better chance for improvement under treatment. He thought that we were warranted in trying systematic physical exercise, at least in cases in which the hereditary factor was not especially prominent. unsteadiness of articulation. The knee-jerks were both exaggerated, particularly on the left side, and there was left-side ankle-clonus. The triceps reflex was exaggerated on the left side. The left hand was decidedly ataxic. The patient could walk, and could move the upper extremity in every direction. There was a remarkable diminution of the pain-sense all over the body, including the mucous membranes. Tactile sensation appeared to be unimpaired. Temperature-sense was exquisitely preserved. The patient talked rationally, and the psychical sphere was intact. Examination of the urine showed albumin, but no sugar. The pulse was rapid, the respirations accelerated, and the temperture 102° F. The opinion was expressed that the intracranial lesion could not be satisfactorily localized, but that there was probably a new formation within the brain, subcortically involving the pyramidal projection on the right side. Three days later the patient was seen again, and was found much worse. He was quite somnolent, and the reflexes had become quite sluggish. There was already marked pulmonary edema. An exploratory opening was made by Dr. J. E. Kelly, the surgeon in attendance, just behind the fissure of Rolando. A hollow needle introduced into the brain in various directions found no unusual collection of fluid. On the second day after the operation his temperature rose to 105° F., although there was no evidence of sepsis in the wound. He died December 1st. It was found on autopsy that a great part of the medulla had been destroyed by the tumor, leaving only a mere shell. The remarkable feature of the case was that the man appeared to be well in every respect up to a short time before his death, and yet nearly all of his medulla was gone. REVIEWS. STUDENTS' AID IN OPHTHALMOLOGY. BY GERTRUDe Dr. JOSEPH COLLINS presented a pathological speci- and they are not few-hardly justify its existence or men of TUMOR OF THE MEDULLA, with the following history: S. J. J., aged twenty-eight years, denied syphilis, and had been extremely temperate. The first symptom, numbness in the fingers of the left hand, was observed eight months ago. This gradually spread up the arm, and later on a similar feeling was noticed in the left lower extremity. About five months ago he became so unsteady that he had to give up his work as a bricklayer, but continued working in a factory till two months ago. About three weeks ago he observed a "stiff feeling" in the left side of the head, and the left upper and lower extremities felt unwieldy. On November 22d, when first seen by the speaker, at the request of Dr. Kelly, the head was fixed and slightly drawn to the left. There was no real stiffness of the head, and no abnormality or tenderness. There was no ocular paralysis; the pupils responded to light and accommodation. The fundus was found quite normal. Vision and color-perception were normal. The senses of smell and taste were normal. There was no counterbalance its deficiencies. It is too small and scrappy to serve as a hand-book or guide for any student desiring thoroughness, and its obligations to a very limited circle of teachers, coupled with a decided myopia or limitation of the field of vision as to others, is too evident. What can be said of a text-book that conveniently avoids the whole subject of the treatment of heter"Various forms of nervous ophoria with these words: disturbance can be traced to faulty muscular power, and complete relief from headache and symptoms of eyestrain is often not obtained until appropriately placed prisms are combined with the lenses which correct the patient's focal error ?'' A WEEKLY JOURNAL OF MEDICAL SCIENCE. VOL. LXVIII. NEW YORK, SATURDAY, JANUARY II, 1896. ORIGINAL ARTICLES. THE NATURE AND TREATMENT OF MAMMARY NEOPLASMS.1 BY W. P. CARR, M.D., PROFESSOR OF PHYSIOLOGY, COLUMBIAN UNIVERSITY. WE shall probably never arrive at anything like unanimity in our treatment of mammary neoplasms until we come to some definite understanding of their nature and morphological significance. And I believe that a too close following of microscopic appearances, and the attempt to classify each apparent variety as a distinct entity, have tended, and are tending, rather to lead us away from a true understanding of their real nature and consequent rational treatment. We have divided tumors broadly into two classes, benign and malignant, and made many varieties or subdivisions of each class. Some of these varieties are generally conceded to be improperly named and classified; and there is much evidence, I may say even positive proof, to show that a given tumor may pass from one variety into another, or even from the one broad class of benign tumors to the other broad class of malignant growths. I shall confine my remarks to some of the more common solid growths met with in the mammary gland, and endeavor to show the real similarity of structure in tumors that have been separately classified and that have at first sight markedly different anatomical characters. The most common tumor of the breast, the so-called adenoma, differs at first sight from the normal gland only in having a greater amount of connective tissue interposed between the glandular elements and in more or less irregularity in size and shape of these glandular elements. But, as pointed out by Rannier, Virchow, and others, the vast majority of adenomata are really a growth of connective tissue into the tubular interspaces, and should properly be called fibrous, sarcomatous, or myxomatous tumors, in which the enclosed glandular elements are a secondary phenom enon. Such a tumor is usually a true fibroma; but, if the infiltrating connective tissue be rapidly forming and rich in cells that have not had time to throw out fibrillary processes and become connective tissue, 1 Read before the Medical Society of the District of Columbia, October 2, 1895. No. 2. the growth would be properly classified as sarcoma. We cannot draw a sharp line between fibroma and sarcoma either clinically or with the microscope; nor can we always distinguish sarcoma from simple granulation-tissue the result of injury or inflammation. It seems clear, therefore, that the chief element of adenoma, adeno-sarcoma, adeno-fibroma, myxoma, and sarcoma is an infiltration of connective tissue more or less rich in cellular elements or mucilaginous material. To go a step further, we may safely say that there are but two possible sources from which this infiltration of connective tissue may spring; and these are, first, the previously existing connective-tissue cells and, secondly, the leucocytes. Two kinds of cells are found in connective tissue, the fixed cell and the wandering cell. That fixed connective-tissue cells proliferate I very much doubt, but there is no reason to doubt the proliferation of the wandering cells, which are really leucocytes. However, be this as it may, we cannot question the fact that white blood-cells do, under a variety of circumstances, pass out of the blood vessels and change into fixed connective-tissue cells. Nor can we doubt that much, if not all, of the new connective tissue formed at the site of various inflammations is derived from wandering leucocytes. The main function of some of the leucocytes seems to be that of changing into connective tissue for purposes of repair or for the walling. up of some foreign body or deleterious substance.. Granted then the infiltration of a tissue with leuco cytes, we have the ancestor for our tumor. Let the fibrous mesh of the mammary gland become infiltrated with cells, as it invariably will under the influence of prolonged irritation; let these cells: change into connective tissue, as they invariably will do under the same influence, and we have a tumor that will be fibrous or sarcomatous according to the slowness or rapidity of the process. We have only to find and understand the source of irritation to complete the etiology. In order to make my propositions intelligible allow me to state some of the physiological processes known to occur in healthy tissues and in inflammations. We know that in the mammary gland we have a collection of gland-tubes surrounded and supported by a rather loose mesh of connective tissue richly supplied with bloodvessels and lymphatics. | We know that normally there is a constant outpour aska State Libr ing of lymph or plasma from the vessels, and that this plasma flows between the meshes of the connective tissue, bathing and nourishing these cells and also those composing the gland-tubes, and finally finding its way into the lymphatics, to be returned to the bloodvessels. We know that the walls of the capillaries are provided with or can create small openings or stomata which allow white blood-cells to pass out in limited numbers and accompany the stream of plasma, while under ordinary circumstances the red corpuscles are unable to pass through these minute openings. sue. Let an irritant be applied, and the capillaries will become distended, plasma and cells pass out much more rapidly than in health, and the loose connective tissue becomes packed with cells and plasma. Stop the irritation, and the capillaries return to their normal condition, the infiltrating cells and plasma are carried off by the lymphatics, and the part returns to its normal condition. But let the irritation be continued long enough, and the infiltrating cells begin to change into connective tisThey will continue to come out of the bloodvessels and form connective tissue as long as the irritation is continued. After a time indeed this newly formed tissue may act as a foreign body and become encapsulated. Whether or not the tumor will continue to grow depends perhaps upon several conditions, such as the continuation of the irritation, the resistance of the tissues, the completeness of the nervous control of the fixed cells of the tissue, and the amount of nutrition supplied. That fibrous and sarcomatous tumors have frequently originated at the seat of an injury cannot be denied, nor can it be proven that most tumors have not been preceded by some inflammatory infiltration. There is much evidence to show that benign as well as malignant tumors usually occur in some tissue that has been the seat of such infiltration. I have myself seen four cases of what appeared to be a simple mammary abscess develop into a tumor. In one case into a carcinoma, in one into a rapidly fatal small round-celled sarcoma, and in two cases into fibromata or so-called adenomata that continued to grow and developed into large tumors. In fact, all inflammations that result in destruction of tissue or suppuration leave behind them a certain amount of fibrous infiltration enclosing gland-tubules that would present exactly the microscopic appearance of adeno-fibroma. I have in my possession a section showing this condition, taken from the breast of a woman who died of chronic parenchymatous nephritis soon after the healing of a mammary abscess. It cannot be distinguished from ordinary adenoma. Keloid growths in scars are common. The frequency of occurrence of tumors in any organ is in proportion to the amount of exposure of that organ to inflammatory influences. Seventy per cent. of all tumors in women attack the reproductive organs, and it is safe to say that seventy per cent. of all prolonged inflammations are similarly situated. The mammary gland is peculiarly exposed to traumatic. injuries, to bacterial invasions, and to prolonged and chronic irritation of a reflex character from the uterus. Its loose anatomical structure seems particularly favorable for tumor development and growth. I am aware that these views are diametrically opposed to some recent and high authorities. Mr. Roger Williams, F.R.C.S., has recently published a monograph upon diseases of the breast, of which J. William White' says: "Mr. Williams, whose previous work in this same direction has been noteworthy, has now given to diseases of the breast a broad and comprehensive consideration which makes his monograph the most valuable contribution of recent years to our knowledge of the subject.' Mr. Williams' book is undoubtedly of great interest, for he has carefully collected and arranged a vast array of facts bearing upon his subject. He makes, however, the startling statement that 95.74 per cent. of all breast-tumors are of archiblastic origin, and only 4.26 per cent. of parablastic origin. If we really believed that nearly 96 per cent. of all tumors of the breast were of epithelial origin, there would be no excuse for leaving any tumor in a breast a moment longer than necessary for its removal; but the explanation of this statement by Mr. Williams is that he regards the common adenoma as an archiblastic tumor because he finds in it the epithelial lining of the glandular ducts, which he believes to be originally derived from the ectoderm. This is, in my own opinion, so grave an error as to destroy the foundation of all his subsequent deductions. Again, says J. William White: "He minimizes the influence of trauma and of pre-existing inflammatory lesions, contrary to the widespread belief both in the profession and among the laity, and concludes his careful review of this part of the subject as follows: The outcome of all this is that intrinsic causes are much more important factors in the origination of cancer than extrinsic ones, which are by no means its necessary antecedents. In the vast majority of cases the outbreak of this disease seems to be entirely spontaneous; that is to say, it cannot be attributed to the immediate action of any appreciable extrinsic cause whatever. The occasional transformation of innocent into malignant growths must be admitted.'" But he thinks this is very different from admitting that such neoplasms are specially prone to develop into malignant disease. Here again his reasoning, I think, is faulty. He persists, like many others, in refusing to take into consideration the statement invariably made by 1 American Journal of Medical Sciences, October, 1894. |