is at first painless, but soon becomes the seat of an acute, localized, pricking pain. This lump grows and becomes irregular and adherent, causing puckering of the soft parts. After the skin or mucous membrane above it has become infiltrated ulceration takes place and a fungous mass protrudes which bleeds and suppurates. The adjacent lymphatics soon become involved, and the constitutional involvement is rapid and certain.

(b) Encephaloid carcinoma is a soft gray or brain-like mass. It is a rare growth, it has no capsule, and it may appear in the kidney, liver, ovary, testicle, mammary gland, stomach, bladder, and maxillary antrum. An encephaloid cancer often contains cavities filled with blood, and this variety is known as a "hematoid" or a "telangiectatic" carcinoma. These growths are soft and semi-fluctuating, they infiltrate rapidly and soon fungate, and they terminate life in from a year to a year and a half. If the cells of encephaloid become filled with melanin, we have the condition known as "melanosis " or "melanotic cancer."

(c) Colloid carcinoma arises from either a scirrhus or an encephaloid cancer when the cells or stroma undergo colloid degeneration. On section we see in the center of the growth a series of cavities filled with a material resembling honey or jelly; the periphery often shows an ordinary scirrhus or encephaloid cancer. Colloid degeneration is most prone to attack cancers of the stomach, mammary gland, and intestine.

Cylindrical-celled carcinomata which occur in the rectum are known as "adenoid" or "glandular" cancers. They may occur in this region at a much earlier age than do cancers elsewhere, being not uncommon between the ages of twenty-eight and forty. At first covered by mucous membrane, they soon ulcerate and involve the submucous and muscular coats in the growth. They grow rather slowly, and take usually from four to six years to kill. They usually, but not always, cause lymphatic involvement and constitutional infection. They are composed of a stroma of fibers between which lie tubular glands lined with columnar epithelium and masses of epithelial cells.

Treatment.-Carcinomata demand early and free excision, with removal of implicated glands. A certain proportion can be cured. Recurrent growths may be removed as a palliative measure, to lessen pain and to relieve the patient from ulceration and hemorrhage. If a growth does not recur within five years after removal, a cure has probably been at

tained. A rodent ulcer should be excised or else be curetted and cauterized with the hot iron or the Paquelin cautery. In cancer of the lower lip, remove the growth by a V-shaped incision or cut away the entire lip and remove the glands beneath the jaw; in cancer of the tongue, excise this organ and any enlarged glands; in cancer of the breast, remove the breast and pectoral fascia and take away the fat and glands of the axilla; in cancer of the rectum, if near the surface, excise the rectum from below; if above five inches from the anus, do the sacral resection of Kraske and then remove the growth; in cancer of the esophagus, perform gastrostomy; in cancer of the pylorus, perform pylorectomy or gastro-enterostomy; in cancer of the bowel, do resection with end-to-end approximation, side-track the diseased area by an anastomosis, or make an artificial anus; in cancer of the penis, amputate and remove the glands of the groin. Erysipelas toxins and erysipelas serum have been tried in inoperable carcinoma, but without any positive benefit. The same is true of pyoktanin, thiosinamin, and of all other drugs that have been suggested.

Cysts. A cyst is a sac containing a fluid or a semi-fluid. Division of Cysts.-Cysts are divided into (1) Retentioncysts, which are due to blocking up of the excretory ducts of glands and accumulation of the glandular secretions. These comprise sebaceous cysts or wens, serous cysts, mucous cysts, salivary cysts, milk-cysts, oil-cysts, and seminal cysts. (2) Exudation-cysts, which are due to accumulations in closed cavities. These comprise synovial cysts (ganglions and bursæ). Dentigerous cysts used to be considered under this head. (3) Dermoid cysts, which are congenital and arise from inversion of the cutis and imperfectly closed fetal clefts. (4) Cystomas, which are cysts of new formation due to cystic degeneration of connective tissue. These cysts are found in the neck (hygroma), in the arm-pit, and in the perineum. An example of a cystoma is found in the bursa which develops from pressure. (5) Extravasationcysts, that form around blood-extravasations. (6) Hydatid cysts, or cysts due to the echinococcus or tape-worm of the dog. A mother-cyst is formed, which becomes filled with daughter-cysts floating in a saline liquor containing hooklets.

Sebaceous cysts arise when the excretory duct of a sebaceous gland is blocked by dirt or occluded by inflammation. The orifice of the duct is often visible as a black speck over the center of the cyst. They are very common in the scalp,

being known as "wens," and upon the face, neck, shoulders, and back. Arising in the skin, and not under it, the skin cannot be freely moved over a sebaceous cyst. A sebaceous cyst is lined with epithelium and is filled with foul-smelling sebaceous material. A sebaceous cyst may suppurate. When a cyst ruptures and the contents become hard, a horn is formed. The other form of horn has been previously alluded to as due to horny transformation of a wart.

Treatment. To treat a sebaceous cyst, dissect it entirely away with scissors or an Allis dissector, trying not to rupture the sac. If even a small particle of it is left, the cyst will return. If it ruptures during removal and it is feared that some portion may remain, swab out the wound with pure carbolic acid. If acid is not used, close without drainage; but if acid is used, drain for twenty-four hours. If an abscess forms in a sebaceous cyst, open it, grasp the edges of the cyst-lining with forceps, dissect out this lining with scissors curved on the flat, cauterize with pure carbolic acid, and drain for twenty-four hours.

Dermoid cysts are lined with true skin. They contain sebaceous matter, hair, teeth, or other epiblastic products. They are always congenital, but may be so small at birth as to escape notice for years. They may be distinguished from sebaceous cysts by the fact that they always lie below the deep fascia, and hence the skin is freely movable over them. They are met with at the root of the nose, at the orbital angles, in the eyelids, upon the floor of the mouth, over the sacrum or coccyx, and in the ovaries, the testicles, the brain, the eyes, the mediastinum, the lungs, the omentum, the mesentery, and the carotid sheaths. They are due to imperfect closure of fetal clefts and inclusion of epiblast. If a dermoid cyst contains bones, it shows that mesoblast was included as well as epiblast.

Treatment. To treat a dermoid cyst, excise, if accessible, the same as in the case of a sebaceous cyst. If it lies over bone, go down to the bone: the growth will be found adherent, so remove a portion of periosteum with the cyst.

Hydatid cysts are especially common in Iceland, and are frequent in Australia, but are very rare in the United States. They are due to the echinococcus. The adult echinococcus is the tapeworm of the dog (tania echinococcus), and its ova or larvæ gain access to man's body by accompanying the food he eats and passing into the alimentary canal, from which canal they are transported to various organs by the blood. Osler says the embryo (which has six

hooklets) burrows through the wall of the bowel and enters the peritoneal cavity or muscles; it may enter the portal vessels and reach the liver, or may enter the systemic circulation and pass to distant parts. The danger depends on two factors: "the situation and the liability of the cyst to suppurate" (Sidney Coupland). The organs most usually attacked are the liver and lung. In 60 per cent. of cases the liver suffers, and in 12 per cent. the lung (Thomas). Cysts sometimes arise in the intestine, genito-urinary passages, brain, or spinal canal. When the embryo lodges the hooklets disappear and the embryo is converted into a cyst. This cyst is composed of two layers, an outer capsule (cuticular membrane) and an inner layer (endocyst). The cyst contains clear fluid (Osler). As the cyst grows, daughter-cysts bud out from the wall of the mother-cysts, the structure of the daughter-cysts being identical with that of the mother-cyst. From the lining membrane of all the cysts, after a time, growths arise known as scolices, which represent the head of the echinococcus and exhibit four sucking disks and a row of hooklets (Osler).

The fluid is not albuminous, is occasionally saccharine, is thin and clear, and may contain scolices or hooklets.

A hydatid cyst may calcify, may rupture, or may suppurate. These cysts are very firm, but usually fluctuate. Palpation with one hand while percussion is practised with the other gives a persistent tremor (hydatid fremitus). The fluid should be drawn and examined. When a cyst suppurates positive constitutional and local symptoms arise.

Treatment.—In a hydatid cyst of a superficial part incise and dissect out the sac-wall (Gardner). Unruptured hydatid cysts of superficial structures should be dissected out. Abdominal cysts should be radically removed if possible; if this is not possible, stitch to the peritoneum, incise, irrigate, and drain with gauze. Bond advocated evacuating the cyst, closing it with sutures and dropping it back in the abdomen. Gardner says tapping is dangerous, as it may cause rupture of the cyst. If aspiration is performed to settle a diagnosis, operate at once after doing it.

XVIII. DISEASES AND INJURIES OF THE HEART AND VESSELS.

Heart and Pericardium.-In an acute pulmonary congestion the venous side of the heart is over-distended with blood, and the surgeon in desperate cases may tap the right

auricle (see Paracentesis Auriculi). Pericardial effusion, if severe, calls for tapping or aspiration, and purulent pericarditis demands incision and drainage.

Wounds and Injuries.-The heart may rupture and cause instant death, but slight wounds may not prove fatal. A wound of the heart causes hemorrhage, usually copious, but owing to the interlocking of muscular fibers the hemorrhage is often slight; the pericardium may be injured by fragments of a fractured rib. If bleeding into the pericardial sac takes place, the signs of a pericardial effusion become manifest. Pain is constant, and attacks of syncope are the rule. Death is apt to occur suddenly from shock, hemorrhage, and inability of the heart to contract because of the severed fibers, or inability of the heart to dilate because of the pressure of blood in the pericardial sac. If a wound of the pericardium or heart does not cause death in the first day or two, inflammation follows (traumatic pericarditis or carditis).

Treatment. The treatment of heart-wounds consists of recumbency and lowering of the head. The body is surrounded with hot bottles, opium is given in small doses, and stimulants are applied in moderation, but never to excess. An attempt must be made to suture the wounds in the heart and pericardium. Access can be gained by resecting one or more ribs. The wounds should be sutured with silk. Rahn sutured a wound of the heart and packed the pericardium with gauze, and the patient recovered. Parrozzani successfully sutured a wound of the ventricle. Williams reports recovery after a stab-wound of the heart, the pericardium having been sutured. Fareni sutured a stab-wound of the left ventricle, and the patient lived several days. Cappelan sutured a wound of the heart, and the patient lived two and one-half days. Traumatic carditis or pericarditis is treated in the same way as idiopathic cases. Pus in the pericardial sac should be evacuated by resection of the fourth left costal cartilage and incision of the pericardium (Von Eiselberg's case). Dalton has sutured the pericardium.

Phlebitis, or Inflammation of a Vein.-Phlebitis may be plastic, or it may be purulent. Plastic phlebitis, while occasionally due to gout, to a febrile malady, or to some other constitutional condition, usually takes its origin from a wound or other injury, from the extension to the vein of a perivascular inflammation, or in the portal region from an embolus. Varicose veins are particularly liable to phlebitis. When phlebitis begins a thrombus forms because of the