Abstracts Experimental Studies; Animal Tumors

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ABSTRACTS EXPERIMENTAL STUDIES; ANIMAL TUMORS

of ’ Discussion on Experimental Production Malignant Turnours, J. A. MURRAY et al. Proc. Roy. SOC.,London, Series B 113: 268-292, 1933. In opening this discussion Dr. Murray pointed out that many of the ideas and conclusions resulting from pathologic study of malignant tumors have obtained precision and validity from the Atudy of the transplantable and experimental tumors of animals during the past thirty years. We can now with some confidence define malignant tumors as tissue proliferations arising in a localized area, growing from their own resources in an uncontrolled manner, and showing a continuous graded series in those arising from any one tissue. We are still without a satisfactory explanation of the process which embraces all the characters of neoplasia, and it is impossible to accept any hypothesis of its nature and origin which omits any of these characters. Theories of carcinogenesis may be divided into three groups. (I) The first of these is the genetic or mutation hypothesis, originating yith Boveri. (2) The virus hypothesis is at present inadmissible because cell-free transmission of mammalian tumors has not yet been demonstrated. Until this is accomplished it is dangerous to transfer conceptions arising from the study of filtrable avian neoplasms to the elucidation of the nature and causation of tumors in other animals and in man. (3) The experimental confirmation of Virchow’s chronic irritation theory has established its validity as a concise description of the emergence of cancer after prolonged, localized, slight irritation of tissue by a variety of agents, and nothing more. The experimental induction of malignant tumors reproduces perfectly the phenomena which occur in the development of occupationd cancer from exposure to tar, x-rays, etc. Wide differences of opinion still find expression as to how this result is brought about. It is possible that the chemical and physicaI carcinogenic agents act indirectly by setting up conditions in the tissues such that here and there cancerous foci are started, but the properties of these agents are so varied as to give no indication of how the uncontrolled type of proliferation is induced, or of the nature of the cellular mechanism involved. Until this difficulty is at least partially overcome, it seems useless to indulge in the further speculation that the less precisely known carcinogenic agents (application of cold, x-rays, etc.) produce this effect by liberating in the tissues subshnces more or less closely related chemically to one or other of the pure substances with carcinogenic action. Dr. W. J. Cook, confining his remarks to the experimental production of cancer by pure chemical compounds, pointed out that chronic irritation ” is a misleading term. There are many examples of industrial skin diseases brought about by chemical irritation, but few of these lead to malignant tumor formation. There are many constituents of coal tar which are powerful irritants and yet are not carcinogenic. On the other hand, not one of the carcinogenic hydrocarbons has any apparent irritating effect on the skin. No view of the origin of malignant disease can lie comprehensive if it fails to take into account the cancer-producing properties of all the known carcinogenic agents. Experimental investigation of the effect of these agents on tissue metabolism is of importance. Boyland, for instance, has found that carcinogenic hydrocarbons influence enzyme systems in a manner similar to arsenious acid, which is undoubtedly responsible for cases of 141 142 ABSTRACTS human cancer. A factor common to all the carcinogenic hydrocarbons is the presence of the phenanthrene ring system, which is also contained in a number of naturally occurring compounds of biologic interest, such as the sterols, the ovarian hormone, possibly the male hormone, vitamin D, etc. Dr. W. Cramer remarked that the close chemical relationship between certain carcinogenic substances and the sterols, which are constituents of every animal cell, suggests that normal cells, if placed under abnormal conditions, can themselves produce carcinogenic substances as abnormal metabolites. The conditions vaguely called chronic irritation may act in this manner. Another and quite different method of inducing carcinogenesis is the trans-, mission of tumors by cell-free filtrates containing an agent which is thermolabile and can give rise to antibodies. This immediate and specific type of carcinogenesis has so far been observed only in birds, and produces only tumors of mesoblastic origin. Spontaneous tumors in fowls, as in mammals, appear in middle-aged or old individuals, and do not spread among healthy birds by contagion; experimental transmission by filtrates is effected more easily in young than in old birds. Work on mammalian tumors has led to the conclusion that the change which constitutes malignancy is a purely cellular one, not due to an extraneous agent, and that it probably resides in the nucleus. Bauer’s suggestion that this change affects the genes, so that the cancer cell represents a mutation of a normal somatic cell, is merely an interesting guess, which does not enable us to understand the characteristic properties of the malignant cell, such as its infiltrative growth and altered metabolism. Warburg’s work seems to offer a better explanation of malignant cell growth than do the conceptions of a virus or a mutation. The changed metabolism makes the cancer cell more independent of an available oxygen supply than the normal cell from which it is derived. But whatever explanation of the intracellular change we may adopt, we still have to explain why the normal cells of one and the same organism can give rise to such varied manifestations of malignancy, each of which breeds true. The.essentia1 features of cancer have been fixed by experimental study and are not affected, whatever may be found to be the intimat,e cellular change. If cancer is a mutation, we cannot mutate back at will; if it is an intracellular virus we can not kill the virus within the cell; an immune system capable of neutralizing completely an active extract of Rous sarcoma has no effect whatever on the cells of this tumor. The correction of an abnormal type of metabolism offers greater therapeutic possibilities, but so far attempts along this line have not been RUC- cessful. Dr. C. E. Andrewes expressed his opinion that the filtrable fowl tumorR afford an important line of attack on the tumor problem as a whole. It is difficult to believe that the fowl sarcomas are essentially and entirely different in nature from mammalian tumors, and to maintain the attitude that these filtrable tumors form a group of virus diseases quite different from fowl tumors as a whole. Whenever a fowl tumor has been studied over a long period, it has proved to be filtrable. If the virus theory of cancer is worth considering seriously, we should also be prepared to accept the principle that the viruses that cause tumors are probably not sharply distinguishable from those causing infections. There are various pathologic conditions which many cancer workers dismiss from consideration as not being true tumors, yet these stand in an intermediate position between the tumors and the infections. Examples are the lymphosarcoma of dogs, the myxoma of rabbits, and Shope’s interesting filtrable fibroma of the rabbit [see Am. J. Cancer 17: 808, 809, 19331, the agent of which apparently behaves at one time like a tumor producer and at another causes an inflammatory reaction bearing no resemblance to a tumor. EXPERIMENTAL 8TUDIEB ; ANIMAL TUMORS 143

Dr. P. R. Peacock agreed that the filtrable avian tumors and their relationship to mammalian tumors present a probIem which must be solved before generaliza- tions as to the causation of tumor growth can be regarded as more than interesting speculations. An obvious method seems to be the induction of tumors in fowls by agents which produce tumors in mammals, and it is surprising that so far only about a dozen such tumors have been described, only one of which has been carried beyond the second generation. This tumor, produced in Murphy's laboratory, was carried through eleven generations of transplantation, but was never shown to be filtrable. But inability to do something is not. proof that it cannot be done. Peacock had found no real difficulty in producing tumors in fowls by injecting carcinogenic tars intramuscularly, provided the birds could be kept alive for from six months to a year. The tumors thus obtained were not distinguishable clinically or histologically from some of the filtrable tumors, such as the Rous sarcoma. These tumors could be propagated, though with difficulty. [See Abst. in Am. J. Cancer 17: 969, 1933.1 Prof. J. McIntosh prefaced his remarks by saying that we have many theories, but more definite facts are required; " the birth,of a fact is the death of a theory." He had obtained tumors in 12 out of 20 birds treated with tar, and even in this mmall number there was considerable histologic variety. Some were fibrosarco- matous, others mainly fibro-endotheliomatous; in others these types were associated with leukosarcoma or leukemia. Three of these different types of tar tumors were carried through one or more passages. One, a fibrosarcoma, originally a leukemia with only a fibrous reaction in the breast muscle, has been carried through six passages and now breeds true, having lost the leukemic element, and it is readily fltrabie. That these tumors were of spontaneous origin seems nega- tived by the fact that before these tarring experiments began, during seven years only one spontaneous tumor had been found among more than 5000 birds used. The work of Ellerman, Furth and others on the leukemias of birds hau shown that there is a good deal of pleomorphism in the type of disease produced by inoculation of a leukemic virus; for instance, Furth, in propagating a single strain of leukosis in a large series of birds, found that at one time or another it gave rise to erythroleukosis, lymphoid leukosis, myeloid leukosis, a combination of myeloid leukosis and erythroleukosis, myeloma, and sarcoma. [Most of the papers on this subject by Furth and his collaborators, and by others, have appeared in abstract in Am. J. Cancer.] Oberling and his associates [see Abst. in Am. J. Cancer 18: 631, 19331 found similar pleomorphism during the propagation of a spontaneous strain of leukemia; the virus, apparently affecting endothelial as well as fibrous tissue, after a time produced tumor-like fibrous nodules, ending finally in a sarcomatous tumor, which was filtrable and which may correspond in type with the fowl endothelioma described by Murray and Bagg. The work of Andrewes and others on the close affinities of the viruses of the different fowl tumors supports the explanation that the proliferative and tumor-Iike effecta are due to a single pleomorphic virus with an affinity for any tissue of mesoblastic origin. Dr. W. E. Gye said he had worked for some time with the fowl leukemias referred to by Professor McIntosh, and could find no,cros8 immunity relation between the Rous tumor and the virus of leukemia, which he thought rather surprising. He emphasized the important results obtained by Murphy and his collaborators on the inhibitory factors in fowl tumors. Working with Dr. Purdy, he had observed that, while the Rous sarcoma normally grew rapidly, from time to time it entered into a benign stage during which growth was very slow. The slow-growing tumors contained something which exerted an inhibitory influence on filtrates of rapidly growing tumors. Gye and Purdy could not devise a technic which would show this with certainty, but Dr. Murphy has obtained more constant results, and there seems no doubt that an inhibitory substance is produced within 144 ABSTRACTS the cells when the tumor grows slowly. Gye believed that in order to make real progress in the study of cancer it is necessary to look within the cell rather than to confine attention to its morphology. Prof. A. E. Boycott suggested that the three hypotheses set forth in Dr. Mur- ray’s opening summary might be regarded as complementary to one another, rather than as alternatives. He could not see how gene mutation could in itself be a cause of cancer, though it might be an expression of why a cancer cell is different from a normal cell. It should be kept in mind that tumors are only anarchic and lawless in the sense in which a criminal’s conduct may be so described. The criminal has his own code and sticks to it; it is different from that of normal people, but it is not strictly lawless. The study of transplantable tumors shows that a tumor maintains the same characteristics, so far as we know, forever and ever. These characteristics are passed on through successive generations of cells and are entirely different from those of the normal tissues among which the tumor is growing. Surely, then, the tumor cells must differ genetically from those of normal tissues. In the case of tumor production by carcinogenic agents the problem is whether these act directly on normal cells and produce “ mutation,” or whether they induce the production of some carcinogenic substance in the tissues. The probabilities seem against the latter explanation, because of the great diversity of the effects produced, different tumors differing considerably among themselves. Another view of these carcinogenic agents regards them as affording a suitable nidus on which a supposed extraneous virus gets a lodging, but this view has failed of confirmation. There is not the slightest epidemiologic evidence that any such extraneous virus exists, and it seems very unlikely that a thing capable of independent life would stand the amount of knocking about that these agents will stand-precipitation, adsorption, resuspension, and so forth. “ It is a remarkably live thing if it gets through to the end of that in a live state.” With reference to what Dr. Andrewes had said, Professor Boycott expressed the opinion that the antigenic argument could be very much overworked. If you make a compound of protein with all sorts of chemicals they become antigeni- cally different from what they were before. Surely a thing like a malignant tumor is very likely to be antigenic. The proteins of the lens of the eye, for example, are antigenic to the very same animal, from which it might be dedured that the proteins of the lens always contained a virus. That might be an illustration of Dr. Cramer’s interesting speculation, in which he talked about non-pathogenic viruses in normal cells.’ I rather thought at the time that if one postulates a normal virus occurring in a normal cell, one had better call it something other than a virus.” [Murray’s opening address appears also in Nature 132: 156-158, 1933 and Lancet 1 : 1301-1303, 1933.1 F. CAVERS

Bacteriologic Examination of Mouse Tumors, SHINGOIKEDA. Bakteriologische Untersuchungen an Mausetumoren, Ztschr. f. Krebsforsch. 39: 492-495, 1933. Several authors have cultivated microorganisms from tumors, and have described the production of neoplasms with them in plants or animals. The author has examined bacteriologically about 1000 mouse carcinomas of the Ehrlich strain and about 100 mouse sarcomas. No bacteria were found in smears from 18.6 per cent of the former and 24.5 per cent of the latter, In contrast to this, only 2 per cent of cultures proved sterile. None of the various organisms isolated gave rise to tumors in either animals or plants, and it is probable that they were harmless contaminants. WM.13. WOGLOM EXPERIMENTAL STUDIES ; ANIMAL TUMORS 145

Effect of Spinal Fluid on the Development of Transplanted Adenomcinomn in the White Mouse, A. MORATTI. L’azione del liquid0 cefalorachidiano (endo- rachidina) sullo sviluppo dell’adenocarcinoma da innesto nel top0 bianco, Tumori 7: 1-25, 1933. The author reviews the literature on the experimental use of cerebrospinal fluid subcutaneously. In most experiments autogenous fluid has been used with the idea of increasing the immunological factors at work in the individual. In this series of experiments the cerebrospinal fluid of the horse was injected subcutaneously in white mice bearing the Ehrlich adenocarcinoma. Four series of ten mice each were given injections of the fluid after successful transplantation of the tumor. An equal number of animals of the same age, sex, and weight, and bearing tumors transplanted at the same time, served as controls. The injected animals showed increases in weight over the controls and a greater vitality, and their tumors attained a larger size. To determine which elements were responsible for the increase in tumor size and general weight, a further series of experiments was instituted. To exclude the possible action of the water in the spinal fluid, a group of tumor-bearing animals was injected with distilled water containing glucose and sodium chloride in the proportions found in cerebrospinal fluid. Tumor growth in the animals so treated was slightly retarded. To rule out the action of the pineal secretion, a series of tumor-bearing animals was given desiccated pineal gland by mouth or subcutaneous injections of the watery extract of the gland. There was no uniform effect caused by the pineal extract injections. The author reviews the literature on the presence of* pituitary hormones in spinal fluid and attributes the growth-producing effect of parenteral injection of the fluid to the presence of the growth-producing hormone of the anterior pituitary lobe. The presence of trephonic substances in the fluid may also assist the action. The article contains a long bibliography. JEANNETTEMUNRO influence upon the Growth of Trans lantable Tumors of Agents Which Produce Acidosis, ANNAGOLDFEDER. tf ber den Einfluss der acidotischwirkenden chemischen Prllparate auf das Wachstum bzw. Verschwindep der trans- plantablen Tiertumore, Ztschr. f. Krebsforsch. 39: 421-435, 1933. Among 45 mice bearing carcinoma 63 and treated with a combination of monoiodoacetic acid, ammonium chloride, and calcium chloride, the tumor disappeared entirely in 9 and regressed partially in 8. Among 29 treated rats bearing the Flexner-Jobling carcinoma, the tumor disappeared entirely in 9, partially regressed in 6, and remained stationary in 1. In most instances it was the small tumors that were thus affected. Monoiodoacetic acid alone seemed moderately successful, though no definite conclusions are drawn in respect to its action. Controls were purposely omitted, because the main object of the experiment was to assess the therapeutic action of the agents employed (“ Wir stellten keine Kontrollversuche an, weil es uns bei diesen Versuchen HauptsiCchlich an einer Beobachturig der therapeutischen Wirkung der angewandten Prliparate lag.”) Thus acidotic treatment produced at least some slight effect upon transplantable tumors. In this connection the writer says that in all her previous experiments she has never once seen spontaneous regression of the tumors employed, though its occurrence is recognized in the literature. WIN. H. WOGLOM 146 ABSTRACTS

Immunity against Transplantable Tumors. Communication 11. The Survival of Tumor Cells in Heterologous Hosts after Passage in vivo, A. 1. WYLEO- SCHANIN. Zur Erforschung der Immunitiit gegen Impftumoren. 11. Mit- teilung. Dauernde Erhaltung von Blastomzellen im lebenden Zustande unter heterologen Bedingungen durch I‘ Passagen in vivo,” Ztschr. f. Krebsforsch. 39: 436-450, 1933. It is well known that the cells of a malignant tumor can be cultivated inde- finitely in uitro without loss of their fundamental biological characteristics, even when the medium is derived from a heterologous source or from an animal actually immune to the neoplasm in question. These observations suggest not only that tumor cells can live for a long time in the absence of homologous material, but that there exists no deleterious agent in the body fluids of a resistant animal. Yet, at the same time, they contradict the universally held belief that heterologous transplantation succeeds only occasionally, and then under exceptional cir- cumstances. Thus two sets of authenticated observations appear to be in conflict: On the one hand, the body fluids of various animals are shown to contain all that is requisite for the nutrition of heterologous tumor cells; on the other, alien cells soon die in uiuo. Is this discrepancy real or only apparent? Analysis of the conditions necessary for growth in uitro shows that one of them is periodic removal to fresh medium. The author therefore reproduced the situation in uiuo, and found that grafts of the Jensen rat sarcoma lived for a long time (thirty-nine days) in mice if transplanted to other mice every five to six days. When removed to different sites in the same mouse, however, their life was not prolonged; hence a general reaction must ultimately develop in the host which makes it no longer a suitable soil. The Ehrlich mouse carcinoma did not do so well in rats under the same conditions, perhaps because it so readily undergoes necrosis; at any rate, only one heterotransplant out of 8 lived for eighteen days. The experiments suggest that successful heterotransplantation might follow systematic removal to fresh hosts at suitable intervals. [The general reaction outlined by the author was described by Bashford and Russell (Proc. Roy. SOC. London, Series B, 82: 298, 1910; Lancet 1: 782, 1910; Third Scientific Report Imperial Cancer Research Fund, London, 1908, p. 341), who showed that when a mouse tumor was inoculated into a rat an active immunity was soon induced (three to nine days), which led to the rapid destruction of any mouse tumor cells subsequently introduced and terminated the growth of those already present.] WY. H. WOOLOM Influence of Magnesium on the Urinary Carbon: Nitrogen Ratio of Tumor-bearing Rats, B. BRAIER. Aaci6n del cloruro de magnesio sobre la relaci6n C/N urinaria de ratas portadoras de tumores experimentales, Semana m6d. 1 : 2006-2010, 1933. The author cites three series of findings by other writers which led him to make the experiments here reported. (1) McCollum and Orent (J. Biol. Chem. 92: xxx, 1931) found that young rats fed on a diet deficient in magnesium showed retarded growth, bone decalcification, loss of hair, and convulsions, and soon died unless they were given magnesium, when the symptoms disappeared and the animals rapidly gained weight. (2) Delbet and others have reported that administration of magnesium retards or even prevents the growth of experimental tumors [for a critical review of this subject, see Shear; Am. J. Cancer 18: 924, 1933, especially pp. 972-984, 1010-10131. (3) Medwedeva (Deutsche med. Wchnschr. 53: 1732, 1927) found that in cancer patients the urinary carbon: nitrogen ratio was 0.9 to 2.71, while in normal subjects it was always below 0.7. [The author does not add, however, that Medwedcva examined only 3 control patients, that out of 17 of his EXPERIMENTAL STUDIEB ; ANIMAL TUMORB 147 cancer patients, 5 showed a normal quotient, and that in each case the determina- tions were made on a single sample of urine.1 In his experiments Braier used 48 rats, divided into three series and treated in the fcllowing manner. (1) Sixteen rats of approximately equal weight were fed similarly for thirty days, except that 8 received a daily subcutaneousinjection of 1 C.C. of a 2 per cent solution of magnesium chloride; each animal was then inoculated with a spindle-cell rat sarcoma; the 8 rats which had been given magnesium continued to receive daily injections. (2) Thirty days after inoculation, a tumor from a magnesium-treated animal was transplanted into 8 rats previously given magnesium for thirty days; a tumor from an animal which had not received magnesium was transplanted into 8 control rats, the two lots being treated as in series 1. (3) The same procedure was repeated with tumor transplantations from a magnesium-treated and a non-magnesium-treated rat from series 2. No evidence was obtained from any of the series that the magnesium given to half of the animals had accumulated in their tumors. In each series the majority of the tumors had become ulcerated by the thirtieth day after inoculation. The results are set forth in tables and graphs. All the magnesium-treated animals gained more in weight than the controls during the thirty days before the two lots were given tumor inoculation, and continued to gain weight even more rapidly during the following thirty days. The tumors of the magnesium-treated animals grew less rapidly in sise and weight than those of the controls, and in three cases underwent absorption between the twentieth and thirtieth days. [The drawings given show that in several instances the thirty-day tumors were practically as large in the control as in the treated rats, and the author himself attaches no significance to the three cases of tumor absorption observed among the oontro1s.I The body and the tumor of each animal were weighed separately between the thirtieth and thirty-fifth days after inoculation; in the magnesium-treated animals the tumors represented on the average 15 per cent, and in the controls 28 per cent of the body weight. The author next determined the amounts of carbon and of nitrogen in the urine of the 48 animals before inoculation and twenty-five to thirty days after inoculation. The C/N ratio was practically the same (average 0.36) in all the animals, whether or not they received magnesium, up to the time when they received the tumor graft. After the magnesium-treated tumors had been growing for twenty- five to thirty days, the C/N ratio in the animals remained practically unchanged (average 0.4), while in the controls it had considerably increased (average 0.86). The author attributes the constancy of the urinary C/N ratio in the animals which were given magnesium chloride for thirty days before the graft, and for twenty-five to thirty days afterward, to the fact that these animals put on weight and remained in good condition, with slowly growing tumors; hence their carbohydrate metabolism remained normal. In the controls, which put on less weight and showed signs of cachexia owing to more rapid tumor growth, the carbohydrate metabolism was disturbed, and a larger amount of unoxidired carbon was excreted. Assuming that the excess of carbon was derived from carbohydrates, that the oxido- reduction processes are augmented in tissues which are growing actively, and that in such tissues the glutathione content is increased, the author determined this content in the tumors of four treated and four control rats. In the former the tumors contained an average of 98 mg. and in the latter 154 mg. per 100 gm. of tumor tissue. F. CAVERS 148 ABSTRACTS

Anemia in Rats Bearing Carcinoma, JULIUSPUTNOKY. Uber die Aniimie der Carcinomratten, Ztschr. f. Krebsforsch. 39: 451-463, 1933. The author says that after many failures he succeeded in getting the Ehrlich mouse carcinoma to grow in rats and reports that it is now in its 125th generation. Rats with growing or receding tumors, as well as those unsuccessfully inoculated or injected with autolyzed or necrotic tumor or with an ethereal extract of the latter, all showed a diminished red cell count. [For the results of total white cell and differential counts, hemoglobin deter- minations, clotting time, sedimentation rate, etc., the original article may be consulted.] WM. H. WOQLOM

Existence of Non-chromosomal Influence in the Incidence of Mammary Tumors in Mice, C. C. LITTLE. Science 78: 465, 1933. The author records some preliminary observations suggesting the existence of extra-chromosomal influences in relation to the incidence of spontaneous mammary tumors in mice. The data are derived from four different sets of reciprocal crosses between “ high tumor ” and “ low tumor ” strains. In each case a significantly higher percentage of mammary tumors is observed among the off- spring if the female parent had been derived from the “ high tumor ” strain. Also the F2generation from one of the crosses where the female parent had been derived from a high tumor ” strain shows a significantly higher proportion of tumors than the Fz progeny from the reciprocal cross where the male parent had been derived from the ‘‘ high tumor ” strain. Since the chromosomal composition of the daughters of reciprocal matings would be identical, Little argues that these marked differences establish the transmission of extra-chromosomal influence and definitely disprove the theory of a simple Mendelian genetic nature of the biological agents influencing the etiology of spontaneous mammary tumors. [This is an interesting contribution, but the fact that no mention is made of the comparative ages of the animals in the several groups in which the differences were observed would make one hesitate to accept as established the theory of the transmission of extra-chromosomal influences, or the fact that any theory of the etiology of spontaneous tumors was definitely disproved. No doubt this information will ultimately be published.] Relation of the Internal Secretions to Tumor Metabolism, OVID0. MEYER,CLAIRE MCTIERNANAND JOSEPHC. AUB. Endocrinology 17: 363-371, 1933. The endocrine picture of mice bearing sarcoma No. 180 and carcinoma No. 63 was altered in various ways. The animals were then killed and the metabolism of the isolated tumor and liver was studied. The administration of anterior pituitary extract, adrenal cortex extract, or thymus extract, or the removal of the suprarenal glands, did not affect the metabolism of mouse sarcoma No. 180. Thyroidectomy depressed the metabolism of both tumor and liver. Orchidectomy depressed tumor oxygen consumption but did not affect liver metabolism. The administration of thyroxin increased liver metabolism, including anaerobic glycolysis, but decreased the oxygen consumption of sarcoma No. 180 and carcinoma No. 63 and left the aerobic and anaerobic glycolysis of these tumors unaffected. H. Q. WOODARD Effect of Thyroxin upon the Metabolism of Isolated Normal and Malignant Tissue, 0. 0. MEYER,C. MCTIERNANAND J. C. AUB. J. Clin. Investigation 12: 723-735, 1933. Thyroxin was administered to normal and tumor-bearing mice for eight to fifteen days; the animals were then killed and the metabolism of the isolated liver EXPERIMENTAL STUDIES ; ANIMAL TUMOR6 149 and tumor tissues was studied. It wea found that the oxygen conaumption and the ana&robicglycolysis of the livers of the thyroxin-treated animals were increased and the respiratory quotient was unaffected. The oxygen consumption of sarcoma No. 180 was in moat cases depressed in the thyroxin-treated animals, while Cog production by respiration and glycolysis was unaffected and aerobic glycolysis wea not increased. The effect of thyroxin on carcinoma No. 63 was similar to that on sarcoma No. 180. Since the nerve supply of tumors is poor, and since other experiments showed that the effect of thyroxin on the dog kidney was independent of the nerve supply, the authors conclude that the nature of the reaponse of the tumor to thyroxin is due not to lack of innervation but to some unknown factor in the tumor tissue. The article contains a bibliography. H. Q. WOODARD Changes Induced by Inrertion of Tu in the RedPelvis of Rnbbits, Guinea-pip and Mice, G. BPITTAZZI.Produsioni epiteliali aperimentali da cetrame del bacinetto e dell’uretere, Gior. d. r. Accad. di med. di Torino 95: 182-192,1932. Several workers have reported the results of inserting tar into the urogenital organs of animals. These reports have been summarized in two excellent collec- tive reviews of the recent literature of tar cancer, published independently, one by Watson (Cancer Review 7: 445, 1932) and the second, and more comprehensive, by &elig and Cooper (Am. J. Cancer 17: 589, 1933. See in particular the section on ‘‘ extracutaneous tar application and extracutaneous tar tumors,” pp. 633- 637). Both of these reviews sought to bring down to date the valuable work published by Woglom in 1926 (Arch. Path. 2: 533, 709). Bettaczi has repeated the experimenta of Latteri, who claimed success in obtaining epithelial changes, ranging from proliferation and leukoplakia to out- spoken carcinoma, in the renal pelvis by operative insertion of cement saturated with tar. In control animals, in which cement alone was used, only slight inflammatory changes were observed, and Latteri therefore concluded that the tumors described were attributable to the carcinogenic action of the tar, and not to the presence of a foreign body acting mechanically. The growths interpreted histologically as malignant tumors (in one case with metastases, especially in the lungs) were not found in animals dying within less than one hundred and twenty days; in most cases they appeared after an interval of a year or more. Bettaazi used 31 rabbits, 52 guinea-pigs and 60 mice. The animals were nephrotomized and a mixture of two parts of tar and one of cement placed in the pelvis of one kidney. In addition, 11 of the rabbits and 12 of the guinea-pigs were painted with tar on the back, and 10 of the mice were given amall amounts of tar in their food; all the animals 80 treated died within fifteen to thirty days. Of the animals subjected to operation alone, all the guinea-pigs died in thirty to eighty days after operation; the mice in seventy to one hundred and twenty days; the rabbits in seventy to one hundred and sixty days. All the animals were autopsied and histologic studies were made of the kidney, renal pelvis, and upper part of the ureter. The early changes observed in these organs were essentially the same in the animals which died from tar intoxication and those which survived for more than a month. In the kidney the most widespread change consisted in proliferation of the connective tissue, leading to marked sclerosis. This was accompanied by infiltration, consisting mainly of lymphocytes, the formation of new blood vessels, areas of hemorrhage, and other changes corresponding to interstitial nephritis. In some cases the kidney was enlarged and hydronephrotic. In advanced stages glomeruli and tubules were largely replaced by fibrous tissue, or dilated into cysts, but in no case was proliferation of the epithelium observed. The final condition was that of general atrophy and sclerosis. In all cases the untreated kidney and pelvis showed only slight inflammatory changes. 150 ABSTRACTS

In the calyces, pelvis, and upper part of the ureter of the treated side the picture was entirely different, the changes being practically confined to the epithelium, which showed active proliferation and thickening (up to 40 cells). This was followed by the formation of papillomatous structures, a few being seen about the seventieth day after operation, and their number increasing rapidly after one hundred to one hundred and twenty days, when the calyces, pelvis and ureter were densely covered by hundreds of short thick papillary processes, mostly simple but some branched. In some places the epithelial proliferation extended into the submucosa, but nowhere did it show signs of invading the muscular tissue. In the submucosa there were cell nests and pseudo-adenomatous or cystic formations. Neither in the papillomas nor in the submucosa were there signs of inflammation or infiltration. The absence of inflammatory changes seems to preclude infection as an etiologic agent, while the absence of infiltration and invasion negatives the interpretation of this papillomatosis as a malignant process. The author points out, however, that he was unable to keep any of his animals alive for more than one hundred and sixty days. He draws no further conclusion from his work, refrains from discussing the subject of tar cancer in general, and modestly makes no mention of his own valuable critical study on the literature of occupational and experimental tar lesions (Arch. ital. di chir. 30: 45-87, 1931). Six photomicrographs illustrate his paper. F. CAVERE3 Tissue Culture, J. T. KING. Journal-Lancet. 53: 276-283, 1933. The author says that his object is to outline the history of the development of the technic of tissue culture and, in an extremely concise form, to describe the technical procedure. He adds no new observations to this already complex field of research but provides a very readable summary of the subject for anyone not particularly familiar with it. GR~YTWOMBLY Lymphatic Leukemia in a Horse, C. BARILE. Leucemia linfatica nel cahdlo, Gior. di batteriol. e immunol. 9: 641-672, 1932. A carriage horse, eight years old, had been in good health until about a year previously, when it showed signs of weakness. Two months before its owner brought it to the author's veterinary clinic, it fell down and sweated profusely; its breathing became rapid and gasping, with dilatation of the nostrils, and there was muscular tremor of the limbs. After a period of rest it recovered from these symptoms, but was too weak to be worked as before. When seen by the author the horse was very weak, its muscles being flabby and the subcutaneous fat very thin. The skin temperature was normal, but that in the rectum was raised (37.8"). The accessible lymph nodes, especially those of the head, neck, and groins, were enlarged; the lungs were normal on percussion and auscultation. The pulse was rapid (60), soft, and small. Microscopic examination of the feces showed no zooparasites; the urine showed a slightly raised albumin content, but was otherwise normal chemically and microscopically. Blood from the jugular vein showed moderate anemia, with 5,100,000 erythrocytes, a diminution in neutrophils, and increase in all the other leukocyte forms. Repeated counts made during the following three weeks showed steady increase in the percentage of lymphocytes. At first the ratio of total leukocytes to erythrocytes was 1 : 20, but finally the lymphocytes formed 85 per cent of the total leukocytes, and the latter exceeded the erythrocytes in number, while the blood had become brown in color. The animal was given an iron-arsenic mixture from the day of admission; it took its food readily and showed insatiable thirst, drinking about 30 liters of water daily. As the emaciation continued, and the condition, diagnosed as chronic lymphatic leukemia with a terminal acute stage, was obviously hopeless, the animal was killed. EXPERIMENTAL AND THEORETIOAL STUDIES ON RADIATION 151

Autopsy showed enlargement of the internal lymph nodes (mesenteric, mediastinal, etc.), liver, kidneys, and spleen (twice the normal size). Histologic examination of these organs, as well as of the medulla of the long bones, verified the diagnosis made from the detailed blood examinations and biopsy of the superficial lymph nodes. The findings are given in considerable detail, and agree entirely with those reported in human lymphatic leukemia. The author discusses the available literature of leukemia in animals, especially in the horse. As to the latter, he points out that relatively few cases have been closely investigated hematologically and histologically. Many cases, therefore, diagnosed clinically as leukemias may have been anemias or pseudoleukemias due to various parasites. Numerous writers on this subject are cited, but without references to their publications. There are three photomicrographs of blood films. P. CAVERS

EXPERIMENTAL AND THEORETICAL STUDIES ON RADIATION

Studies on the Effect of Roentgen Rays and Gamma Rays upon the Eggs of Drosophila Melanogaster, OTTOGLABSER AND F. R. MAUTZ. Am. J. Roent- genol. 29: 815-825, 1933. The authors describe somewhat elaborately the technic for keeping a Drosophila colony and obtaining the eggs; nothing essentially new is recorded. They find, in ageement with other workers, that the radioresistance of the eggs depends on their developmental stage at the time of irradiation, and for this reason conclude that “ their utilization in absolute measurements of dosage are of little value.” [No mention is made of the fact that Packard in his irradiation survival studies with Drosophila eggs has so successfully controlled the age factor that his survival curve has been checked by Henshaw in this country and by Holthusen and Glocker in Germany.] To test the comparative effectiveness of roentgen rays (90 kv. in the text, 140 in the table, 2 mm. Al filter) and radium gamma rays from a pack with 4 mm. brass filter (quantity not mentioned), eggs of the same age were exposed for equal periods to the two types of radiation with intensities adjusted to give approximately equal times for the same killing effect. The roentgen-ray dosage was measured in roentgens with the authors’ standard air chamber. On the other hand, the gamma-ray dosage from a small radium pack was measured with a small thimble chamber, although this method of measuring gamma rays in roentgens “ may not yet rest on sufficiently well established theoretic foundations.” As measured in this way the dose of gamma rays required to kill half the eggs was 50 per cent larger than the corresponding roentgen-ray dose. [It is equally proper in the present state of our knowledge to say, however, that this represents the error in the method of measurement of the radium radiation. Also there is no discussion of the circumstance that while the ionization of the air in the thimble chamber is the result of the secondary beta radiation from the spherical chamber wall, the eggs are affected by secondary radiation from a very complicated surrounding distribution of wood, glass, and air.]

The Time-Intensity Factor in Irradiation. GEORGET. PACKAND EDITHH. QUIMBY Am. J. Roentgenol. 28: 650-666, 1932. The writers attempt to sum up, from an extensive bibliography, the experimental work which has been done on the relationship between the biological effect and the rate of administration of irradiation, and seem puzaled to find that the results of experiments made under varying conditions and on different materials give different results. On the whole they feel that the use of small dosage and 152 ABSTRACTS

prolonged exposure has clinically the same effect as large dosage and shorter exposure. Obviously the situation varies greatly with the site and type of tumor. For example, they hold that there is little advantage in giving prolonged irradiation to an epithelioma of the lip because by the insertion of needles large quantities of radiation are delivered to a moderately sized tumor and complete destruction is brought about in a very short time. Their own experiments are on the production of a skin erythema; they find that with beta rays from unfiltered radon equal erythemas on the human skin are produced by equal doses, but that with gamma rays greater amounts of “ roentgen ” [presumably a misprint for gamma] radiation are required if the exposure be long than if it be short. The time varied from one hour to eight days and the total dose was 225 to 250 millicurie hours. The authors realize that this statement is not in accord with clinical experience, which is showing that relatively long exposures to small quantities of radiation are better than short exposures of high intensity frequently given. ‘I The explanation probably lies in the greater differential effects on tumors than on normal tissue with the longer duration and lower intensity.” [As a matter of fact the authors’ results are quite in accord with modern opinion, and the lesser effect from small, prolonged doses is due to the regeneration of the tissues during the exposure. If they had used small enough doses no erythema would have been produced no matter how long the exposure.]

Theory of the Action of Radiations of Short Wavelength on Living Cells, MARCEL JOLY. Th6orie personnelle de l’action des radiations de courte longueur d’onde sur les cellules vivantes, NCoplasmes 12: 102-106, 1933. Also in Bull. et m6m. SOC.de radiol. m6d. de France 21 : 103-106,1933 and Progres mbd., pp. 193-194, Feb. 4, 1933. The author constructs the framework of a theory which ‘‘ will explain all the facts of radiobiology,” but he has not yet succeeded in bringing together the material necessary for its verification.” The basic idea is simple. All living things consist of moving electrons with their associated waves. These waves obey the laws applying to waves in general, particularly to that part which con- cerns interference. If we can properly synchronize a beam of any kind of radiation (gamma rays, infra-red, etc.) so that by interference it damps or entirely stops the electron waves, then electron motion ceases, and death ensues. If the amplitude of the electron waves is increased, life processes are quickened, as in tumor growth. The author feels that this theory, which is almost certainly valid, “ throws a flood of light on the phenomena of fertiliaation, development, health, disease, epidemics, physical and mental activity, old age, and death.” CHARLESPACKARD

THE NATURE OF CANCER; THEORETICAL DISCUSSIONS

Definition of Cancer, E. CISNEROS. La definici6n del c&ncer, Semana m6d. 2: 171011711, 1932. The author says he has for many years maintained-in papers which, he complains, were read to various medical societies but evoked neither comment nor discussion-a theory of cancer causation which seems to be similar to Lebert’s obscure and long forgotten “ amorphous blastema ” hypothesis. He believes that the development of a tumor is preceded by the formation in the blood of a solid sediment, which on escaping from the vessels immediately grows into a tumor. He has observed at several autopsies [whether in cases of cancer is not stated] a membranous deposit in the blood vessels which seemed to be quite different from blood fibrin, and he thinks that the electromagnetic forces which THE NATURE OF CANUER ; THEORETICAL DISCUSSIONS 153 control the blood circulation are concerned in the production of this blastema ” sediment and, therefore, of cancer. [This does not seem a convincing theory, though the author tells us it is the outcome of many years of thought.] F. CAVERS

Problem of Cancer, JULIOSCHILKEN. Sobre el problema del c&noer,Prensa med. argent. 19: 475-484, 1932. Schilken presents a long discussion of the problem of cancer and of the way the world is meeting the problem from the standpoint of etiology and treatment. JOHNE. WIRTH

The Cancer Problem, J. M. MARTIN. J. Arkansas M. SOC.29: 51-55, 1932. A general discussion is given of the nature of cancer, its etiology and diagnosis, and the accepted methods of treatment, especially radiotherapy.

Natural History of Cancer and Other Tumors, C. M. MOULLIN. M. Press & Circular 185: 468-471, 1932. The author discusses in a general fashion many phases of the cancer problem.

Cancer as the Terminal Phase of a Biological Reaction, JOSEPHL. DE COURCY. J. Med. 13: 136-140, 1932. General theories on cancer.

Cancer: Reflections on the Past and the Present, GILBERTBARLINO. Birming- ham Med. Rev. 7: 78-95, 1932. Barling’s paper is a general review, discussing experimental discoveries, the natural history of cancer in man, resistance, heredity, and improvements in treatment. No bibliography.

A Biological Explanation of Cancer: Etiology, Prevention and Treatment, 0. S. FOWLER.Southwestern Med. 17: 87-91, 1933. The possible relationship of neoplasms to the endocrine glands is discussed. W. S. MACCOMB Chemistry of the Sex Hormones and of Substances Causing and Curing Cancer, E. JUBTER.Chimie des hormones sexuelles et chimie des corps cancerigenes et cancericides, J. de m6d. de Paris 53: 627, 1933. This is a brief review of work which has been reported in the literature on the chemical nature of hormones, vitamins, and carcinogenic agents, on the influence of various inorganic substances on the growth of cancer, and on the chemical peculiarities of the “ cancer terrain.” There is no bibliography, and no new experimentrrl work is described, H. Q. WOODARD

An Untried Line of Cancer Research, CHARLE~WALKER. Liverpool Med.-Chir. J. (pt. 2) 40: 147-154, 1932. The author suggests that the occasional cure8 reported as the result of chemo- therapeutic measures in cancer, as well as the rare spontaneous cures observed, may be due to the counterbalancing of the mdtiplication of cancer cells by increased leukocyte activity. He reports no experiments of his own, but suggests this line of research as worth a trial. [Why, if cancer and leukemia coexist, as they do in man?] 154 ABSTRACTS

Considerations on the Etiology of Infectious Diseases, RAPPIN. Consid6rations sur 1’6tiologie des maladies infectieuses, Gaz. m6d. d. Nantes 46: 105-122, 1933. In a section devoted to cancer the author states that in 1881 he isolated the micro-organism which he has since found constantly in malignant tumors. He regards it as playing an important part in the genesis and development of such tumors. The Effect of Soil Moisture on the Origin of Cancer, U. SARTER.Zur Frage des Einflusses der Bodenfeuchtigkeit auf die Krebsentstehung, Montasschr. f. Geburtsh. u. Gynak. 91 : 250-257, 1932. The city of Cleve, near the Dutch border of the Rhineland, is divided into an upper town situated on relatively high land and a lower part, which in certain seasons of the year is partly flooded. Sarter has studied the incidence of cancer in the two parts of the city to determine the possible effect of soil moisture upon the origin of cancer. The results show that the mortality from cancer is no higher in the lower city of Cleve and in the towns of the flooded area than in the upper city and adjacent towns situated on high land. HOWARDC. TAYLOR,JR.

Specificity of the Cancer Cell, P. RONDONI.Especificidad de la c6lula del chcer, Bol. Asoc. m6d. de Puerto Rico 24: 477-486, 1932. In a general discussion of the specificity of the cancer cell Rondoni reviews the past as well as the ideas of current writers. He explains briefly some of the fallacies and shortcomings in Cohnheim’s theory, touches on mutation of chromo- somes, dismisses parasitic theories, and spends considerable time on the chemistry of carbohydrates, proteins and fats, and cell metabolism, as well as the serology of the cancer cell. He concludes that the cancer cell is specific in the sense that it is biologically abnormal in its relation to the organism, but that as yet we have been unable to find the factor or factors that determine its specificity. He seems to believe that the biochemistry of lipoids or lipo-proteins holds out some small promise for the future, for though they are not specific in their reactions in the cancer cell, they are at least somewhat different. There is no bibliography other than the mentioning of names throughout the text. [This is a translation of an article originally appearing in Italian (Scientia, Milan, 51: 216, 1932.1 Radiation and Enzyme Activity, M. COPI~AROW.Nature 130: 1001, 1932. Is Methylene-Blue Anti-Carcinogenic? M. COPISAROW.Science 78: 212, 1933. Copisarow believes that the depletion of respiratory enzymes in cancer, as shown by Warburg’s work, may be due to enzyme starvation, for which our diet and culinary methods are responsible. [Why, then, do certain strains of mice have an abundance of breast cancer while another strain on the same diet and in the same laboratory has none?] Hence he advises yeast as providing a suitable enzymatic association. A number of somewhat theoretical reasons for considering methylene blue anti-carcinogenic are enumerated. Copisarow states that in his opinion cancer is produced by suppression of the respiratory enzyme by (a) “ dietary depletion ” and (b) ‘‘ environmental inhibition.” He refers with approval to the suggested extension of Bancroft’s physico-chemical corrective treatment to malignant cell colloids. [Inasmuch as Bancroft’s corrective treatment is now in considerable disrepute, this suggestion can scarcely carry much conviction. The question asked in the second title is easily answered, however. Methylene blue does not posses8 important anticarcinogenic qualities. Large quantities can be injected into ani- GENERAL CLINIOAL OBSERVATIONS 155 mds and administered to human beings bearing tumors, without producing the slightest effect upon the growth. This is true even though, when placed in immediate contact with cancer cells or normal cells in vitro, methylene blue is toxic, though not more so than some other dyes (see, for example, Roffo: NBoplasmes 10: 257,1931. Abst. in Am. J. Cancer. 16: abst. p. 526,1932). Whether this toxicity depends upon its oxido-reduction capacity has not yet been satisfactorily demonstrated. Certainly methylene blue increases the respiratory activity of red corpuscles very greatly, but there seems no definite proof that it increases the respiration of cancer cells. The difficulty is the passage of the cell membrane, 80 that it is generally held that only dead cells stain with methylene blue. Hence, even if methylene blue should have a toxic action on the malignant cell, owing to alteration of ferment activity, the only way in which it can be effectively applied to the cell in practice is by intravenous injection, and, as has just been said, experiments on animals have shown that it has no effective action on tumors. Other dyes without oxido-reduction capacity are also toxic for tumor cells, as will be seen by conRulting Roffo's paper. Activation of anaerobic glycolysis can easily be accomplished in uitro by the addition of sodium pyruvate to the Ringer's solution in which the tumor tissue is suspended, but no one has suggested that the cell is damaged by such activation (see Dickens and'Greville: Nature 130: 206, 1932. Abst. in Am. J. Cancer 16: abst. p. 1278, 1932).]

GENERAL CLINICAL OBSERVATIONS Clinical Aspects of the Cancer Problem, GEORGEW. CRILE. Nebraska M. J. 17: 153-159, 1932. The content of this paper, based on the experience of Crile and his associates in treating over 7,000 cases of malignant growths, is very similar to that of an earlier paper by the same author (Ann. Surg. 93: 99, 1931. Abst. in Am. J. Cancer 15: 1662, 1931). Special stress is laid on precancerous conditions.

The Cancer Patient, D. Y. KEITHAND J. P. KEITH. Kentucky M. J. 31: 160- 164, 1933. The author has briefly discussed the recent experimental work of Roffo on the possible association of a high cholesterol content of tissues with the anatomical distribution of cancer. W. S. MACCOMB

Hemorrhagic Diatheses in Occult Carcinoma, W. BEIQLB~CK.Ueber die Bedeut- ung hilmorrhagischer Diathesen bei occulten Carcinomen, Ztschr. f, klin. Med. 124: 411-419, 1933. Two cases are reported in' which the chief symptoms were those of purpura hemorrhagica and in which a carcinoma was found only at autopsy: in one case a carcinoma of the sigmoid flexure, in the other a carcinoma of the prostate. A third case of bronchial carcinoma, diagnosed during life, is reported, in which purpura was also a symptom. In the sigmoid flexure and bronchial carcinomas the platelet count was normal, and the author believes the purpura is to be attributed to changes in the blood-vessels, induced, in part at least, by the carcinoma. In the prostatic carcinoma there was a definite thrombocytopenia, which is probably to be attributed to bone metastases. From his own observations and a review of literature, the author concludes that iD the great majority of cancer patients there are no hemorrhagic symptoms. Very few reports have appeared of such symptoms without blood changes indicating bone-marrow metastases. Cases with extensive bone metastases have been 156 ABSTRACTS reported without reduction of the platelet count; some of these showed hemorrhagic symptoms, while others did not. More frequently extensive bone-marrow metastases in cancer are associated with thrombocytopenia and hemorrhagic symptoms.

Melanuria, S. N. BLACKBERQAND J. 0. WANQER. J. A. M. A. 100: 334-336,1933. Melanuria has been reported as occurring in a variety of apparently unrelated pathological conditions, such as melanotic tumors, wasting diseases, intestinal obstruction, lobar pneumonia, pernicious anemia, extensive liver destruction, over-exposure to sunlight, and following roentgen treatment. A survey of 15 cases of melanotic tumors showed that melanins were present in the urine of only 4. Eppinger (Biochem. Ztschr. 28: 181, 1910) states that only when there is metastatic involvement of the liver does melanin appear in the urine. The authors found that the usual tests for melanin may give unreliable results, and they therefore devised the following test: 1. A twenty-four hour specimen of urine is evaporated to one-fourth of the original volume. 2. One gram of potassium persulphate is added for each 100 C.C. of the concentrated urine. 3. At the end of two iours, an equal volume of absolute methyl alcohol is added. The precipitated melanin is allowed to settle. 4. The precipitate is filtered off and washed with water till the washings are colorless, then washed with methyl alcohol to remove any soluble pigments remaining. Finally, it is washed with ether. If the test is positive, there remains on the filter paper a brownish-black precipitate, which can be dissolved off with alkali-most conveniently with 5 per cent sodium hydroxide. Acidification of the alkaline solution causes a reprecipitation of the melanin. If quantitative estimation is desired, the 5 per cent sodium hydroxide solution can be acidified with one-tenth normal hydrochloric acid collected on a Wade filter paper, washed with water until the acid is removed, dried and weighed, and the total excretion calculated. This test gave positive reactions only in those cases of melanotic growths with metastatic involvement of the liver. The only other positive reactions were obtained in five patients with advanced carcinoma or sarcoma, in none of whom was the tumor melanotic. These 5 cases were found among 65 patients tested. No reaction was obtained in 17 cases of pernicious anemia, in 4 cases of pneumonia, in a case of melanosis coli, in 3 cases of severe sunburn, 2 cases of advanced liver destruction, and a variety of other diseases. R. S. FERGUSON

Signi5cance of the Red Angiomas, V. SERRA.Sul significato degli angiomi rubino, Osp. maggiore 20: 261-273, 1932. From his experience in examining, with a capillary microscope, the telangiectases or red angiomas in a large number of patients afflicted with various diseases, the author concludes that these telangiectases are most common in subjects with diseases of the liver. Persons with cirrhosis of the liver, cholelithiasis, congestion of the liver due to too heavy eating and drinking, or syphilis of the liver, most frequently develop these red angiomas. An extensive bibliography is included. C. D. HAAQENSEN

Regional Lymph Node Reaction in Cancer, N. MONTANINI.Le reazioni linfoghiandolari nei distretti sede di cancro, Tumori 6: 328-334, 1932. From his experience in examining regional lymph nodes from 280 cases of cancer, the author concludes that it is impossible to determine by the gross characteristics whether or not metastases will be found in the nodes. He believes GENERAL CLINICAL OBSERVATIONS 157 that the chronic lymphadenitis so frequently seen in regional nodes is a defense reaction against a toxin elaborated by the neoplasm. C. D. HAAQENSEN

Reticulum in Tumors, L. L. TUREENAND M. G. SEELIQ. Arch. Path. 15: 498- 508, 1933. The authors took sections from 56 carcinomas removed routinely at the Barnard Free Skin and Cancer Hospital, St. Louis, and stained them with one of Foot’s modifications of the Bielschowsky method for staining reticulum. Hematoxylin- and eosin-stained sections from the same tissues were graded according to the method of Broders. It was thought that possibly the amount of reticulum present might give a more accurate indication of the degree of malignancy of the tumor than the morphology in routine sections, but the investigation disclosed no relationship between the abundance of reticulum and the malignancy of the cell. It was observed that the stroma of tumors could be divided into three groups: (1) thin areolar stroma, either scanty in amount and around blood vessels or abun- dantly spread between the cells, filled with reticulum; (2) fibroblastic stroma made up of young growing fibroblasts showing many reticulum fibers; (3) stroma composed of dense collagenous fibers, as in scirrhous carcinoma, containing little or no reticulum. The type of stroma and the abundance of reticulum depend largely on the organ in which the tumor is growing. GRAYTWOMBLY

Relationship between the Thyroid Gland and Tumors. Cancer of the Mouth, Larynx and Thyroid, A. MORATTI. Sui rapporti tra ghiandola tiroide e tumori. 11. Cancro della bocca, cancro del laringe e tiroide, Tumori 6: 359- 391, 1932. In 25 cases of cancer of the mouth and 7 cases of cancer of the larynx the author made a careful study to determine what changes had occurred in the physiology of the thyroid. There were no clinical signs to suggest altered thyroid activity. The basal metabolism was found to be abnormal, i.e. more than +10 or less than -10, in only five of the cases of mouth cancer. All seven of the patients with laryngeal cancer had an abnormally high metabolic rate, however. Moratti concludes that hyperthyroidism is frequently found in patients with laryngeal cancer. [The author’s earlier study on the relationship of the thyroid to tumors concerned mammary cancer (Riv. di pat. sper. 7: 324, 1931. Abst. in Am. J. Cancer 16: abet. p. 1289, 1932.1 C. D. HAAGENSEN

Precaution in the Diagnosis of Traumatic Tumor, DEUBNER.Vorsicht mit .der Diagnose von traumatisch entstandener Geschwulst, Monatschr. f. Unfall. 40: 129-133, 1933. A soldier aged twenty-eight years fell and struck his abdomen on a large log. For several days he carried on his duties, though he suffered increasing pain in the umbilical region and a lump appeared there. The army surgeon, who had made a diagnosis of small umbilical hernia, referred the man to the author’s clinic. A hard nodule with part of the peritoneum, to which it was adherent, was removed. The pathologist’s diagnosis was at first scirrhous carcinoma, but was later changed to fibroma. X-ray investigation of the gastro-intestinal tract showed a filling defect in the pyloric antrum and a similar defect in the transverse colon. At laparotomy, considerable ascitic fluid escaped. A tumor some 7 om. in diameter, attached to the peritoneum at the umbilicus, was resected, and it was then found that the omentum and mesentery contained innumerable disseminated nodules. In the mesocolon was a hard tumor measuring 4 or 5 cm. in diameter, 158 ABBTBACTH and a larger one WM felt in the prepyloric region of the stomach. Since it was uselese to proceed further, the abdominal wound WM cloeed. The patient died a few days later. At autopsy the primary pyloric tumor waa found to be a ecirrhous carcinoma. The umbilical hernia resulting from the injury had simply allowed some of the underlying metastams to protrude and perhaps to grow more rapidly. The patient had never had any gastric symptoms. No illustrations are given. F. CAVEES

TramIn Relation to Metratatic Cucinomr in Bonea, H. HInLLNIIE. Unfall und Krebsmetaatsee im Kawhen, Monatachr. f. Unfallh. 40: 65-76, 1833. A man of twenty-four bad been operated upon for a tumor in the right adduator magnus muscle, which w@ easily shelled out and waa clinically diagnosed M a lipoma. The histologic report WM solid carcinoma, and the pathologist suepted that the maas WM meteatutic from a primary tumor eleewhere in the body, but search for thia proved unsuaoeeeful. Sixteen months after operation the patient injured his right shin; the region ewelled considerably, and WM treated with fomentations and other local applioa- tions without result. X-ray examination revealed an area of bone destruction in the lower end of the tibia. There WM also a tumor the Sire of a haselnut in the old operative mar on the thigh. Thie WM excised, M well aa a piece of the tibial swelling. The histologist’s report on both ia given simply as largwell carcinoma, The patient next presented himself in the surgical clinic of Mnnster Univeraity, almost two years after the original operation, and WM kept under observation while fruitless search waa pade for a primary tumor. Repeatad radiograms were taken of the tibial tumor, Fhich was found to be growing steadily. The tumor in the old operative scar also recurred. This tumor WM now widely resected, and the femur waa amputated ebove the knee. The pathologiet at Manster diagnosed both tumors M large-oell carcinoma, but possibly sarcoma. At the time of reporting, nearly two yean after amputation, there waa no sign of recurrenae, and the patient WM in good health. The author discusees the part played by injury in determining the development of primary tumors or the slte of metastatic ones, and concludes that in the preeent caae trauma could have had nothing to do with the tibia1 tumor. There are two illustrations. F. Cavmae

Metutuea of Neoplumr to Traumatized Tiuue, M.SIEBNEB. Uber Mefaetasen- bildung von Qeechwllbten im gemhadigten Gewebe, Deuteche Ztechr. f. Chir. 239: 664-676, 1933. The author reporte the case of a thirty-onsyear-old man in whom a Billroth I1 type of resection with entero-enteroetomy WM done for carcinoma of the etomach. Autopsy, eighpn months later, showed meteetatic tumor in the duodenal stump, along the suture line of the entenwntemstomy, and on numerous portions of the adjacent in(eatinal aeroaa. Hiatologio study of these areas showed that the tumor in all insta cm WM implanted in small granulomatow areaa which were thought to be the rea t of sutures and tissue damage. There WM no evidence of recurrence of the tumoa4 in the stomach, and widespread peritoneal or liver metaataaea were absent. The author stresses the fact that gentle handling of tissues with the avoidance of undue peritoneal irritation is important for the best renulta in cancer eurgery. The article is well illuatrated by photomicrographs. BENJAMINR. SHORE GENERAL CLINICAL OBSERVATIONS 159

Some Pictures of Carcinoma Metastases into the Lymph Nodes and Spinal Column, PHILIPP. Einige Bilder 5ur Frage der Karainommetastasen in Lymphdrtisen und Wirbelsliule, Monatswhr. f. Geburtsh. u. Gyniik. 91 : 516-517, 1932. Two cases are reported with roentgenograms illustrating the appearance of large masses of carcinomatous lymph nodes and of destructive lesions of the spinal column following treatment of cancer of the cervix. HOWARDC. TAYLOR,JR. Unusual Metastases of Malignant Tumors. Report of Six Cases, ANQELO M. SALAAND ELMABARANY. Arch. Path. 14: 429-431, 1932. A brief presentation of six cases: (1-2) two of carcinoma of the cervix metasta- siring to the lungs; (3) one of epithelioma of the pharynx with a metastasis in the kidney; (4) one of epithelioma of the pharynx metastasiaing to the liver and lungs; (5) one of epithelioma of the penis with metastatic growth in the intestinal serosa; (6) one of epithelioma of the tongue with metastases in the heart. In all the cam, the secondary growths were found post mortem. Photomicrographs of the metastatic tissue in cases 5 and 6 are reproduced. Mucoslt Metastaees, N. PUENTEDUANY. La metastasis por via mucosa, Rev. de med. y cir. de la Habana 37: 946-955, 1932. Puente Duaay reports two cases of metastases to unusual sites. In the first case, a carcinoma of the floor of the mouth, the primary lesion had been cured for four months by radiation when a stricture of the lower third of the esophagus appeared. In the second case, a carcinoma of the epiglottis, a lung abscess believed to be carcinomatous developed four months after treatment of the original lesion by radiation. There is no biopsy report on either of the two secondary lesions and the author’s suggestions are not verified by autopsy. JOHN E. WIRTH Spontaneous Regression of Cancer, J. L. DE COURCY.J. Med. 14: 141-146,1933. Rohdenburg (J. Cancer Research 3: 193, 1918) collected 302 cases from the literature in which spontaneous regression had been observed in cancer cases that were considered inoperable and hopeless. In approximately one-third of these cases the diagnosis of malignancy had been made microscopically. Spontaneous regression has also been observed in transplanted animal cancer. Absorption of an inflammatory exudate, fever, chiefly after attacks of erysipelas, excision of small sections for biopsy, loss of blood supply due to thrombosis, and hemorrhage have all been found to be associated with regression of tumors. In cases where complete surgical removal is impossible and biopsy shows the presence of signs of regression in the tumor the prognosis may be regarded as relatively favorable!

Adenowcroids, J. Noc~mows~r.uber Adenocancroide, Frankfurt. Ztschr. f. Path. 44: 547-565, 1933. Herxheimer nearly thirty years ago proposed the term adenocancroid for a type of malignant tumor, using the synonym “ carcinoma cylindrocellulare cancroidale ” to express his view that this was a single carcinoma arising from two kinds of epithelium, Nochimowski states that adenocancroids fulfilling this definition have been seldom reported, though probably they are not very rare. He describes the histologic features of four cases, the first three coming to autopsy. (1) The first was a primary tumor of the left bronchus, with metastases in the paratracheal and para-aortic nodes, the pleura and lung of both sides, the left femur, and various vertebrae; also disseminated carcinosis of the peritoneum. The primary tumor consisted mainly of adenocarcinoma, but there were also 160 ABSTRAaTS strands of squamous-cell cancer with early keratinisation, and in other places sheets and masses of undifferentiated epithelium were observed. The metastases showed only adenocarcinoma. (2) The second patient had primary tumor of the gallbladder of similar atructure, cylinder or cuboid adenocarcinoma predominating and the squamous cells showing no keratinisation. The growth had spread to the liver and produced multiple nodules in that organ [no histologic account of these is given]. (3) In the third case a primary tumor of the common bile duct, mainly of squamous type with small patches of adenocarcinoma, had produced metastases in the liver, periportal nodes, and peritoneum. One of the peritoneal nodules, in the pouch of Douglas, had perforated into the rectum, and the condition had been diagnosed during life as one of primary rectal cancer with hepatic metastasis. (4) The fourth patient, a woman of forty-nine, who had lost considerable weight, was found to have a large tumor of the posterior lip of the 0s cervicis. The tumor consisted mostly of slightly differentiated squamous carcinoma, passing into well defined adenocarcinoma; in the plane where these met there were solid strands of quite undifferentiated epithelial tumor tissue. The author distinguishes between false (secondary) and true (primary) adenocancroids. The former are compound tumors formed either by collision and interlocking of two tumors of independent and simultaneous origin from adjacent patches of the two types of epithelium, or by one of the constituents either undergoing metapleeia or arising from heterotopic epithelial islands. The true primary adenocancroid arises, according to the author, from undifferentiated bipotent epithelium. [Unfortunately no illustrations are given. Good photomicrographs might have helped the reader to follow the author’s discussion of the histogenesis of these interesting tumors.] F. CAVERS PsthoQeaesis of Myxonms, T. GRHICO.Sulla patogenesi dei mixomi, Tumori 7: 134-159, 1933. This article discusses in detail the structure, origin, and significance of tumors showing mucoid tissue. The author believes [as did Ribbert] that true mucoid tissue is an embryonic tissue not present in the adult organism after birth. It arises directly from the mesenchyme and may undergo transformation along one line into the various types of connective tissue, along another line into cartilage and bone, or, possibly, taking a th$d direction, may be transformed into sarcoma. At the time of birth even the Wharton’s jelly has acquired a more fibrous appearance than embryonic mucoid tissue, and the young organism contains no demonstrable mucoid formations of the embryonic type. Such formations, if demon- strabIe, would have to be considered congenital malformations like persistent branchial clefts. Greco assumes the presence of such embryonic rests as points of origin of myxomas. He considers that the so-called pure myxoma is of real neoplastic significance. It contains areas of mucoid tissue similar to that found in the embryo, but ale0 perivascular centers of proliferation suggestive of malignancy and not observed in the embryo. These areas contain unditrerentiated, atypical round cells with large, often double nuclei, and may represent centers in which the mucoid cells are undergoing transformstion into young connective-tissue cells destined to form adipose or fibrous tissue, cartilage, or possibly sarcoma. The locally destructive character of the myxoma and the tendency to local recurrence suggest a certain degree of malignancy in the tumors. That the myxoma is a true tumor and not a phase of degeneration is shown by the definite structure of the mucoid tissue. Where degeneration causes a mucoid appearance in stained sections there is not found the finely fibrillar background with stellate, loosely spaced oells connected by delicate processes typical of true mucoid tissue. The author reports two cases of myxomas, illustrated by x-ray photographs GENERAL CLINICAL OBSERVATIONS 161 and microphotographs, and briefly touches on other cases where so-called mucoid degeneration caused a faulty diagnosis of myxosarcoma. He believes that these tumors should be called myxomatoid sarcomas and the term myxoma should be reserved for those showing true mucoid tissue with proliferation centers. In this group are to be included the tumors heretofore described as pure myxomas and probably a very few of the myxosarcomas. JEANNETTEMUNRO

Endothelioma, LEE RICEAND HENRYHARTMAN. Texas State J. M. 27: 742-744, 1932. The authors present a brief review, with bibliography, of the three principal forms of endothelioma: (1) endothelial myeloma, or Ewing’s tumor; (2) intracranial endothelioma; (3) endothelioma of the lymph nodes. An example of the latter is reported. Malignant Epithelial Tumors in the Cellular Tissue of the True Pelvis, B. KECHT. Zur Kenntnis bosartiger epithelialer Geschwulste im Zellgewebe des kleinen Beckens, Wien. med. Wchnschr. 83 : 581-589, 1933. Two unusual cases of primary epithelial tumors arising in the connective tissue of the true pelvis are reported. The first was a well circumscribed tumor lying near the anus in the fectovaginal septum in a woman fifty years of age. Histologic study of the excised tumor showed it to be composed of relatively unwerentiated epithelial cells with a marked tendency to the formation of alveoli. It was thought to have arisen in a remnant of Giirtner’s duct, although the possibility of ite being a neoplasm of the perianal sebaceous glands could not be eliminated. The second patient was a man sixty-one years of age with a circumscribed adenomatous carcinoma about 3 cm. in diameter situated in the rectovesical connective tissue. Its origin from a derivative of the Mtillerian ducts was considered highly probable. This tumor was thought to be the first carcinoma of this type reported in the literature. There are no illustrations. BENJAMINR. SHORE Certain Desmogenous Tumors in Their Orthopaedic Aspects, A. H. FREIBERO. J. Med. 13: 134-140, 1933. Five cases of sarcoma interfering with the function of a limb are presented. The first was a chondrosarcoma of the tendon sheaths of the vastus lateralis femoris mistaken for a tuberculous hip; the second a perithelioma arising in the flexor tendon sheaths of the foot; the third a fibrosarcoma of the plantar fascia; the fourth a rapidly growing spindle-cell sarcoma of the flexor tendon sheaths of the hand, thought at operation to be a tuberculous tenosynovitis; and the fifth a chondrosarcoma of a flexor tendon sheath of the hand, also thought preoperatively to be tuberculous. GRAYTWOMBLY

Choleeteatoma, S. J. KOPETZKY.Laryngoscope 43: 118-131, 1933. The duthor reviews in great detail the pathology, clinical symptoms, and treatment of the true and pseudocholesteatomata. Nothing of importance has been omitted. W. S. MACCOMB

Precanceroses of the Male and Female Genital Regions, Y. KATAYAMA.Pra- cancerosen der Genitalgegend, Acta dermatol. 20: 77-82, 131-132, 1932; 21 : 68-69, 1933. In this report from the skin clinic of Kyoto University, statistics are given regarding the incidence of various lesions, collectively [but not always justifiably] termed precancerous, occurring in the genital regions. These include Paget’s and Bowen’s diseases, erythroplasia, leukoplakia, condylomas, cutaneous horns, 162 ABSTRACTS and proliferating and other keratoses. Bowen’s precancer (or carcinoma) and leukoplakia predominate in females; the other lesions mentioned were found chiefly in males. Most of the patients were between forty and sixty years old, though the proliferating and often ulcerated precancerous lesions were found at various ages over twenty years. Many of the melee had phimosis. In women the chief site of these lesions was the labium majus, in men the penis. The develop ment of these “ precanceroses ” is very slow, except in the case of condylomas. The chief histologic characters common to all of them are hyperkeratosis, dys- keratosis, acanthosis, and cellular infiltration. F. CAVERS

Relationship between Cancer and Tuberculosis, J. B. AIKENAND A. A. Rooow. Univ. Toronto M. J. 10: 216-219, 1933. The authors conclude that there is a definite antagonism between tuberculosis and cancer and have a theory about it.

Multiple M~~IIMc~,Exhibition and Report of a Case, L. FRANKAND A. J. MILLER. Kentucky M. J. 31: 138, 1933. The authors present a case of adenocarcinoma of the corpus uteri and a sarcoma of an ovary in the same patient. W. 8. MACCOMB

Two Cases of Multiple Tumore of the Upper Extremity, J. MINNEAND R. LOORIUS. Deux cas de tumeurs multiples du membre supbrieur, Eoho m6d. du nord 37: 216-216, 1933. Two cases of multiple tumors of the upper extremity in children-a boy aged seven years and a girl of fourteen years-are described. One of these was a cystic lymphangioma of the axilla, the other a chondroma of the hand. Lymphoblastoma (Mycoslr Fungoides) and Hemorrhagic Sarcoma of Kapori in the Same Pereon, C. GUYLANE AND ARTHURM. GRIDEWWOOD.Arch. Dermat. & Syph. 27: 643-654, 1933. The uncertainty surrounding the background of both mycosis fungoides and Kaposi’s sarcoma lendA an added interest to the coincidental occurrence of the two dkeases in the same person. In the case reported by Lane and Greenwood the rnvnosis fungoides developed first and was followed by the blood picture and node enlargement characteristic of a mild lymphatic leukemia. In the last four months of the patient’s life a mass of nodules developed on the right foot with a few lesions elsewhere, having the histologic characteristics of Kaposi’s sarcoma. These grew with extreme rapidity so that in a few months they involved the entire right foot and extended widely over the leg. Following a Gritti-Stokes amputation the patient developed a streptococcus septicemia and died. The complete autopsy findings are included and are illustrated by excellent photomicrographs and clinical photographs. WILLIAMJ. HOFFMAN

Sacrococcyged Chordoma, C. GRANDCWUDE,J. DIUESSENSAND P. TISON. Chordnme sacro-coccygien, Echo m6d. d. nord 37: 186-189, 1933. A chordoma is reported in a woman thirty-six years of age, who had had pain in the spine and pelvis for two years. A diagnosis of tuberculosis was first made, but a palpable tumor appeared, which was found to be adherent to the sacrum, and films showed erosion of the bone. Because of the slow growth of the tumor and relatively good general condition of the patient, a diagnosis of congenital tumor was made. Biopsy showed a chordoma. Radium treatment resulted in diminution of the sise of the growth and relief of pain for several months, but later the tumor increased rapidly in sise, symptoms recurred, and the patient died in a state of cachexia. No autopsy was permitted. DIAGNOSIS AND TREATMENT 163

Sarcoma of the Leg, L. BELDENAND M. CORNACCHIONE.Med. Art 36: 31-33, 1933. This is an incomplete report of a case of fibrosarcoma of the lower leg occurring in a male Negro, thirty years of age. W. 9. MACCOMB

DIAGNOGIS AND TREATMENT

Scientiflc Basis of Biopsy in Tumors, C. ALEXANDERHELLWIO. Arch. Path. 14: 517-554, 1932. Hellwig presents a general review of the scientific basis of biopsy, with a tong bibliography. Taking up, first, the cytologic and hietologic criteria of malignancy, he states that Virchow’s view that it is impossible to recognize a tumor cell under the microscope still holds today. The in uitro cultivation of tumor cells and the metabolic investigations of Warburg have not as yet led to results of practical value, while the study of experimental cancer has also failed to establish reliable cytologic criteria of malignancy. Few rely on cytologic diagnosis in examining surgical specimens. Only in the special field of brain tumors does cytologic diagnosis seem feasible. Here the use of the supravital technic has proved its value. R. Meyer holds that the finer study of cell characteristics is of great importance in the diagnosis of carcinoma of the cervix, but the cytologic changes that are so valuable in such cases are much less helpful in cancer of the uterine body. In early cancer of the skin and in tumors of the bladder atypical cell changes are valuable factors in microscopic diagnosis. In 1908, Lubarsch stated that in principle it is possible to diagnosticate cancer only when clear criteria of destructive growth are present, and there is general agreement that penetration of tumor cells into the surrounding tissue with resorption of tissues ake conclusive evidence of malignancy, even when cytologic criteria of malignancy are absent. Invasive epithelial growth, however, is not always identical with carcinoma, and in biopsies of very early cancer invasive lesions may be missed. Under the heading precancerous lesions opinions are cited as to leukoplakia, gastric ulcer, adenomatous polyps, chronic cystic mastitis, and other conditions that have been considered as forerunners of cancer. Hellwig concludes that precancer as a histologic diagnosis is meaninglsss. In diagnosing a lesion by biopsy, either the pathologist should take the full responsibility by pronouncing the lesion malignant or benign, or, if he is unable to arrive at a definite diagnosis, he should have the courage to admit that he does not know, and leave the responsibility to the clinician. Nothing is gained by calling a suspicious change in the tissue a precancerous lesion, a term which is a confession of ignorance. Histology in its relation to the prognosis of malignant tumors is discussed in the third portion of this paper, in which the author expresses the opinion that the problem of histologic grading of cancer is far from being solved, and that its practical value is limited. The concluding section deals with the histologic character and radiosensitivity of tumors. Hellwig finds that there is a mass of contradictions and misunder- standings in 11 matter of theoretical and practical importance. Further knowledge must come through painstaking analysis of particular groups of tumors. As Wood pointed out at the Cancer Symposium of the Radiological Society in 1930 (Radiology 14: 246, 1930), the great clinics of this country, which have a large amount of material at their disposal, owe to the medical profession, and through it to humanity, the publication of mass statistics that will incIude not ohly complete clinical histories and five-year results, but also photomicrographs of all 164 ABSTRACYTS individual types of cancer. Such a complete and detailed atlas, demonstrating the relation between morphologic characteristics and radiosensitivity on several thousand tumors of one particular kind, would be appreciated by pathologists throughout the world as a real contribution to the ultimate conquest of cancer. [The author has reviewed other phases of biopsy in an earlier article (Arch. Path. 13: 607, 1932. Abst. in Am. J. Cancer 18: 418, 1933).]

Aschhekn-Zondek Test Proposed by Engel for the Biological Diagnosis of MU- mtTumors, M. FERRO.Sulla reaaione Aechheim-Zondek proposta da Engel per la diagnosi biologics dei tumori, Tumori 6: 314-327, 1932. Following the technic proposed by Aschheim and Zondek, the author tested the urine of 26 patients with carcinoma (no testicular tumors were included) and 6 patients with sarcoma. Not a single positive reaction was obtained. The modification of the test proposed by Brouha and Inglais was tried with the urine from 18 carcinoma and one sarcoma patient (including no testicular tumors). With this technic male rather than female mice are used. The results were all negative. In another series of 16 carcinoma6 and 6 sarcomas (including no testicular tumors) the test was done according to the technic of Probstner et d. In this modification young male and female rats are used. The results were all negative. Friedmann’s variation of the test, in which the female rabbit is used, was tried in 10 carcinomas and 3 sarcomas (including no testicular tumors), also with negative results. The modification of the test suggested by Eberson and Silverberg, in which the hormone in the urine is concentrated, was used in 10 cases of carcinoma (all extra-testicular), with negative results. In another series of 10 carcinomas and 6 sarcomas (all extra-testicular) the author attempted to extract the hormone from the blood rather than the urine, but got no positive results. He concludes that the Aschheim-Zondek test is negative in cancer in general. C. D. HAAQENSEN

Intradennal Test for the Determination of Malignancy, B. GRUSKIN. J. Lab. & Clin. Med. 17: 1237-1243, 1932. The author assumes that a foreign protein of embryonal character is present in neoplasia and that this protein ie so characteristic that not only does it produce specific precipitins, but the allergic reaction produced when an antigen of embryonic tissue is used shows that the fixed cells, as well, respond to the embryonic protein. These embryonic proteins are either epithelial, in the case of carcinoma, or of connective tissue origin, as in the case of sarcoma. The author uses for his carcinoma antigen the pancreas and submaxillary glands of calf embryos not beyond the second month of fetal life. The technic of preparation is described. Embryonic liver may also be used. The antigen for sarcoma is prepared from a mixture of Wharton’s jelly and red bone marrow of calf embryo. The antigen is injected intradermally (0.2 c.c.). In positive cases a slight area of inflammation appears within fifteen minutes. In negative cases no such reaction appears. A control of physiologic saline with each test is advisable. Sixty-one cases are tabulated in which the results of the test were in close agreement with the diagnosis LLB determined by biopsy, operation, autopsy, or clinical evidence. It is also stated that of 116 students tested, only 9 gave a positive reaction. All of these gave a familial history of malignant disease. DIAGNOSIS AND TREATMENT 165

Experiences with the Freund-gaminer Intracutaneous Carcinoma Reaction, H. KOTRNETZAND H. WEBER. Erfahrungen uber die Freund-Kaminersche intracutane Carcinomreaktion, Deutsche Ztschr. f. Chir. 240: 533-553, 1933. In 177 proved cases of carcinoma of the gastro-intestinal tract, kidneys, pancreas, bladder, prostate, penis, breasts, and buccal cavity, positive reactions were obtained in 153 cases following the intradermal injection of the Freund-Kaminer “ cancer acid.” In 108 of these cases definite palpable cutaneous nodules were formed, while in 45, inflammatory reactions were observed. A study of 118 control cases of all types of disease, excluding carcinoma, showed 58 negative, 36 undetermined, and 24 positive results. Of 43 clinically undiagnosed conditions the diagnosis made from the cutaneous reaction was proved to be correct at operation or autopsy in 25 instances. The aubhors conclude that the Freund-Kaminer reaction is useful in the diagnosis of carcinoma, special reliance being placed on a negative result. The article is illustrated by photomicrographs of typical skin lesions. Extensive tables show the sites and kinds of neoplasms and other clinical characteristics of the cases studied. BENJAMINR. SHORE

The Cytological Diagnosis of Cancer, F. P. TINOZZI.Su di un metodo citolitico per la diagnosi di cancro, Diag. e tecn. di lab. 3: 541-551, 1932. The author has followed out the modification proposed by Willheim and Stern for Freund and Kaminer’s cytological reaction for the diagnosis of cancer. The sera from 70 patients were tested, of which 31 were from cancerous and 39 from non-cancerous individuals. The reaction was positive in 90 per cent of the former, but was also positive in 40 per cent of the latter. Irradiation of the tumor did not modify the result of the reaction, which was sometimes modified by radical extirpation of the neoplasm. The author concludes that the test has no value in differential diagnosis. C. D. HAAGENSEN

Value of Botelho’s Reaction in the Diagnosis of Malignant Tumors, FRANZ PAQLIANI.Sul valore della reazione di Botelho nella diagnosi dei tumori maligni, Tumori 6: 301-313, 1932. Botelho’s reaction, according to the technic described by the originator, was done on the serum of 136 patients, of whom 109 were proved to have malignant tumors and 27 benign tumors. The patients with malignant tumors gave 69.73 per cent positive, and 30.27 per cent negative reactions. There was a general tendency toward a negative reaction when the patient was in an advanced stage of cachexia. An extensive bibliography is included. C. D. HAAGENSEN

“ Cancer Reactions ” of Roffo and Botelho, F. FERNANDEZMARTINEZ, E. SU~REZ PEREGRINAND J. M. CLAVERA.Las reacciones de Roffo y de Botelho en el diagn6stico del chncer, Semana m6d. 1: 1478-1484, 1933. Also in An. de med. int. 1: 917-933, 1932 and Med. argent. 11: 1611-1620, 1932. The authors give a classification comprising a good many of the serodiagnostic tests for cancer, and single out for special diRcussion those of Roffo and of Botelho, which have been the topic of hundreds of publications. They have repeated both tests on 50 patients, 23 with cancer and 27 with other diseases. Botelho’s reaction, in ita latest improved form, gave a larger percentage of positive results (23.1) in the non-cancer than in the cancer patients (15.4)! That is, in the cancer cases, false negatives were 7.5 times more frequent than positives; while in the non- cancer cases the false positives were about one-third as frequent as negatives. The chief drawback to the Roffo reaction was the impossibility of getting a definite result in many of the cases. Omitting doubtful reactions, Roffo’s test 186 ABSTRAOTS gave for cancer patients nearly twice as many negatives as positives, but in the non-cancer group the ratio of false positives to negatives was only 1 : 11. The authors conclude that these two tests are too unreliable to be of value in diagnosis. A bibliography is appended. F. CAVIDRS

Our Cancer Studies: Prelimhry Note [Hydatid Tents in Cancer Diagnorir, Hydatid Fluid in Cancer Therapy], V. SA~~ISPERPIRA AND F. SANZDE FRTJTOS.Unsere Krebsforschungen (Vorbericht), Zentralbl. f. Chir. 59: 2408-2416, 1932. The authors state that in 1927 they operated on two cases in which the clinical findings and the positive hydatid reactions pointed to a diagnosis of hydatid cyst of the liver, and found to their surprise that the liver tumor wm a sarcoma. They have since then had several similar experiences. Theae have led them to the conclusion that there is some relationship between hydatid diseaee and oancer. They have therefore applied the Weinberg serum test for hydatid disease to a number [not stated] of doubtful cases and found that this was positive in from 50 to 90 per cent of cancer cases (the lower percentages in skin cancers, the higher in those of internal organs) and 95 per cent of sarcoma casea. The Wwermann reaction was negative in all cases. Moreover, the Weinberg reaction became negative within a short time after operation-for instance, in twelve hours after an amputation for breast sarcoma. As a logical outcome of this discovery, the authors have applied hydatid antigen [no details given regarding the methods used] to the treatment of cancer in experimental animals and in man, and they claim to have obtained regression and in some cases complete disappearance of the tumors. [Nothing is said as to animal species, kind of tumor, or numbers of animals or patients dealt with.] The authors describe their successes as “ astonishing.” F. CAVERS

Modfiicatione of the MetaboUan in Cancer. Application to Medical Diagnods, E. J. BIQWOOD.Modifications du metabolisme dans le cancer. Applications ail diagnostic medical de cette maladie, Scalpel 86: 85-108, 1933. The author reviews the various studies that have been made of blood chemistry and metabolism in cases of cancer. In addition to the valuable work of Warburg on the reepiration of cancerous tissues, various investigators have studied the carbohydrate metabolism, protein metabolism, mineral metabolism, and acid-base balance of the blood, but no metabolic alterations pathognomonic of cancer have yet been definitely demonstrated. Equally numerous have been the attempts to apply the findings of different investigators to the development of practical diagnostic tests for cancer, but so far no biochemical test entirely specific for cancer has been developed,

Value of the Dad6 Reaction for the Dhgnods of Malignant Tumors, LORIDNZO SANGUINO.Sul valore della reaaione di Davis per la diagnosi dei tumori maligni, Diag. e tecn. di lab. 3: 193-211, 1932. The Davis reaction [see Am. J. M. So. 145: 857,19131 is camed out as follows: to 100 0.0. of urine add 5 0.0. of hydrochloric acid, boil, add 15 C.C. of ether. Allow to stand twenty-four hours. Pipette off the ether and evaporate. The color of the residue indicates the result of the reaction. A reddish color is preeumed to indicate a malignant dieeme. The author did the test on 72 cases of carcinoma which gave 58 per cent of positive reactions. Twenty-four cams of sarcoma gave 70 per cent positive reactions. Twenty-six normal subjects gave 80 per cent positive reactions, while 100 patients with various non-cancerous diseases gave 31 per cent positive reactions. DIAQNOSIS AND TREATMENT 167

Sanguino concludes that the test is not specific and that it has no particular value in cancer diagnosis. C. D. HAAGENSEN Value of the Davis Reaction for the Diagnosis of Malignant Tumors, P. PIERO. Sul valore della rearione di Davis per la diagnosi dei tumori maligni, Boll. d. lega ital. per la loth contro il cancro 6: 97-101, 1932. Piero tried the Davia reaction [see above] on 16 patients with malignant tumors; 14 gave positive reactions and 2 negative, which later became positive. JEANNETTEMUNRO Value of Pyelography in the Diagnosis of Tumors of the Iliolumbar Region, LAFFITTE. Valeur de la py6lographie dans les tumeurs de la region lombo- iliaque, J. d’urol. 34: 492-497, 1932. Also in Bull. SOC.frang. d’urol. pp. 277-282, 1932. The author says he has found pyelography useful in the diagnosis of extrarenal tumors and other lesions in the iliolumbar region causing pressure upon and therefore distortion of the ureter and renal pelvis. In a woman of fifty who complained of progressive swelling of the right lower abdomen, an indefinite tumor was palpable in this region midway between the costal margin and the anterosuperior iliac spine, but x-ray showed no filling defect anywhere in the bowel. Pyelography showed displacement curvature of the entire ureter to the left, the middle of the arc almost reaching the left of the vertebral column. Laparotomy revealed a tumor of the ascending colon which had extended downward into the iliac fossa and was attached to the duodenum and some coils of the ileum. Ileotransverse anastomosis was done aa a palliative measure. There are two illustrations. F. CAVERS me Metal Catheter as an Aid in Difierentiating Tumours of Pelvic Origin, A. D. CAMPBELL.Canad. M. A. J. 28: 71-72,1933. In briefly discussing the diagnosis of tumora in the female pelvis, the author points out that normally, with the patient in the lithotomy position, the direction of the vaginal canal is downward and backward; that upon the pubocervical fascia, the chief structure of the anterior vaginal wall, lies the bladder, which depends on this fibromuscular sheet for its support; and that the position of the bladder therefore varies with this supporting structure. When the uterus en- larges, as in pregnancy or from tumor growth, it emerges from the pelvic cavity and the position of the bladder is altered as the vagina is drawn upwards. If a metal catheter is passed into the bladder in such cases, the direction of the base of the bladder is found to be upward and forward instead of downward and backward. On the other hand, adnexal tumors emerge from the pelvis as they enlarge, developing a pedicle, and lie over the pelvic inlet, pressing downward upon the pelvic organs, especially the uterus and the fundus of the bladder. The position of the vagina and therefore of the bladder base may remain unaltered, as these pedunculsted tumora do not exert sufficient traction on the vagina to alter its direction. More frequently, however, with cystic tumors, the normal downward and backward direction becomes exaggerated, and if a catheter is passed into the bladder gentle palpation will reveal a tumor above, or above and anterior to, the catheter. Two illustrations are given. F. CAVERB

Value of an Exact Diagnosis, CABOTCASE 18281. New England J. M. 207: 88-90, 1932. This report is presented as an example of the value of establishing an exact diagnosis even in an apparently hopeless case. The original diagnosis was car- 9 168 ABSTRAUTS

cinoma of the stomach with widespread metastases. Biopsy of an inguinal lymph node showed lymphoblastoma. The value of this correction is obvious, since deep x-ray therapy affords the patient with gastric cancer no relief, but to the patient with lymphoblastoma may give months or even yeam of comparative comfort and usefulness.

Recent Progress in the Treatment of Cancer, C. F. GESCHICKTER.Clin. Med. & Surg. 40: 73-77, 150-164, 1933. An excellent survey of the present status of cancer therapy. W. MACCOMB The Treatment of Carcinoma and the General Practitioner, E. WOLF-JACOB. Karrinombehandlung und praktischer Arzt, Monatschr, f. Geburtsh. u. Gynak. 91: 460-463, 1932. To give the point of view of the general practitioner toward the treatment of cancer of the cervix, the author of thie paper presents her experience with 56 cases of cancer, divided as follows: carcinoma of the internal organs, 18; carcinoma of the breast, 10; carcinoma of the genitalia, 25; cancer of the skin and bones, 3. In surveying the results obtained in these cases, she comes to the conclueion that operation is rarely to be preferred to radiation treatment and that, particularly in cases of genital carcinoma, radiation is superior to surgery. HOWARDC. TAYLOR,JR.

Surgery of Tumors by Electrothermic Methods, DEHARVEN.Chirurgie des tumeurs par lee proc4dBs Blectrothermiques, Scalpel 86: 145-158, 1933. The author uses endothermic currents in the reploval of malignant growths. The field is cleaner; cancer cells are destroyed for a millimeter or so beyond the none of actual coagulation; and infected and ulcerating tumors can be destroyed by this means. The electric knife can also be used in obtaining biopsy specimens.

Place of Diathermy in the Cancer Problem, GTJSTAVHOLISCEER. Arch. Phyeical Therapy 13: 401-404, 1932. The author discusses some wholly theoretical explanations for the therapeutic merit of diathermy in the treatment of cancer. He believes that the macro- phages of the reticulo-endothelisl system are attracted in large numbers to the “ perithermic aone,” where they exert their destructive action on the cancer cells, though this destructive action in a great many instances is not completely successful. To excite an overproduction of these defensive cells and to stimulate their functional capacity, electrocoagulation should be supplemented by protein therapy.

The Radiologist IS Kepman in Cancer Work, A. SOILAND.Texas State J. M. 28: 762-764, 1933. The radiologist has risen in a few decades to the same position as a diagnostician as that attained by his professional colleagues engaged in the practice of thoee specialties which are many centuries old. In the majority of institutions, especially in the Western states, a radiologist and not a surgeon is handling most of the cancer work of his territory. W. 8. MACCOMB

Surgery, X-ray and Radium in the Treatment of Cancer, H. K. SCATLIFF. Illinois M. J. 62: 357-359, 1932. A general discussion of the principles of treatment of cancer. DIAONOBIS AND TEEATMENT 169

Comparative Value of Surgical and X-ray Treatment of Malignancies, E. G. SHARP. Eclectic M. J. 93: 151-153, 1933. A few general remarks on the treatment of cancer. It presents no new ideas or observations. [The author classifies lupus a8 a malignant disease.] GRAYTWOMBLY Radiotherapy and Its Use in General Surgery, EDWINL. RYPINS. J. Iowa M. SOC.22: 248-252, 1932. This is a brief review of the current literature on radiotherapy in combination with surgery.

Present Position of Deep X-ray Therapy, A. T. NIBBET. Fourth Australian Csn- cer Conference, Canberra, March 1933. This paper is a general survey of the results of radiation therapy based on the author’s experience. Such statistics as are given are taken from his practice and from two hospitals during the past three or four years. The different types of benign and malignant tumors from various sites are considered separately.

High-Voltage Therapy in Cancer, G. C. MCELFATRICK.Delaware State M. J. 5: 50-52, 1933. A short statement of the author’s belief that high-voltage x-rays are of value in the palliative treatment of inoperable cancer and to prevent recurrences in operable cases. He uses saturation of the treated area by means of divided doses over a period of a month. GRAYTWOMBLY First Annual Report of the Use of X-rays and Radium by the Tumor Clinic of the Creighton Memorial St. Joseph’s Hospital, J. F. KELLY. Nebraska M. J. 18: 138-142, 1933. During a period of fourteen months 149 cases were presented for discussion in the tumor clinic from which this report comes. Of these, 93 were advanced when first treated and 40 of the patients were dead at the end of the first year; 28 are still living, some in good condition. In the remaining twenty-five patients the disease was less advanced and it is believed that their lives can be considerably extended. W. S. MACCOMB

Sarcoma, D. C. L. FITZWILLIAMS.Med. World 37: 269-272, 1932. The author discusses the radium treatment of sarcomas. From his experience, round-cell sarcomas are least differentiated and therefore most radiosensitive, spindle-cell forms the most highly differentiated, and mixed forms intermediate. Early diagnosis and accessibility are the keynotes of success in radium treatment, and radium, therefore, holds out no hope in tumors in inaccessible sites, in which, moreover, early diagnosis is difficult. The I‘ surgery of access ” has proved to be limited in scope and in this respect has disappointed the hopes of those radio- therapeutists who had expected a greatly increased field of work. Size is a factor in radium treatment, for the author.has treated many large tumors, but has never obtained real success. The author cites three instances of failure, two probably due to the use of too small an amount of radium and too few foci of application; in the third case the patient, who had bone sarcoma, is alive after two years, but has an intractable abscess, and the author thinks that amputation would have been better treatment. As an offset, four instances of success are reported. The most striking was in a case that appeared at first utterly hopeless. A boy of seven years had a nasopharyngeal sarcoma which had rapidly spread up through the base of the skull, 170 ABSTEtbOTS pushed apart the bones of the calvarium, and projeated in ~BBBBBwhich gave the child a grotesque appearance. Sufficient radium ww obtainmi with dificulty (thia was in 1913), the tlimor regressed under treatment, and the patient is alive and well sixteen years afterwards. [May thia not have been one of the nasopharyngeal polypi which do so well with radium. Microscopically they often resemble sarcomata.] F. CAVIRS

New Methods in the Treatment of Cancer and Their ScientMc Basis, J. MAISIN. Au sujet des nouvelles methodes de traitement du cancer et de leure basee scientifiques, Scalpel 86: 389-400, 1933. The author discusses various modern methods used in the treatment of cancer and describes his om method of palliative therapy for carcinoma of the rectum. He has found that extracts of the brain, the bone-marrow, the thymus, the pituitary, and the suprarenal have an inhibiting effect on the growth of cancer in mice. In human caaes the use of extracts of the brain or bone-marrow (which appear the most active of the extracta used experimentally) had definite palliative effects in advanced cams and caueed the disappearance of some smdl cubneous tumors. Various salts of barium were also used; in small doaea, 0.1 to 0.002 mg., the glu- conates and saccharatem of barium have an inhibiting effect. [Thie is intereating because tracea of barium are frequently found in the tissues, espeoially the liver.] Combined with radiotherapy the barilim salte have been found to be of definite value. In general it hes been found that the best resulta in the treatment of cancer are obtained by a combination of various methods, surgery, diathermy, x-rays, radium, medical means. [Unfortunately Maisin's optimistic conclusions as regards organ extracts have not been substantiated.]

So-called 'I Acidotic Therapy " of Malignant Tumom, ANNA GOLDFBID~R. Besprechung iiber die sog. ,,Acidotische Therapie" der b6sartigen Qeachwtilste, Ztachr. f. Krebsforach. 39: 417-420, 1933. Though it ie thought by many that a shift in the environment toward the acid side would be deleterious to the malignant cell, thia conception is not easy to carry out in practice. For if the agent which it is desired to employ be given by mouth, the geetro-intestinal canal is disturbed, while intravenous, intramuscular, or subcutaneous administration introduces the danger of local thrombosis or inflammatory and necrotic lesions. Secondly, the buffer capacity of the blood and hues is so high that it is difficult to bring about anything more than a transient acidosis without using measures that would entail serious damage to the organism; yet the tumor cell ie still more efficiently buffered than any of these. Here liee the difficulty of discovering a useful acidotic therapy. Wx. H. WOQLOM Chordotomy in a Case of Sarcoma of the Left Gluteal Region, J. MON~NIQRO AND J. 0. MATOEI.Cordotomia por sarcoma da regiio glutea esquerda, Rev. hoc. pauliata de med. 1: 213-215, 1932. This is a report on a cam of sarcoma of the left buttock and perineum in a seventeen-yearsld boy in which a chordotomy (Spiller-Martin-Frasier operation) was performed in order to relieve severe pain. The operation caumd retention of urine and paresis of the right leg and left arm, but within three weeke these had entirely disappeared. A slight weskneas of the right leg persisted, but the pain was relieved. JOHANNEEIP. M. VOGIWXI THE SKIN 171

Mtration Anesthesia for Removal of e Large Tumor of the Gluteal Region, JULI~NVILLARREAL. Anesthesia por infiltration para extirpar un gran tumor de la region glbtea, Gac. m6d. de Mexico 63: 419-421, 1932. For operative work under local anesthesia Villarreal tries to we the smallest quantity of anesthetic possible. In excising a large tumor of the gluteal region, where the skin incision alone was 25 cm. long, he used only 35 C.C. of a 1 per cent anesthetic solution [name of solution not given]. He tries to cover 4 to 6 linear centimeters of skin with 1 C.C. of solution and use the remainder for necessary subcutaneous injections. JOHNE. WIRTH Notes on the Management of the Advanced Cancer Patient, H. C. SALTZSTEIN. J. Michigan M. SOC. 32: 36&362, 1933. At Mercy Hall, Detroit, Michigan, 73 cancer patients were cared for from Oct. 26, 1931, to Oct. 22, 1932; of this number 55, or 75 per cent, were terminal cases. In these patients, while the chief factor is the control of pain, the use of morphine has been avoided as far as possible and in most instances oodein and aspirin in combination have given satisfactory relief. In some instances gardinol (a combination of pyramidon and luminal) was also used. In a few patients, a morphine derivative, dilaudid, has been found to have definite advantages over morphine. In some cases alcohol injection of the proper nerve trunk entirely relieves pain. Occasionally cordotomy has been done for intractable pelvic pain. In cases with severe anemia, ventriculin with iron has been found useful, definitely improving the patient’s general condition. Aspiration of accumulations of fluid in the chest or abdomen is also done for re-accumulation is slower. [X-ray therapy may also check the return of fluid.] As a deodorant for foul wounds, vaginal douches, etc., a pine oil preparation (solupin) in 1 : 10 solution has given the best results. A Perepective of Cancer, D. P. BIRD. J. Florida M. A. 19: 430-431, 1933. A general review with special reference to early diagnosis and methods of treatment. THE SKIN

Study of Ten Cases of Cutaneous Carcinoma, S. UCHIKIAND S. SUZUKI. Zur Anatomie und Klinik der Hautkarainome, Mitt. ti. allg. Path. u. path. Anat. 8: 103-122, 1933. In 9 of the 10 cases studied the tumors were surgically excised; in the tenth case the patient declined operation, but a biopsy was made prior to x-ray treatment. The patients’ ages ranged from forty-eight to seventy, all except two being in the sixth and seventh decades. In 6 cases the lesion first noticed was a small wart; in one each, a slight wound, an erosion, a small abscess, and an atheromatoua cyst. Five of the tumors were of squamous-cell type; one was diagnosed as a medullary form of basal-cell cancer arising in a sweat gland; 4 were metatypic form (including the transitional-cell type). Apart from the full cme histories, most of the paper is devoted to a description and discussion of the pathogenesis of the metatypic tumors. All four of these occurred in women, and were located in various regions but never on the face, which is usually said to be their chief site. In one case, the tumor was of mixed type, being squamous-cell in the center and basal-cell in its peripheral region. In the other cases the tumor cells were of strictly intermediate or transitional type, being rounded, ovoid, or polygonal, hydropic, larger and better differentiated than basal cells, and differing from the squamous type in showing no prickles or horny pearls or nests. One of these cases showed rapid recurrence and metastasis, following free excision of the primary tumor and the regional lymph nodes, and the patient died with increasing cachexia. 172 ABSTRAOTB

The authors have compiled from the literature a useful table giving the percentage incidence of the three main types of superficial carcinoma:

Type Bloodgood Darier Montgomery Juon Squamowcell 76 50 63 46 Baeel-Cell 19 35 24 40 Metetypic 5 15 12 12

Bloodgood is cited as giving 86 per cent cures by excision, and MacKee 85 per cent cure8 by x-rays. Bloodgood’s surgical cure estimate for squamous-cell cancers was 40 per cent, for transitional or metstypic cancers 33 per cent. The authors agree that the prognosis for surgical treatment of the metatypic forms is bad; these tumors usually grow very slowly for a long period, but are apt to assume rapid and extensive growth in middle or late life. There are five good photomicrographs and a fairly comprehensive bibliography is appended. F. CAVERS

Skin Cancers Arising on the Scars of Burns, HAMANT,BODABT AND CHALNOT. Cancers d6velopp6s sur des cicatrices de brtllures, Bull. Soc. frang. de dermat. et syph. 40: 26-28, 1933. In each of the four cases described by the authors a squamous-cell carcinoma developed in the scar of a burn sustained many years previously. (1) A woman of forty, with ulceration of the scalp, had been severely scalded when one year old, suffering permanent baldness, destruction of the right eye, and loss of the right external ear. Six years before admission to the hospital she ~11s- tained a scalp injury which left an intractable ulcerated and infected wound in the old scar. The borders of the plate-like tumor were thickened, and biopsy showed numerous mitoses in the epitheliomatous cells and micro-abscesses in the stroma. The tumor, as large as the palm of the hand, was ablated, and the defect repaired by skin grafts. (2) A man of fifty-six, when six years old, had been severely burned on the right hand. The worst scar was on the palmar surface, where the skin had several times opened and discharged pus. Two years before admission to the hospital a large purulent fissure opened over the thenar eminence, and soon afterwards there appeared at this site a tumor, which now measured about 6 om. in diameter. As the tumor appeared to be spreading towards the deep tissues above the wrist, the humerus was amputated at its lower third. There was no sign of recurrence a year later. (3) A woman of sixty-two had burned the back of her left hand on a stove, when she was twenty-eight years old. During the past two years a raised ulcerated patch had appeared on the scar, and this had now become a large epithelioma with metastases in the epitrochlear nodes. The humerus was amputated, but six months later the patient returned with extensive axillary metastases adherent to the skin. The axilla was cleared, and the stump of the humerus used to help in closing the large skin gap. Eight months later the patient again returned with infected axillary adenopathy. She died a month later. (4) A woman of sixty-six, had burned her left thigh at the age of fourteen years. Two years ago she had noticed in the scar a tumor, which was now the size of the palm of an adult hand. She refused amputation or radiotherapy and had not been heard of since. These cases illustrate several points in connection with the origin of malignant epithelial skin tumors on the basis of burn scars of long standing. The “ latent period ” between the infliction of the burn and the appearance of the cancer is THE SKIN 173 very long, in this series thirty-nine, fifty, forty-five, and fifty-two years. In most cases the scar becomes ulcerated and infected, and in many cases it is traumatized. Within a short time after either of these events a tumor appears and grows fairly rapidly. Since these burn scar cancers are located chiefly in the extremities, especially on the back of the hands, the authors believe that the treatment of choice is amputation combined with node dissection. When adenopathy has appeared, the prognosis is extremely unfavorable. F. CAVERB

Rapid Appearance of Poat-Traumatic Skin Cancer, E. DUFIOT,G. LOYOUBAND DI~LACOURT.Rapidit6 d’apparition d’un 6pith6lioma spino-cellulaire post- traumatique, Bull. et m6m. SOC.m6d. d. hbp. de Paris 56: 1406-1409, 1932. An electrician injured his right hand early in April 1931 while handling some old copper wire. Twelve days later there appeared on the injured spot a small swelling, which was excised on April 25 and found to contain a fragment of copper. The operative scar healed badly, and another nodule appeared, which was more extensively removed in June. Again the scar failed to develop normally and became covered with villous outgrowths, found on biopsy (August 18) to consist of squamous-cell carcinoma. A month later the involved fingers (index and middle) were removed at the upper third of the metacarpals. The authors are convinced that this is a case of traumatic cancer of unusually rapid development. F. CAVERS Epithelioxnas of the Skin, V. PARDOCABTELLO. Epiteliomas de la piel, Bol. d. 1. Liga contra el chcer (Ed. cient.) 7: 266-280, 1932. Pardo Castello lists senile keratosis, senile seborrheic concretions, senile pig- mentations, verruca vulgaris, pigmented nevi, leukoplakia, Paget’s disease of the nipple, Bowen’s precancerous dermatoses, cicatrices, radiodermatitis, and chronic ulcerations as frequent precursors of cancer and hence deserving of careful observation and treatment. He discusses melanomas, classifies cutaneous carcinomas on a histologic basis, and gives a brief clinical differential diagnosis. There is a brief discussion of treatment. No bibliography is included. JOHNE. WIRTH

Epithelioma of the Face, C. 0. KINO. J. M. A. Alabama 2: 318-321, 1933. This constitutes a brief r6sum6 of the etiology, differential diagnosis, and treatment of the different types of epithelioma of the face. W.S. MACCOMB Studies of Rodent Ulcer Including Cell Structure, C. THEBLEFF.Studien tiber das Ulcus rodens einschliesslich seiner Zellstrukturen, Arb. a. d. Path. Inst. d. Univ. Helsingfors 7: 51-158, 1933. This is a detailed histological study of 48 skin tumors diagnosed clinically as rodent ulcer. Histologically 26 cases were basal-cell carcinoma; 4 were of adenomatous type; 5 of mixed form. In 7 cases there were groups of prickle cells in the basal-cell parenchyma. Six cases were prickle-cell carcinoma. The original paper must be consulted for details of the histology. Forty-one photomicrographs, 4 other, illustrations, and a bibliography are appended. Treatment of Cutaneous Cancer, ROBERTOQUBRO. Tratamiento del cancer cutaneo, Bol. d. 1. Liga contra el c&ncer (Ed. cient.) 7: 309-317, 1932. This is a general discussion of the treatment of cutaneous cancer with surgery, electrosurgery, and radium. Radium is used in small quantities with a filter of 174 ABBTRAOTS

0.5 mm. platinum at a distance of 1 am. from the skin. [Many eeaential details of the technic of radium therapy are omitted and there is no bibliography,] JOHNE. WIBTH

Carcinoma in a Xative of Tmk Mend, T. MOQAMAND T. MIJBATA. Ein Fall von Karsinom bei einem Eingeborenen auf der Insel Truk in der Sfidsee, Acts dermatol. 20: 136-137, 1932. A boy of tpelve years, a native of one of the Middle Caroline Islands, came for treatment for yaws, and was found to have also a basal-cell carcinoma. This had evidently ariseh in the conjunctiva and spread over the cheek. F. CAVEBS PsorAa6k Rupioidee with Carcinoma, E. W. JOHNS. Southwestern Med. 17: 95- 100, 1933. A case of psoriasis rupioides is reported occurring in a forty-year-old male, present since the age of six. Three years before admission to the hospital an ulcer had developed on the right heel: There waa present on the lateral aspect of the right foot, below the ankle, a tumor mass measuring 4 inuhw in diameter and 2 inches in depth. An amputation was performed below the knee. The pathological examination showed epithelioma of the skin with psoriasis. W. S. MACCOMB hpo6i’S SarCOXUtOSi6, HEBNLND. GONZLLEZAND MANUELF. VIDAUBBIDTA. Sarcomatoeis de Kaposi, Prensa m6d. argent. 19: 366-374, 1932. The authora report an interesting case of Kaposi’s multiple hemorrhagic sarcoma which eventually came to autopsy. An Italian fifty-five years of age gave a history of a small tumor appearing on the index finger of hie left hand about three months before hie admission to the clinic. He said that shortly after this initid ledon numerous other small nodules appeared on the dormm of both hands, both forearms, and both feet and lower legs. There were no generalized systemic symptoms. Physical examination revealed violet colored, slightly tender, hemorrhagic, cutaneous nodules, varying in sise from a pin head to the size of a large pea, scattered over the dorsum of the left hand, wrist, and forearm and to a less extent over the corresponding parts of the right upper extremity. On the lateral surface of the left foot and leg and on the inn- surface of the right foot and leg were leaions similar to those of the upper extremities. Some of the lesions were slightly ulcerated, othera tended to form confluent tumors. The hands and feet presented a generalired edema. Nodules were also found in the pinna and lobe of the right ear. The blood Wassermann reaction was positive, and a cell count of the blood was essentially normal. A biopsy taken from the left forearm showed the typical structure of Kaposi’s disease. The patient was given an intense course of treatment with arsenic, mercury, and iodides, and told to protect hie hands and feet from trauma, Roentgen-ray therapy was not used. No improvement was observed. Four months later the patient returned with the condition much more advanced. New lesions had appeared, the old ones had grown larger and ulcerated, the edema had become more marked, and pain had become so severe that morphine was needed in large quantities. The patient became emaciated and died a few months later. At autopsy it was noted that the prooeea had been limited entirely to the cutaneous structures. The thoracic and abdominal organs were free of the disease. The article contains numerow photographs, 2 photomicrographs, a fair discussion of the disease from a review of the literature, and a good bibliography, JOHNE. WIRTH THE SKIN 175

Multiple Subcutaneous Darier-Roussy Sarcoids, J. NICOLAB,G. MASSIAAND J. ROUBSBT. SarcoIdes sous-cutanbe multiples du type Darier-Roussy, Bull. SOC.frang. de dermat. et syph. 40: 42-46, 1933. A woman of twenty-four had been operated upon for tuba1 pregnancy and during recovery was given several injections of camphorated oil and of physiologic saline into both thighs. About five months later she noticed on her right thigh several small hard lumps, which were neither painful nor itching. She was given a diversified treatment, including hot fomentations, massage, baths, and several proprietary medicines by mouth. The nodules steadily increased in number and sire, and others appeared on the left thigh and on the right arm. On admission to the hospital the patient produced a report from a consulting pathologist to whom she had been referred, stating that nodules taken from both thighs showed chronic inflammation, with numerous giant cells surrounded by epithelioid cells and associated with acid-resistant bacilli, the diagnosis being “ tuberculoma.” The authors examined some of the nodules, and confirmed these findings, except that they failed to detect bacilli. They inoculated part of a nodule into a guinea-pig, which when killed a month later showed no sign of tubercle. Meanwhile, although the blood Wassermann reaction was negative, they gave antiluetic treatment, injecting bismuth hydroxide, because they had found that in many cases these sarcoids were associated with syphilis and disappeared under specific treatment. In this case the nodules showed rapid regreqion. The authors at first euspected that the nodules might be oleomas, but rejected this explanation when biopsy of nodules on the forearm showed the same tuberculoma-like structure as those on the thighs where the injeotions had been given. They believe that in any case of sarooid antiluetic treatment should be tried, irrespective of the histologic findings and the result of the Waseermann test. A good photomicrograph is given. F. CAVERE

Hirtology of a Case of Subcutaneous Sarcoma, MARCIALJ. QUIROOAAND PABLO BOSQ. A prop6sito de la histologfa de un caso de sarcomas subcutheos, Prensa med. argent. 19: 578-579, 1932. A brief discussion of a case in which the diagnosis was indefinite. JOHNE. WIRTH

Histiwytoma of the Skin, F. WORINQERAND S. KVIATKOWBKI.L’histiocytome de la peau, Ann. de dermat. et syph. 3: 998-1010, 1932. In looking through their collection of biopsy specimens the authors found several which were diagnosed as fibromas but which they regard as being in reality examples of a special tumor type to which the senior author has given the name histiocytoma [see Abst. in Am. J. Cancer 16: abet. p. 1328, 19321. They now report six further cases. These tumors are of slow growth, occur in adults in small number (one to five) , are painless, arise in the dermis, and do not recur after excision. They consist chiefly of fusiform celle, accompanied by collagenous fibers which often show thickening and hyalinirationl In the tumor are included groups of small foam cells resembling, except in sire, the large ones found in typical xanthomas, and containing cholesterol crystals. In froren sections the tumor cells are seen to be infiltrated with fat drops. The authors point out that true fibro- cytes do not store fats and lipoids, whereas those of the reticulo-endothelial system do. They therefore consider that these histiooytomatous tumors are derived from the reticulo-endothelial tissue of the dermis. There are five illustrations. F. CAVERE 176 ABBTRAOTS

Benign Epidermal Ihoplasms, S. WZLLIAMBECKER. Arch. Derm. & Syph. 26: 838-848, 1932. The author calls attention to the fact that in the usual classification of tumors no provision is made for benign epidermal neoplasms. In such a group he would include senile verruca. Of this condition he reports briefly, and illustrates with photomicrographs, 3 cases, histologic examination of which revealed that the tumors consisted essentially of epithelial hyperplasia, not of the inflammatory type known as acanthosis, found especially in condylomata acuminatum, but more closely resembling that seen in basal-cell carcinoma. The growth of the tumor, however, is outward, not inward as in malignant epidermal neoplasms. Such tumors were classed by MacCallum and others as papillomss and by Darier as nevi, while Jadassohn was inclined to consider them of infectious origin. The author believes that a clue to their nature is to be found in their similarity or identity with the pigmented epithelioma of Bloch. They are primarily epithelial proliferations in which the papillary overgrowth is secondary. The designation papilloma, therefore, should not be used for them but should be reserved for certain other tumors in which papillary overgrowth is the essential feature. Two examplea of papiIloma are briefly reported and illustrated. The author discusses, also, the use of the terms carcinoma and epithelioma. For malignant epithelial growths he considers the term carcinoma the more logical one. For benign epidermal neoplasms epithelioma is the proper designation. A very complete bibliography is appended. W. BAYARDLONG Myomas of the Skin, E. L. OTHAZ. Dermatomiomas: consideraciones sobre esta afeccih, Semana m6d. 1: 1130-1138, 1933. The author describes a case of multiple myomm occurring in the skin of the right forearm of a man of thirty years, and gives a good general account of these tumors. The chief symptom is pain of a spontaneous or easily induced kind, which is almost pathognomonic for these tumors. There are three iIiustrations, and a useful bibliography is given. F. CAVERS Benign Sweat-Gland Tuxpor (Annular Hidradenoma) of the Forehead, SEZARY AND G. L~vY-COBLENTZ.Hidrad6nome annulaire du front, Bull. 500. frang. dermat. et syph. 40: 224-225, 1933. A man of forty-four showed a tumor on the forehead and in addition two nevi, each the sine of a pea, at the internal angle of the left eye and on the left ale nasi. On biopsy the tumor of the forehead showed no change in the epidermis, but in the dermis there were strands of epithelial cells, evidently derived from a sweat gland, without infiltration. In discussing the paper, Milian said that the histologic appeeranoes were not quite typical for hidradenoma, and suggested that the authors should try diagnostic therapy, in the form of an erythema dose of ultra-violet rays, which had cured a case of hidradenoma. No illustrations are given. F. CAVERH Treatment of Angiomas by Injection of Sodium Solicylate Solution, A. TOURAINE AND P. RENAULT.Traitement des angiomes tub6reux par les injections scld- rosantes de salicylate de soude, Presse m6d. 41: 259, 1933. Treatment of Angionuxs by Injections of Quinine and Urea Hydrochloride, Atimciated with Cryotherapy, A. S~XARY,M. DUCOURTIOUX AND G. BAXBARA. IA traitement des angiomes cutan68 par ies injections scl6rosantes de chlor- hydrate double de quinine et d’urde associ6es la cryothdrapie, ibid. 41 : 260, 1933. Touraine and Renault state that very small anpiomas can be cured by various forms of treatment, but when they become large the only satisfactory treatment is TEE SKIN 177 injection of sclerosing substances. Surgery, electrolysis, and diathermy leave ugly scars; cryotherapy (solid carbon dioxide) and x-rays act too slowly; radium gives good results only if applied with extreme care by an expert. They have used injections of 20 per cent sodium salicylate solution, in doses of 2 to 5 c.c., and have rarely found more than four or five daily injections necessary for cure. SBzary, Ducourtioux and Barbara agree with the opinions of Touraine and Renault, but say their best results have been obtained by using a 5 per cent solution of the double hydrochloride of quinine and urea, supplemented by applications of solid carbon dioxide. F. CAVERS Mycosis Fungoides with Immediate Tumor Formation, S. SCHUJMANmn T. OCAWA. Micosis fungoide a tumores “ d’emblge,” Semana m6d. 2: 1505-1515, 1932. The authors have made a fairly complete study of a case occurring in a man of forty-six, who a month previously had.noticed a small red lump on the right shoulder, followed by another on the left arm. The first lump had grown rapidly, the second very slightly. A blood count showed 4,500,000 erythrocytes and 10,000 leukocytes, the chief feature of the differential count being the presence of 17 per cent monocytes. Blood obtained by scarification of one of the nodules showed 46 per cent monocytes. No lymph node involvement was observed. Histologically the epidermis of the nodule showed acanthosis, interstitial edema, and reticulosis. The tumor consisted almost entirely in enormous proliferation of the reticulo-endothelial tissue of the dermis, with the production,of dense masses of cells of various types. By staining methods these tissue elements are traced to an origin from the lining endothelium of blood vessels. The differential diagnosis of conditions which originate in proliferation of the reticulo-endothelial tissue is discussed. The authors consider that mycosis fungoides is on the whole sharply distinguished from leukemic and lymphadenoma- tous condition8 which also have cutaneous and lymph-node manifestations. The patient was given one application of x-rays [no details given], after which the tumors promptly disappeared and the blood monocytes fell to 2 per cent. There are seven good photomicrographs. F. CAVERS Papillomatous Tumor of the Skin Containing Botryococcus-Like Bodies, E. CORTELLA.Studio di una forma singolarissima di neoformazione vegetante della cute, Gior. ital. di dermat. e sif. 73: 1827-1845, 1932. A woman of sixty-seven had a small tumor in the left zygomatic region, which her physician had diagnosed as probable epithelioma. It recurred after several attempts at ablation by the ordinary and the electric knife, and was found entirely resistant to radium and to arsenobenzol ointment. It was evidently only locally malignant, there being no sign of spread to the lymph nodes. It had an ulcerated papillomatous surface, which bled freely on a touch. Biopsy showed a structure which the author at first interpreted as squamous-cell carcinoma. After the tumor had become very large it began, without further treatment, to regress even more rapidly than it had increased in size. The patient died of intercurrent disease before the tumor had disappeared. Material from the ulcerating tumor had been found to contain a microorganism which a bacteriologist identified as a botryococcus. Several pieces of tumor examined after this seemed to the author to show the structure of a human pseudo- botryomycosie. Several animals, including rats, rabbits, guinea-pigs, and horses, as well as the patient herself, were inoculated subcutaneously with fragments and emulsions of the tumor, but the results were negative. The author examined more pieces of the tumor, and as he found abundant newly formed fibroblasts and also vascular neoformation, he concluded that the tumor was best designated as a 178 ABSTUOTS soft telangiectatic fibroma. The eight illustrations, though not particularly good, seem to justify this histologic diagnosis. [Doubtless the organism found on the ulcerated surface of the tumor was a banal saprophytic coccus of some sort; various kinds of such microorganisms occur in infected tumors.] F. CAVIORS A Case of Skin Tumours, with a Doubtful Diagnosis, Probably Lympho~uloma- tosie Cutis, E. MANNHIOIMIOR.Acta dermat.-venereol. 13: 570-584, 1932. A man of sixty-six had during the past eight years noticed numerous lumps scattered in the skin of various parts of the body, including the adlae and groins, but had had no itching, pain, or other symptom. Blood examination showed slight anemia, with normal total and differential leukocyte counts. X-ray examination of the chest, abdomen, and skeleton gave negative reaulte. Biopsy of several of the skin nodules and of the enlarged axillary and inguinal lymph nodes showed uniform hueresembling that seen in Hodgkin’s disease, except that no typical Sternberg giant cells could be found in the large number of serial sections examined. There were a few polynuclear cells, some of them with an atypical appearance and *others somewhat resembling Sternberg cells. &vend x-ray treatments were given, with varying dosages, but the nodules and lymph nodes remained unaffected. The chief diseases discusaed in the differential diagnosis are tuberoulosis, probably excluded by the negative Pirquet and other reactions and by the histologic pieture; aleukemic lymphadenoeis, probably excluded by the normal sire of the spleen, resistance to x-ray treatment, and normal blood picture; and mycoeis fungoides, probably excluded by the resistance to x-ray and the histology. The author concludes that this may be a oaee in which Hodgkin’s disease begins with skin lesions, to spread later by way of the lymph veasels to internal organs. He cites several reported cases in which the disease has run this course. Six illustrations are given. F. CAVER8 Giant Angionu Tuberosum of the Face, V. PARDO-CASTBLLO.Arch. Derm. & Syph. 26: 907-908, 1932. A child of two months had an enormous angiomatous mass involving the left side of the face. It was treated by radium (50 mg. per square centimeter on successive dates, filtered with 1 cm. Columbia wax, with .05 mm. lead and 0.5 mm. platinum). At the time of this report, when the child was eighteen montha old, no treatments had been given for five months. Dr. MacKee, commenting on the case, stated that the result was good and the likelihood of continued improvement strong. He believed nothing was to be gained by further use of radium. Xanthomatosis, v. PABDO-CABTELLO. Arch. Derm. & Syph. 26: 004-905, 1932. This is a report of a case in a child who at the age of eight moqths showed large numbers of pedunculated sessile tumors practically covering the body. One of the tumors was excised and showed the histologic features of xanthoma. The blood cholesterol was within normal limite, as was the blood sugar. On a low-fat diet, with administration of vitamin D and iron, the tumors had largely disappeared by the time the child was four years old, leaving atrophic rounded or oval scars surrounded by a ring of firm tissue-the typical lesions of smelled macular atrophy. Some fully developed xanthomatous lesions were still present and others appeared to be in the process of reabsorption. Cane of Poetidoxanthonu Elreticum with Angioid Striae Rehe, MITSTJ~U MURATA. Em Fall von Peeudoxanthoma elasticum mit Stria angioidea rethe, Japanese J. Dermat. and Urol. 33: 485-492, 1933. A man of thirty-eight complained of failing vision. Examination revealed THE EYE 179 angioid striae of the retina. There were also degenerative changes and hemorrhages in the retina, and skin changes attributable to pseudoxanthoma elasticum. The nodules were sharply circumscribed, with round to oval centers, extending from the corium to the deeper layers. Elastic fibers formed the inner half of the friable and grumous centers. With v. Kossa’s method a distinct calcium deposit was demonstrated in the elastic fibers. K. STJGIURA

THE EYE

Ocular Papillomata, W. B. DOHERTY.Am. J. Ophth. 15: 1016-1021, 1932. Two cases of papilloma arising from the ocular conjunotiva are described, and photographs of the clinical appearance and microscopic structure presented, In the first case there were multiple growths around the corned-scleral margin which had the macroscopic appearance of granulation tissue. The patient died of another cause before treatment could be instituted. In the second case there were three small papillomas situated on the semilunar fold at the inner canthus, the adjacent edge of the upper lid, and the caruncle, respectively. They were removed under local anesthesia. A review of previously reported cases and a bibliography are included. C. D. HAAGENSEN

Metastatic Sarcoma of the Choroid. Report of a Case, W. E. FRY. Arch. Ophth. 9: 248-255, 1933. While metastatic sarcomata from the choroid to other parts of the body are fairly common, cases of the reverse condition of primary sarcoma elsewhere in the body with metastases to the eye are exceedingly rare. Fry reviews the literature, finding 9 previous cases, of which only 3 are not open to some degree of question. He then records the history of a man of forty-nine who had a mole 2.6 cm. in diameter on his shoulder. It was injured a year before admission and had never healed. Examination showed, in addition to the local lesion, enlarged cervical nodes, enlarged liver and spleen, and, in the left eye, just to the temporal side of the disk, a pigmented tumor 1.5 disc diameters in size. At the patient’s death a complete autopsy was done and metastatic melanomas found throughout the body. The growth in the eye was felt to be secondary because of the history of long duration of the nevus on the shoulder, the lack of ocular symptoms, and the fact that the cells of the nevus were diffusely infiltrating, while those of the choroidal tumor were well circumscribed. GRAYTWOMBLY

Metastatic Carcinoma of the Eye and Brain, I. FINKELMANAND L. L. MAYER. Arch. Ophth. 10: 83-90, 1933. A woman of fifty-one died of carcinomatoeis following a primary inoperable carcinoma of the breast. Autopsy showed extensive metastases to the skeleton and to the dura mater and brain. There was metastatic carcinoma in the right optic nerve and a flat metastatic growth involving much of the choroid and causing complete retinal separation. The case is reported because of the rarity of metastases to the choroid. GRAYH. TWOMBLY

Epibulbar Melanosarcoma, P. FIETTA.MBlano-sarcome Bpibulbaire, Rev. g6n. d’opht. 45: 303-311, 1932. A woman sixty-four years old had a dark-colored tumor in the right eye that pushed the lower eyelid outward and downward, extending the limhurr of the cornea. It was easily removed together with a large flap of conjunctiva around it. 180 ABSTRACTS

Histologically it proved to be a melanosarcoma, the sarcoma cells and also the hyalin connective tissue stroma containing varying quantities ’of melanin. It involved the conjunctiva and external layers of the cornea, but waa not adherent to the sclera. After removal, the site of implantation on the cornea, and the pigmented Bone around it, was treated by galvanocautery; a second cautery treatment was given a week later; and a third five months later. The pdtient was kept under observation for four years after this last, treatment. In that period three recurrences developed, which were treated by excision and the galvanocautery. There have been no signs of recurrence for six months since the last removal. The author presents a review of the symptomatology, prognosis, and treatment of epibulbar tumors, based largely on Lagrange’s Trait6 des tumeurs de l’oeil, 1901.

Traumatic Pearl Cyst of the Iris, P. BONNETAND PAUFIQUE.Kyste per16 de l’iris. Cil dans la chambre anthrieure, Lyon m6d. 151: 491-492, 1933. Also in Bull. SOC. d’opht. de Paris, pp. 309-311, 1933. Eighteen months before hospital admission a boy [age not stated] had been struck on the left eye by a stone. Though the wound bled freely, it healed well and vision was not impaired. During the past few months the boy had noticed a white spot on the iris, which grew in siae, though not causing pain or disturbing vision. With the slit lamp a pearly cyst was seen occupying the lower inner quadrant and evidently arising from the pupillary border of the iris. A piece of eyelash was seen in the cyst; this had evidently been driven into the anterior chamber by the injury and the wound had healed around it. The authors propose to perform partial iridectomy. F. CAVERB

Boeck’e Sarcoid of the Conjunctiva, 0. BLEOVAD.Boecks sarcoid af conjunctiva, Hospitalstidende 75: (Det oftalmol. Selskab’s Forh.) 69-60, 1932. The author has previously reported 3 cases of Boeck’s sarcoid of the conjunctiva (Hospitalstid. 73: 47,1930) and at the time of writing kad an early case under treatment. He has studied 28 cases of Boeck’s sarcoid collected by Kissmeyer of the Finsen Institute [Kissmeyer himself published a study of this subjeot in 1931 (see abst. in Am. J. Cancer 16: abst. p. 574, 1932), and a monograph in 1932 (see review in Am. J. Cancer 16: 937, 1932).] Iritis, formerly considered as a frequent complication, waa not observed in Kissmeyer’s series, but the conjunctiva was involved in 3 cases. Five cases of Boeck’s sarcoid of the conjunctiva had been previously reported in the literature, but only two were microscopically verified (Luts: Arch. f. Dermat. u. Syph. 126: 947, 1918-19; Igersheimer: Klin. Monatsbl. f. Augenheilk. 74: 618, 1925). The conjunotival lesions occur chiefly in the palpebral folds, but may be mofe widespread. They are for the most part small, yellowish, transparent follicles, distributed in groups, though larger nodules have been described. The microscopic picture is identical with that of cutaneous sarcoid. There is no clinical resemblance to tuberculosis, and swelling of the pre-auricular nodes, nearly always present in tuberculous disease of the conjunctiva, is not observed. Case of Hemangioma of the Orbit Arising Probably from the Optic Reme Sheath, MARKJ. SCHOENBERO.Arch. Ophthal. 8: 472-473, 1932. A case is reported of an orbital tumor which proved on enucleation of the affected eye to be a cavernous hemangioma. THE ORAL CAVITY AND UPPER RESPIRATORY TRACT 181

Solitary Neurofibroma of the Orbit, J. A. MACMILLANAND W. V. CONE. Arch. Ophth. 10: 51-57, 1933. The authors report a case of a man of twenty who was found to have a tumor in the right orbit behind the eye, measuring 42 by 34 mm. It weighed 23.17 gm. It was well encapsulated, showed no obvious nerve attachment, and was removed operatively together with the eye. Careful histological examination was made with differential stains. Sections stained by the Weigert-Pal method showed medullated nerve fibers, while non-medullated fibers were easily seen in Gros- Bielschowsky preparations. There was marked palisading both of nuclei and fibers. The authors follow Penfield’s classification and call this a neurofibroma. GBAYH. TWOMBLY

Meibomian Epithelfoma, L. DUPUY-DUTEMPS.Epithelioms meibomien, Bull. SOC. d’opht. de Paris, pp. 40-41, Jan. 1932. A tumor of the eyelid in a man seventy years of age was recurring for the third time when removed by the author. The tumor at its periphery showed the formation of a sebaceous adenoms, but at the center there were masses of epithelial cells with prolongations invading the surrounding connective tissue, so that it was classified as a sebaceous or meibomian epithelioma.

THE ORAL CAVITY AND UPPER RESPIRATORY TRACT Possibility of Precancerous Oral Lesions from Eleckicul Causes, H. A. SOLOMON, M. C. REINHARDAND H. I. GOODALL.Dental Digest 39: 142-145, 1933. Among many sources of irritation which may be considered possible factors in the production of precancerous and cancerous lesions in the oral cavity, may be included the electrical irritation produced by some combinations of metals used for filling teeth and constructing dental restorations. The occurrence of a patch of leukoplakia opposite a metallic-Wed tooth is well known. The authors measured the electrical potential existing between dental fillings and restorations within the mouths of 48 persons. They were able to demonRtrate s flow of current not only between metals of two different potentialities, but also between alloys of the same type, namely, amalgam to amalgam, and gold to gold. That this flow of current actually exists in the mouth, however, is not absolutely established. The authors are of the opinion that while a galvanic cell may exist in the mouth, little or no current flows from one dental restoration to another; however, the nature of the metallic restorations, when alloys are used, is such that some pathological disturbances in the mouth may be ascribed to “ local electrical action.” An alloy such as copper and gold is merely a physical mixture of separate and distinct crystals of each constituent, and when these crystals coexist on the surface of a restoration there will be potential differences between them and the saliva so that current will flow, thus constituting a minute galvanic cell. In this instance the external circuit is the restoration itself and the internal circuit is through the saliva. When it ia considered that there may be thousands of such minute galvanic cells on the surface of a single restoration, and that they are working continuously, it is seen that considerable current may be generated, so that the accumulated products of electrolysis may be sufficient to produce definite changes in the adjacent soft tissues. WILLIAMJ. HOFFMAN 182 ABSTBAOTS

Tumorr of the lore and *at, GORDONB. Nmw AND WALTEBA. KIRCH. Arch, Otolaryng. 17: 563-582, 1933. This ia a review of the literature on now and throat tumors for the latter part of 1931 and the first half of 1932. Most of the articles referred to have appeared in abstract in the AMERICANJOURNAL of CANCER. Carcinoma of the Up, R. STEWART-IFABRISON.Das Lippenkarsinom. Richt linien aur Behandlung, Roentgenpraxis 5: 583-588, 1933. This is a shorter presentation of the data appearing in Strahlentherapie 46: 401, 1933 (abst. in Am. J. Cancer 19: 701, 1933). C. D. HAAQENSEN Operation for Carcinoma of the Lip, OSKARWIIODHOPF. Zur Operation des Lip- pencarcinoma, Deutsche Ztschr. f. Chir. 238: 741-744, 1933. The author believes that better cosmetic and functional results are obtained following the removal of a rectangular portion of the upper or lower lip containing carcinoma than is uaually seen after the removal of the ordinary V-shaped segment. The full thickneea of the lip to the buccal mucosa is removed, and lateral undermining, even around the corners of the lips, allows adequate closure without tension. Saving of the buccal mucosa secures better functional results and does not compromise the thoroughness of the operation. The end-result following this type of operation is a symmetrical mouth, rounded chin, without a redundant lip. Radical dissection of the neck is advocated in all cams. The article is well illustrated by drawings, but there are no photographs of actual cases. BSNJAMINR. SHORE Nodular Myolyeis of the Tongue, A. H. ROFFO. Knotigo Zungenmyolyse, Ztschr. f. Krebdorech. 39: 464-470, 1933. Also (in Spanish) in Bol. Inst. de med. exper. estud. y trat. cancer 9: 48Q-502,1932 and Rev. m6d. latino-am. 18: 891-897, 1933. Roffo describes a nodular lesion of the tongue parallel with the line of the central furrow, in a thirty-one-year-old woman otherwise in good health. Three years before she was seen there appeared on the dorsum of the tongue a nodule which gradually grew until it measured 2 x 3 em. It was hard, and the surface waa smooth and covered with normal mucous membrane. It waa not tender and the nodes were not enlarged. The microscopic picture shows the chief leaion to be a granular necrosis or lpb, aa Roffo prefers to call it, which involvea the muncle fibera and ultimately leads to their destruction, leaving only a cavity filled with structureless material surrounded by the sarcolemma. Operative removal cured the patient. [The six excellent photomicrographs which illustrate thia paper suggest a xanthomatous or myomatous lesion, and reference to the description of a previous case in Bol. Inst. de med. exper. para el estud. y trat. del c6ncer, 4: 237,1928, with colored drawings and three photomicrographs, renders it still more probable that what Professor Roffo is describing is one of the well-known myoblsetic myomas, to our knowledge of which Abrikoesoff hes been the chief contributor (see Abrikos- so&: Virchow’s Arch. 260: 216,1926; 280: 723, 1931, and Meyenburg, in Henke- Lubarsch’s Handbuch, vol. 9, part 1: 464-468, 1929, where a considerable bibliography ie given). These myomas have often been ddgnated 88 xanthomas because they are yellowish and granular, like the true xanthomse, but lipoid stains seem to differentiate the two, though, of course, Pollitrer’s original description of xanthoma in 1899 called attention to the fact that the leaions in the eyelids, the tongue, and elsewhere were a lipoid degeneration of the striated muscle fibers (New York M. J. 2: 73, 1899). At present the tendency is to abandon the term THE ORAL OAVITY AND UPPER RESPIRATORY TRAOT 183 xanthoma, because of the lack of stainable lipoid material in the granular matter of the degenerated muscle fiber, and consider the tumors as a regenerative growth of muscle fiber following injury, as was noted by Roffo in both of his cases.] WY.H. WOQLOM Fibroma of the Tongue, GOUQEROT,P. MOURNAND 0. EUABCHIOFF.Fibromes dermiques de la langue, Arch. dermato-syph. 4: 593-594, 1933. A woman of twenty-eight had two tumors of the tongue, one first noticed three years and the other eight years previously. They were removed and found to consist of hypertrophied and keratinieed epideEmis overlying a dense fibromatous nodule derived from the dermal connective tissue. The vessels around the mass had thickened walls, but there was no general infiltration. There are no illustrations. F. CAVIORS Giant-cell Tumor near a Fistula of Dental Origin, H. CROCQUEFER.Tumeur 21 mybloplaxes d6velopp6e au niveau, Rev. de stomatol. 35: 9-11, 1933. A hard, pedunculated tumor developed from the periosteum on the gum, in the region of the root-apex of the upper right bicuspid, which was badly decayed, Close to the pedicle was a dental fistula that extended to the root-apex of the tooth. It was excised and found to be a giant-cell epulis. Deep Roentgen Therapy in a Case of Mandibular Sarcoma with Vertebral Metas- tasis, M. KARZIB. R6ntgen-Tiefenbehandlung eines Falles von Sarkom des Unterkiefers mit Paralyse der Extremitilten, infolge Wirbelmetastase, Med. Welt 7: 666, 1933. A man of forty-seven had a carious right molar extracted. Three months later he complained of a painful and palpable swelling of the lower jaw at this site, and x-rays revealed a well defined bone tumor, 1 om. in diameter. Biopsy showed spindle-cell sarcoma. The regional nodes were enlarged. The patient returned two months later, having had two operations in the meantime, but the tumor had recurred after each. The author inserted 6 radium needles of 3 mg. each in the jaw tumor, for five days, and gave x-ray therapy to the nodes. After three weeks the tumor and nodes were no longer visible. Meanwhile, however, the patient complained of loss of power in both arms, ending in complete paralysis, and a few days later the lower extremities also had become paralyaed. Metastasis in the region of the upper cervical cord was suspected, but before lipiodol examination was made the patient was suddenly attacked by dyspnea, with a rise of temperature. X-ray treatment was given to the upper cervical vertebral region, and within a few days the reapiration and temperature became normal and the general condition improved. Descending lipiodol showed arrest at the level of the fourth to Gfth cervical vertebrae. After x-ray treatment to this part of the spine, in small, long-continued dosage, the patient regained bladder and reotal continence, with slight movements of fingers and arms. Repeated x-ray pictures taken during thia time showed gradual descent of the lipiodol, indicating rapid disappearance of the obstructing tumor process. Within six weeks from the commencement of this treatment the patient could eht without help, and a month after this had regained full use of his limbs. F. CAVIORS Cystic Paradental Tumor of the Upper Jaw,L. CIJBLLO. Tumor qulstico para- dentario del maxilar superior, Bol. Asoc. m6d. de Puerto Rico 24: 254-255, 1932. A fifty-year-old womn had a large tumor of the right upper jaw which had developed during five years. A unilocular cyst filled with a seropurulent liquid WBB removed. There was an intimate relation between the new growth and the 184 ABSTRACTS first premolar, which showed advanced caries and which was removed with the tumor. Complete extirpation of such cysts, which are very frequent in Porto Rico, is the only proper treatment. Transformation into sarcoma and carcinoma has been observed. The siie of the tumor, reaching to the lower edge of the orbit, is exceptional, since most of these tumors are small in comparison with the large unilocular cysts of non-dental origin which may occur in the upper jaw. JOHANNESP. M. VOQELAAR

Importance of Early Carcinomatous Diagnosis, I. SALMAN.Am. Med. 39: 9-11, 1933. Two case reports of early squamous carcinoma of the hard palate and upper jaw treated by excision and radiation. Both patients are well, three and a half years and one year respectively. GRAYTWOMBLY

Epithelioma of the Uvula, L. SANCHEZMORENO, R. DELLEPIANIRAWBON AND C. CAMPAQNAEI.Epitelioma de la dvula, Semana m6d. 1: 490491,1933. A man of fifty had pain in the postnasal region, of a month’s duration, especially when swallowing food. This pain had become more intense and radiated to the right ear. The uvula showed a crater-like lesion, spreading to the right half of the soft palate. Biopsy .showed the characters of a pi no cellular carcinoma with horny pearls, and the patient made a good recovery after extirpation of the tumor with the diathermy knife. Two good photomicrographs are given. F. CAVERS Multiple Granulomatous Hyperpltasia of the Soft Palate as a Precursory Symptom of Epitheliomas of this Site, N. PUENTEDUANY. La hiperplds granulosa mdltiple del velo del paladar coma sintoma precursor de 10s epiteliomas del mismo sitio, Bol. Liga contra el chcer (ed. cient) 7: 71-82, 1932. The author reports three casea of carcinoma arising in the soft palate. These spread locally and metastasiied to the cervical nodes. A description of the histology is given, illustrated by photomicrographs. There is no bibliography. JOHNE. WIRTH Primary Epithelioma of the Palatel Vault in a Ten-Year-Old Child. Radiother- apy. Cure, DURAND-DABT~Lfipithdlioma primitif de la vodte palatine chei une enfant de dix ans. Curiethdrapie. Gudrison durable, Toulouse m6d. 34: 280-281, 1933. A firm, fixed tumor 1 to 1.5 cm. in diameter involved the midline of the palatal vault of a ten-year-old child. It was removed, and microscopic study revealed adenoid cystic epithelioma. Three weeks later the growth recurred but following surface application of radium it disappeared. The child is well and free of disease five years later. WILLIAMJ. HOFFMAN Plastic Repair in Extensive Operations for Cancers of the Mouth and Oropharpnx, R. BERNARD.Le ddcollement des teguments de la face; voie d’abord dans les grandes op6rations d’ex6rhe sur la bouche et l’oropharynx; cancers du maxillaire infbrieur, cancers du plancher de la bouche, cancers de l’amygdale et du pharynx, Presse m6d. 41: 748-761, 1933. Bernard discusses various methods of surgical approach to malignant tumors of the jaws, buccal floor, tonsils, and oropharynx, with special reference to (1) extending the operation as far as is necessary for complete removal of the growth, (2) keeping the operation strictly intrabuccal, and (3) at the same time planning the incision so that the skin defect can be adequately repaired by a flap fashioned THE ORAL CAVITY AND UPPER RESPIRATORY TRACT 185 from the skin of the face and not of the neck. In discussing the indications for surgery, the author says that radium is contraindicated when it has been previously tried and has failed, or when the tumor is located in bone, either primarily or by invasion, or lies near bone, because of an almost certain risk of necrosis. [The methods described do not seem to differ from those of various other surgeons.] There are ten good illustrations, occupying about half the paper. F. CAVERS

Treatment of Malignant Disease of the Nose, Throat and Ear by Means of Radium and Deep X-Ray Therapy, J. S. FRABER.J. Laryng. & Otol. 48: 264-268, 1933. The author reports 6 inoperable cases treated with roentgen therapy. Multi- ple portals of entry were used, generally four to six Small intensities were administered during four to six weeks, one or two skin fields being treated daily until each field had received two or three skin doses at a voltage of 180,000;the filtration was 1 mm. copper and 3 mm. aluminum. The focal skin distance was 60 cm. Most of the patients were dead at the time of reporting. The author calls attention to the unreliability of the history given by patients with advanced malignant disease of the upper air passages; some of them complained of pain and discomfort for only a few days; yet a large ulcerating tumor was found. F. CAVERS

Two Cases of Osteoma of the Nose, GAULT. Sur deux cas d’ost6ome du nez, Ann. d’oto-laryng., pp. 277-278, March 1933. This is a brief report of two cases of osteoma of the nose. An eighteen-year- old boy had a tumor mass 1 to 1.5 cm. in diameter, arising from the supero-internal angle of the orbit and internal orbital process of the frontal bone. The second patient, a seventeen-year-old girl, had a large tumor in the left nasal fossa. The exact point of origin could not be determined. In both instances the tumors were excised Gault discusses the pathogenesis of these tumors and inclines to the belief that they represent calcification occurring in areas which have long been the site of chronic infection. WILLIAMJ. HOFFMAN Cancer of the Nasopharynx, J. C. GRoss. Chncer de la nasofaringe, Rev. de med. y cir. de la Habana, 37: 546-550, 1932. The author gives a brief summary of the incidence, symptomatology, and diagnosis.of cancer of the nasopharynx. No new ideas or facts are recorded. There is no bibliography. JOHNE. WIRTH

Nmopharyngeal Malignancy: Case Report, E. H. MOYLE. Laryngoscope 43: 283-284, 1933. A twenty-one-year-old male had swellings in the neck, sore throat, and difficulty and pain on opening the mouth. Three months after the appearance of symptoms trismus developed. Satisfactory examination of the throat was not possible, but external examination revealed enlarged nodes in the preauricular and anterior cervical chain on the right side. These were hard, discrete, not attached to the skin, and not tender. A tentative diagnosis of Hodgkin’s disease was made, and lymphosarcoma or epithelioma suggested. Biopsy of a cervical node revealed metastatic plexiform epithelioma. Postnasal examination with the nasopharyngoscope showed a large tumor mass in the vault, which also proved to be plexiform epithelioma. Three of the author’s patients with similar tumors exhibited trismus, and he regards this symptom as a definite indication of the presence of a nasopharyngeal tumor. He suggests the use of the nasopharyngoscope in all such cases, since examination with the postnasal mirror is practically never adequate in the presence of even the mildest trismus. WILLIAMJ. HOFFMAN 186 ABSTRAOTS

Primary Squamour-Cell Carcinoma of the Nasopharynx in a Youth of Seventeen. Etiology of NlleopharyngedTumors in the Young. K. M. MENZEL. 8ber ein primilres Plattenepithelkarzinom bei einem Siebzehnjlihrigen, augleich Versuah einer Darstellung der kausalen Geneee der malignen Nasenrachentumoren Jugendlicher, Monatschr. f. Ohrenh. 67: 418-430, 1933. A youth of seventeen years stated that from early childhood his parents had told him that he snored, and urged him to keep hie mouth shut when breathing, and that the family doctor had said something about adenoids but advised against operation. The author found a large mass of adenoid-like vegetations and bilateral enlargement of the upper cervical nodes. Biopsy of a node showed only hypertrophic inflammatory features. The patient was not seen again until two months later, when he complained of excessive nasal secretion. Anterior and posterior rhinoscopic examination showed an extensive tumor of the nasal fossae and naaopharynx. A piece was removed and found on histologic examination to be squamous-cell carcinoma. The author says that doubtless the adenoid vegetations observed two months previously represented the first beginnings of the malignant nasopharyngeal tumor [though he makes no mention of earlier rhinoscopic examination]. Intensive x-ray and radium treatment was given to the nasopharynx for nearly seven months [no details are given except that the radium was given in an intensity of 2,660 mg. hours]. At the end of that time the tumor had almost disappeared, but the cervical glands were still enlarged, and the patient complained throughout this period of right-aided headache. He was given a supposedly caneericidd preparation, “ tumorsen.” The tumor again began to increase in sine, and during the last months of life became larger than at first, Spreading to the posterior nasopharyngeal wall. The patient died with pneumonic symptoms a year after admission to hospital. At autopsy the tumor was found to have invaded all the air spaces and practically all the bones of the cranial floor, extending backwards into the middle fossa and forming a thin layer over the hypophysie. Alarge part of this paper is devoted to the development of a theory, apparently original with the author, that in some way the hypophysis is concerned in the etiology of malignant nasopharyngeal tumors in childhood and adolescence. There are three illustrations. F. CAVERS

Epiphugngsrl Rhabdomyoma Invading the Ear and Meninges, FOLWS~DXZZ- BEBG. Rhabdomyome Bpipharyngd ayant envahi l’oreille et les m6ninges, Acta oto-laryng. 18: 453-469, 1933. A seven-year-old boy had a bloody discharge from the left ear. Two months later he experienced attacks of diaainess, especially in the morning. Temperature and appetite remained normal. A diagnosis of acute otitis media with labyrinthine complications was made. Examination revealed a left-sided peripheral facial palsy, a marked horiaontal rotatory nystagmus, especially to the left. The auditory canal was completely obstructed by polypoid masses of pale tissue covered with a purulent discharge. There was no hearing in the left ear. The radiographic diagnoais was acute mastoiditis. Biopsy from the polypoid masses within the auditory canal revealed only necrotic tissue with many leukocytes and bacteria. The patient’s condition rapidy became worse. A second biopsy was done but revealed no evidence of malignant tumor. The mlrstoid process was explored in search of an intracranial souroe of infection. It was lined with tissue resembling granulations, which was preserved for histological study. A few days later epileptiform seiaures oocurred, followed by periods of unconsciousness. The dura mater was exposed over the posterior fossa and found bulging, but when it was incised no pus was obtained. Three days later the patient died during a convulsive seizure. THE ORAL CAVITY AND UPPEIR BEBPIRATORY TRAUT 187

At autopsy a grayish-yellow tumor was found enveloping most of the left hemisphere of the brain. It was firm and elastic in consistence and had invaded the left auditory, facial, and trochlear nerves, and tympanic cavity. The original site of the tumor was found in the epipharynx, where a lobulated, partly gangrenous mass projected toward the choanae without actually invading or obstructing the nasal cavities. Histologic examination of the tumor revealed the appearance of a benign rhabdomyoma, but metastatic deposits throughout the parenchyma of the lungs and on the surface of the diaphragm indicated rhabdo- myosarcoma. Rhabdomyoma of the nasal cavity is exceedingly rare, only two other cases having been reported (cited by Henke and Lubarsch: Handbuch der spec. path. Anat. und Histol. vol. 3 (pt. l), page241). WILLIAMJ. HOFFMAN Cancer of the Pharynx, DURAND-DASTBS.A propos des cancers du pharynx, Toulouse m6d. 34: 276, 1933. Durand-Dastbs describes a case of metastatic cancer of the cervical nodes from an undiscovered primary tumor, suspected to have originated in the pharynx or esophagus. Under x-ray treatment the cervical mass disappeared, and the patient has remained clinically free of disease for fifteen months. The primary tumor has not yet been discovered. [Tumors of the nasopharynx often exhibit this peculiar tendency to yield large cervical metastases while the primary tumor still remains extremely small. The most frequent location of the primary tumor is in the neighborhood of the fossa of Rosenmtiller or behind the posterior tonsillar pillar, and it is here that it should be sought.] WILLIAMJ. HOFFMAN Report of a Case of Pharyngeal Diverticulum Containing a Neoplasm in Its Walls, J. V. SPARKB.Brit. J. Radiol. 6: 233-236, 1933. The case reported by Sparks is remarkable for the large size of the diverticulum and the unusual family history, pharyngeal pouches having occurred in the patient’s father, paternal uncle, and a cousin. The patient, a man of fifty-nine, had a thirty-year history of difficulty in swallowing at the end of his meals, with the appearance of a swelling in the left side of the neck. Regurgitation of food afforded relief from these symptoms. A diagnosis of pharyngeal pouch was made and a gastrostomy was performed. The radiographs showed a huge diverticulum in the retropharyngeal space, whose antero-lateral margin presented a large irregular filling defect. The diverticulum was so large that it contained more than half a pint of barium when completely filled. Esophagoscopy revealed a tumor mass near the orifice of the pouch, and a biopsy specimen showed squamous carcinoma. The pharyngeal pouch with the tumor was removed at operation. The patient died eleven days later from a secondary hemorrhage from the pharyngeal branch of the external carotid artery. WILLIAMJ. HOFFMAN Malignant Tumors of the Nasal Fossae and Sinuses. Note on Radiological- Surgical Technic, LEDOUX.Tumeurs malignes des fosses nasales et des cavit6s sinusiennes. Note de technique curie-chirurgicale, Rev. d. laryng. 53 : 1059-1063, 1932. Except for lymphosarcoma and certain rare types of basal-cell carcinoma, the malignant tumors usually found in the nasal fossae and sinuses are radioresistant, since they are usually epidermoid carcinoma. Because of this fact they cannot be expected to respond to external radiation, and intercavitary sources of radiation must be employed, preceded by surgical exposure and drainage. Ledoux describes briefly various surgical approaches to the ethmoid and maxillary sinuses. He emphasizes three points of importance: heavy filtration, small amounts of 188 ABSTRAUTS radium element, and prolonged treatment. It is his practice to insert the radium in the cavity to be treated in a capsule of platinum and aluminum, anohoring the capsules in place by wires brought out through the skin. With this technic no obstructive gaure packing is required, and drainage is not impeded. It is thus possible to allow the radium capsule to remain in position for eight to twelve days; during this period daily irrigation of the cavity is practised without disturbing the radium. WILLIAMJ. HOFFMAN Radium in Malignant Tumors of the Nasal Sinuses, G. A. ROBINSON.Laryngo- scope 43 : 285-280, 1933. Malignant tumors of the nasal sinuses are rarely diagnosed early, since pain and hemorrhage are late symptoms. The symptoms may include nasal obstruction, prominence of one cheek, protruding eye, lacrimation, bulging of the hard palate, and dull aching pain in the face. Biopsy is essential. Treatment is a combination of surgery and radiation. The author lists ten cases, with freedom from disease from two to fourteen years, WILLIAMJ. HOFFMAN Report of n Case of Papillary Carcinoma of the Maxillary Sinus, JOSEPH H. BRYAN. Ann. Otol. Rhin. & Laryng. 41: 983-989, 1932. Bryan reports a case of papillary carcinoma of the antrum in a woman of thirty& years, treated by radical surgical excision and radiation by x-rays and radium element needles inserted for a dosage of 2,850 milligram hours. The patient has been clinically free of disease six months. WILLIAMJ. HOFFMAN

Carcinoma of the Larynx in the Young, G. PORTMANNAND R. PHILIP. L’Bpi- th6lioma du larynx cher les jeunes, Rev. d. laryng. 54: 1-48, 1933. Carcinoma of the larynx is rare before the age of thirty years. The literature contains reports of only a score of cases. Before the age of twenty, females appear to be more frequently affected than males. After this age males show an increasing percentage, so that among those cases developing in middle age or later, 95 per cent are found in men. It is difficult to account for this predisposition of the adult male. Irritation by alcohol and tobacco may play a part. In young people laryngeal carcinoma frequently is preceded by polyps or papillomata of the vocal cord. The tumors are noteworthy for the frequency with which they are localired in the posterior larynx, arytenoids, and posterior portion of the vocal cord. Extrinsic cancer is rare in young people. When it is found, it is usually due to the extension of a tumor originally confined to the larynx. Microscopic sections of these tumors reveal a high degree of malignancy. They are highly cellular, with a marked tendency to wide extension. Clinically their rapidity of growth is proportional to the youth of the patient. The earliest symptom is hoarseness, soon followed by dyspnea, which shortly requires tracheotomy. Pain and dysphagia occur somewhat later, with fixation of the vocal cords, infiltration of the ventricular bands, and rapid impairment of the general health. The duration of an untreated case averages eighteen months. Death, when not due to suffocation, occurs aa a result of hemorrhage, perichondritis, and sepsis or bronchopneumonia. The authors report two of their own cases and a selected list of twelve caBes taken from the literature. WILLIAMJ. HOFFMAN

TWO Case8 Of CaIICer Of the Treated by Deep RoenQen Therapy, DURAND- DAsTBs. Deux cas de cancers du larynx, trait68 par radiothbrapie profonde, Toulouse m6d. 34: 276-276, 1933. The author reports two cases of laryngeal cancer. The first patient, a man of fifty-two, had a tumor invalving the right vocal cord. Two series of roentgen-ray THE ORAL UAMTY AND UPPER REBPIRATORY TRAUT 189 treatments were given. The first series totalled 3,000 r, the second series, two months later, 2,000 r. The tumor disappeared and the patient did not return until eighteen months later, at which time a massive recurrence filled the whole larynx and invaded the pharynx. Death occurred the next day, in an attack of dyspnea. [The radiation dosage was certainly insufficient for cure.] The second patient, a man of forty-nine, presented a tumor of the right aryt- enoid with metastases to the right cervical nodes. Three courses of x-radiation were given during the next eight months. The patient slowly declined and died as the result of a sudden hemorrhage, ten months after his first examination. WILLIAMJ. HOFFMAN Thyrotomy in Two Stages for Epithelioma of the Larynx in an Elderly Patient, F. Z. HAVENS.Proc. Staff Meet. Mayo Clin. 8: 233-234, 1933. The chief causes of morbidity following operation for laryngeal carcinoma are infection of the soft tissues of the neck from inevitable soiling by tracheal secretions, and tracheitis with possible secondary bronchitis and bronchopneumonia. With poor operative risks it is necessary to carry out the surgical procedure in stages, thus converting a highly dangerous procedure into one of relative safety. Havens’ seventy-four-year-old patient had a growth locizliaed to one vocal cord, easily removable by thyrotomy. Biopsy revealed squamous carcinoma, Grade 111. A simple tracheotomy was first performed. Ten days later the larynx was opened, the growth was removed, and the base destroyed by diathermy. In 72 such cases treated by thyrotomy, Havens and his associates have not had an operative death. WILLIAMJ. HOFFMAN

Carcinoma and Tuberculosis of the Larynx, J. G~MEZAND J. ~~(NCHEZLUCAS. Carcinoma y tuberculosis de laringe, Arch. d. med. cir. y especial. 35: 461-462, 1932. A forty-four-year-old male, suffering with dysphegia, had a tuberculous ulcer on the epiglottis, this diagnosis being determined by biopsy and stained smears. The lungs showed no physical or radiographic evidence of tuberculosis. After about two months of local treatment with silver nitrate and lactic acid, a new nodule was observed in a different site on the epiglottis, and a small node was diu- covered over the right carotid bulb. A biopsy specimen from the new lesion on the epiglottis showed a typical epithelioma. A laryngectomy was performed and the node in the neck removed; it was found to be tuberculous. [It is beginning to be learned that the treatment of mouth lesions with silver nitrate over long periods is not infrequently followed by carcinoma.] JOHNE. WIRTH Carcinoma of the Extrinsic Larynx, Carcinoma of the Nasopharynx Treated with Divided Doses of High-Voltage X-Radiation, R. F. MCNATTIN. S. Clin. North America 13: 460-462, 1933. McNattin reports two cases of carcinoma of the upper respiratory tract (extrinsic larynx and nasopharynx) treated by daily divided doses of x-radiation in accordance with the method advocated by Coutard. The first patient, with a fungating, papillary, squamous carcinoma, 2 cm. in diameter, involving the left aryteaoid, left aryepiglottic fold, and left edge of the epiglottis, received a daily dose of 380 roentgen units to alternate sides of the neck over a period of thirteen days. The total dose delivered to each side of the neck was 2280 roentgens. The primary tumor disappeared and the patient has been free of disease nineteen months. The second patient had an ulcerated lesion 1.5 am. in diameter in the right 190 ABSTRAOTS posterior nasopharynx, close to the foass of RosenmUer. In the right aide of the neck was a confluent mass of nodes 12 x 10 om. in diameter, mmt prominent at the angle of the jaw. Biopsy revealed transitional-cell carcinoma, Grade 11, radiosensitive. A series of twenty-four high-voltage x-ray treatments in the come of fifteen days was administered, the daily dose being 260 t to each side of the neck and cheek for a total of 3650 t to each aide. Both the primary tumor and the cervical metastases disappeared. The patient has now been free of disease for eighteen months. WILLIAMJ. HOFFMAN Extrin~icLipoxm of Larynx, JAMESA. FLYNN. Laryngoscope 43 : 294-297,1933. Flynn reports a case of lipoma of the periglottic space extending out into the tissues of the neck dong the body of the hyoid bone over the great veaeela. Fol- lowing an operation for its removal, it recurred and a second attempt was made. Seven years after the seoond operation a small lobulated mwat the beee of the tongue afforded evidence of another recurrence. The hisfological study of the tumor revealed adipose tissue, and a diagnosis of simple lipoma was made, It is difficult to determine whether these were true recurrences or evidences of incomplete removal of a lobulated lipoma. WILLIAMJ. HOFFMAN Radium Treatment of Inoperable Cancer of Phuyax and Larynx (S~USM- formits), M. BLEICHBIR.Le traitement curiethhpique des cancers pharyngo- larynges inop6rablesI Rev. de laryng. 53: 1176-1186, 1932. The author deals with malignant tumors of the piriform ainua, holding that for inoperable tumors in this site radium treatment is the method of choice. He has fashioned a pessary-like piece of rubber tubing which follows the various curves of the periphery of the laryngeal entrahce. Into the open end of this tube he inserts the radium carrier or carriers; the ends are then sealed and thd tube is so placed that the carrier is in contact with the tumor. [Though he mentions the dosages used by other writers on radium treatment of pharyngeal and laryngeal malignancy, the author fails to state what dosage he himself usee.] During the past three yeam Bleicher has treated 26 patients with carcinoma of the piriform sinus, and states that all have shown amelioration of symptoms after each application, though there has been no oure. The majority of these patients have been lost sight of. The remissions have vaned from two months to a year in those followed up. Though he admits that the method has not been long enough in use to allow of definite concluaons, the author daims that it hsa given “ aom- plete satisfaction.” There are two illustrations. F. CA~BIRS Multicentric Origin of Cancer of the Vocal Cord, C. E. BENJAMINB.Sur l’origine multicentrale du cancer de la code vocale, Rev. d. Iaryng. 54: 273-284, 1033. Benjamin6 reports a caae of carcinoma of the vocal cord in which serial sections of the operative specimen revealed several separate areas of carcinoma, apparently independent and having no demonstrable anatomical connection with one another. The case demonstrates that cancer of the cord can develop from aeverd independent centem. This possibility is an additional retwon for wide exdon of such tumors, lest a too economical laryngectomy cost a pstient’s life by swift growth of a remaining independent area of malignant tissue. WILLIAMJ. HOFFMAN Roentgen and Radium Treatment of Malignant Tumora of the Toruit, C. SIMEONI. Sul trattamento fish0 dei tumori meligni delle toneille palatine, Arch. ital. di otol. 43: 612-627, 1932. The author reporta the results of combined irradiation of 28 cases of malignant tonsillar tumors. The cams were divided equally between carcinomas and sar- THE ORAL OAVITY AND UPPER RESPIRATOBY TRAUT 191

aomas. The outstanding feature is the uniformity with which initial improvement was followed by continued growth of the tumors, the end-results being about equally poor for the two types. The author emphasizes the need for careful histologic diagnosis and the difficulty sometimes encountered in this respect, citing a case in which a simple hypertrophy was irradiated; a biopsy diagnosis of lymphosarcoma was made at first, but a second examination showed the true state of affairs. The details of the cases are comprised in a table extending over several pages. The age range was from forty-one to eighty-two years in the 14 carcinoma cases, and from twenty-five to seventy-one in the 14 sarcoma cases. The more recent oases, of which there were 14, were treated by radium alone. Thirteen earlier cases were treated by x-rays alone, one by x-rays to a metastasis and radium to the primary tumor. The details of the methods of radiation used are not stated. Half of the patients showed extension of the growth from the tonsil to nearby regions or had distant metastases, and nearly all died within a year after treatment, most of them within a few months. F. CAVEBS Epithelioma of the Tonsil with Multiple Metastases. Indications and Technic of Postoperative Radiotherapy, MATHEY-CORNAT.Epithelioma de l’amygdale A foyers multiples.. Considthtiom sur les indications et la technique du traitement radiothkpique postophtoire, J. d. m6d. d. Bordeaux 110: 404, 1933. Mathey-Cornat presented a male patient, forty-eight years of age, who had a local recurrence following a toneillectomy for carcinoma. There were also metastases to the cervical, axillary and epitrochlear nodes. Under heavy roentgen radiation these mawe all regressed, including a bony metastasis in the region of the olecranon. The treatment consisted of the application of daily divided doses of 200 kv. roentgen rays to a total of 3000 7 per field. WILLIAMJ. HOFFMAN Case of Lymphosarcoma of Tonsil Treated by Roentgen Therapy, P. CACCIALUPI. Linfosarcoma della tonailla palatins, Valsalva 8: 888-895, 1932. A man of forty had six months before hospital admission noticed a small, painful swelling of the left fauces, which had meanwhile grown considerably in size. The tumor, now some 5 cm. in diameter, arose from the left tonsil and extended to the middle of the soft palate and to the base of the tongue. Its surface was covered by small blood vessels, and it was so soft as to be easily dented on pressure by the fingers. No enlarged nodes were felt; the blood picture was within normal limits. Biopsy showed a lymphosarcoma. X-ray treatment was given in ten sittings, each of one-third of a skin erythema dose, and the tumor rapidly regressed. Three years later the patient had gained weight, and there had been no recurrence. There are two good photomicrographs. F. CAVERS Fibrolipoma of the Tontail, B. M. LIFSCHITZ.Un cas de fibrolipome de l’amygdale gauche, Acta oto-laryng. 18: 495-499, 1933. Report of a soft, pedunculated tumor of the tonsil in a woman of thirty-eight years. It had been noticed several years before and had slowly grown to a length of 1.5 cm. and a diameter of about 8 mm. The presence of this mass produced a sensation of a foreign body within the pharynx. Following its surgical removal, histologic study revealed it to be a fibrolipoma. WILLIAMJ. HOFFMAN Secondary Tumors of the Tod, V. TANTURRI.Contributo ai tumori tonsillari secondari, Tumori 6: 351-358, 1932. Tanturri reviews the nine cases of metastasis to the tonsil previously reported and describes one case which he observed. The patient waR a man of thirty-nine 192 ABSTRAOTS who had had a teratoma of the testicle removed. Retroperitoneal metastases appeared a month after operation. At this time it was also noticed that the left tonsil wag reddened and slightly swollen. Within a few weeks this swelling had developed into a definite but non-ulcerated tumor. A biopsy was done which showed it to be a metastasis from the testicular tumor. No roentgen treatment was given and the patient died shortly afterward. Ten excellent photomicrographs and a good bibliography accompany the report. C. D. HAAGENSEN

Studies on the Cylindrormtous Parotid Tumors, A. SNELLYAN.Studien iiber zylindromatSse Parotisgeschwiilete, Arb. a. d. Path. Inst. d. Univ. Helsingfors 7: 11-50, 1933. A detailed histological study of 5 cylindromatous tumors of the parotid gland, from the University of Helsingfors, is reported. The tumor was excised in each case; in 2 the patient has not been traced; in one death occurred from pneumonia in less than six months after operation, with no signs of recurrence; in one the patient died of an unknown cause two years after operation; in the fifth case there was a recurrence six months after operation, but without further treatment this patient was living and working more than a year later. The remainder of this excellent paper is taken up by a detailed cytologic study of the neoplasms. Thirteen photomicrographs and a bibliography are appended.

‘‘ Orbital Inclusion ” Cysts and Cysto-adenornu, of the Parotid Salivary Glands, C. J. KRAISBLAND A. P. STOUT. Arch. Burg. 26: 485-499, 1933. Two examples of cysts of the parotid gland are reported by Kraissl and Stout, and reference is made to a third. In each instance the lining of the cyst was of stratified cylindric epithelium, and in one case this overlay definite lymph follicles. A cure following surgical excision was obtained in both instances, with a follow-up of seven months and three years respectively. The embryologicbasis for the origin of such cysts is discussed and it is concluded that a group of cells found along the fundus of the buccal sulcus posterior to the anlage of the parotid and separated from it in human embryos of about 10 milli- meters is responsible. This structure has been called the orbital inclusion, and the authors have given this name to cysts found in the parotid gland whioh they believe to be derived from it. The article is illustrated by photographs, photomicrographs, and drawings, and a good bibliography is appended. [Other names which have been applied to these cystic growths are adenolymphoma, papillary cystadenolymphoma, onkocytoma, etc. See Jaff6: Am. J. Cancer 16: 1415, 1932.1 BEINJAMINR. SHORE Tumor of the Parotid Gland Resembling Parathyroid, R. HUCKEL. Eine para- thyreoidealhnliche Geschwulst der Ohrspeicheldriise, Centralb. f. allg. Path. u. path. Anat. 57: 57-58, 1933. In 1930 the author described two parotid tumors resembling the parathyroid, with illustrations (see abet. in Am. J. Cancer 15: 410, 1931); another case was recently reported by Franssen (see abst. in Am, J. Cancer 18: 192, 1933). A similar tumor is now described, occurring in a man of sixty-eight. The tumor, which had first been noticed two years previously, was the sine of a hen’s egg, and was well encapsulated and therefore easily shelled out. The greater part of the mass consisted of normal parotid tissue, but in places there were large epithelial corde showing a striking resemblance in architecture and cellular morphology to parathyroid tissue; no mitotic figures were seen. The author agrees with Frsnssen that these tumors do not originate in ectopic deposits of parathyroid tissue but TmBREAST 193 represent an unusual form of adenoma derived from the parotid epithelium itself. In the tumor here reported there was gradual transition between the two types of structure. F. CAVERB

Mixed Tumor of the Submaxillary Gland, J. P. TOURNEUX.Tumeur mixte de la glande sous-maxillaire, Toulouse m6d. 34: 281, 1933. A forty-five-year-old woman had a small swelling the size of an almond beneath the horizontal ramus of the mandible. For a time it remained stationary in she, then it grew slowly so that after four months it measured 4 or 5 cm. in diameter. It was excised, and microscopic study revealed myxochondro-epithelioma. WILLIAMJ. HOFFMAN THE BREAST

Observations of Some Common Breast Lesions, W. P. NICHOLCJON,JR. J. M. A. Georgia 22: 90-94, 1933. This paper discusses the differential diagnosis between inflammatory and neoplastic diseases of the breast and between malignant and non-malignant lesions. It concludes with some general remarks on the palliat,ion of inoperable breast carcinoma by surgery and radiation. GRAYH. TWOMBLY

Clinical Manifestations of Diseases of the Breast, J. N. JACKSON. J. Missouri M. A. 29: 555-557, 1932. The author maintains that every lump in the breast should he removed before signs appear from which a definite diagnosis of cancer can be made. Only the operative findings and the pathologist’s report can determine whether it is malignant at this stage. If the patient is not seen in this early stage, the most significant sign of cancer of the breast is the absorption of overlying fat and the fixation of the growth .

Multiple Tumors of Breasts, J. J. DUFFYAND A. N. ARNEBON. Surg. Clin. North America 13: 449-456, 1933. In a series of 1470 cases of breast carcinoma collected from the literature, the authors found involvement of both breasts in 34 cases, or 2.3 per cent. In certain types of cases the incidence of bilateral involvement is higher; thus in a 001- lected series of 94 cases of recurrent carcinoma following amputation of the breast, the recurrence appeared in the second breast in 11 cases, or 11.5 per cent. The authors report 3 cases of multiple tumors of the breast. In the first case there were multiple tumors in both breasts; in the right breast the tumors were proved to be carcinoma; in the left breast, they were diagnosed clinically as benign, and, although no tissue was obtained for biopsy, the subsequent course confirmed this opinion. In the other 2 cases, there was a single tumor in each breast. In one case both growths were of the same type-carcinoma simplex; there was axillary metastasis on both sides; the tumors developed within a year of each other. Neither breast was removed in this case, and it cannot be proved whether the tumor that developed last was a metastasis or another primary growth. In the last case both breasts were removed; the two tumors were both found to have arisen from the duct epithelium, but they were of different histologic types. One tumor had metastasized to one axillary node; the other showed no axillary metastasis. This case is regarded as primary bilateral carcinoma. 194 ABBTRWT8

Hiatopathology and Therapy of Bleeding from the Nipple with Special Coddera- tion of the Late Results in Twenty Cams, I(. SCH~BWXTE.Bdtrag SM Hieto- logie und Therapie der blutenden Mamma mit beaonderer Bertlcksichtigung der Spiltergebnisse bei 20 Kranken, Deutsche Ztschr. f. Chir. 239: 677-691, 1933. Of 20 patients with bleeding from the nipple, 9 were proved to have papillary cystadenomas, 2 of which were malignant, and 5 chronic cystic maetitb, which in one case had undergone malignant change. In 4 cases no histologic study was made, while in 2 others the diagnosis and origin of the tumors were not clear. Two of the patients were men. Amputation of the breast was performed 8 times, local excision of a cyst or tumor 6 times, and in the 6 remaining cases non-surgical treatment was given. A study of the end-results shows 2 patients dead after three years, and one after six years. The remaining patients were well from one to twelve years. Detailed histories of the 20 patients are included. BENJAMINR. SHORE Sensory Innemation of the Lower Angle of the Scapuk, in Relation to Local Pain in Certain Cases of Breast Cancer, J. AUCHB. Considbrations sur l’innervation sensitive de la dgion correspondent B I’angle inf4rieur de l’omoplate, B propos de la douleur qu’y localisent certain8 canc4reux du sein, J. de m4d. de Bordeaux 109: 927-929, 1932. In a case of cancer of the left breast the pain was localised in a circular patch of skin about 3 om. in diameter, immediately below the lower angle of the left scapula. After operation the pain disappeared. The author found several reports of similar cases in the French lite’reture, but on consulting various French books on anatomy could not find any description or picture showing the distribution of the sensory nerves from the breast and from this scapular area that would explain this refedpain. He has made one hundred dissections of female bodies, and finds that apparently the innervation of these regions had not been correctly worked out. The main point he claims to have demonstrated is that the perforating branches of the fourth and fifth dorsal nerves emerge from the serratus magnus muscle more anteriorly than has hitherto been supposed. Each of these nerves, on itcl emergence, divides into an anterior branoh supplying the breast and a posterior one supplying the skin area mentioned. The author correlates this finding with that of H. Stiles (1892), that the breast tissue is frequently more extensive than had been previously supposed, extending outwards as a tail towards the axilla and as a thin layer covering the greater prut of the pectoralis major at the level of the fourth and fifth intercostal spaces, that is, overlying the points of emergence of the two perforating lateral nerves. The author sttributea the pain in the lower scapular area to direct preasure on these nerves by tumora growing in the external quadrants of the breaet. He further suggests that tenderness in this skin area may help in determining the extent of growth of a breast cancer. F. CAVERS Roentgen-ray Evaluation of Breast Symptoms, I. H. LOCKWOOD.Am. J. Roent genol. 29: 145-165, 1933. The author presents a series of roentgenograms of patients suffering from maso- plasia, cystiphorous desquamative epithelial hyperplasia, intraductel papillomata, fibroadenoma, cystic mastitis, simple fibrosis, and carcinoma of the breast. The reproductions are good and show clearly the differences betyeen these lesions which can be distinguished by careful technic. Roentgenography is superior as a diagnoe- tic procedure to transillumination in lesions in the upper and axiflary portions of the breast, according to Lockwood. It is not, however, to be thought of as a substitute for other methods, but as an addition to the present methods of Wer- ential diagnosis in breast lesions. Gaar H. TWOMBLY THE BBEAST 195

Carcinoma of the Breast in a Fourteen-Year-Old Girl, J. B. CABNBITT,B. P. WID- MANN AND J. C. HOWELL. Surg. Clin. North America 12: 1363-1368, 1932. A girl shortly after her fourteenth birthday showed a swelling in the left forearm following an injury. The tumor and an enlarged lymph node in the left axilla were treated by irradiation and disappeared. The forearm tumor recurred in less than six months and proved resistant to further irradiation. At this time four nodules were found in the right breast and three in the left breast. There were no palpably enlarged nodes. The forearm tumor was excised; it was found to be an infiltrating growth situated beneath the deep fascia, extending down to the interosseous membrane. A simple amputation of the left breast was done. The breast nodules and the tumor of the forearm were found to be carcinoma of similar structure, indicating that the breast tumor was primary. There was no history of any abnormality in either breast, and it was impossible to determine which breast contained the primary lesion. While the authors are of the opinion that cancer usually spreads by the lymphatic route, they believe that in this instance the cancer cells were transported by the blood stream, as there was not a single demonstrable focus of cancer between the breasts and the forearm metastasis. The growth in the right breast advanced rapidly and invaded the lymph nodes; skin nodules developed in the chest and head, and a recurrence in the amputated scar of the left breast. The patient’s condition grew rapidly worse, and she died in less than a year after the tumor on the arm was fiat noticed. This is the youngest patient to be reported with breast cancer as far as the authors know; and the rapid advance of the disease illustrates “ the old adage that the younger the patient, the more viruIent the cancer.”

Erysipeloid Carcinoma, G. BINDER. Uber Erysipelas carcinomatosum, Deutsche Ztschr. f. Chir. 240: 654-659, 1933. A case of erysipeloid carcinoma of the breast in a sixty-six-year-old woman is reported. Enlargement of the axillary lymph nodes was the first clinical sign and was noticed before the tumor in the breast. Histologic study of the biopsy specimen showed diffuse carcinomatous infiltration with involvement of the blood and lymph vessels. Satisfactory improvement of the skin lesion was obtained by radium therapy, but the final result and duration of life are not given. Radical mastectomy in this type of case is contraindicated. The article ia illustrated by a photograph of the gross lesion and photomicrographs. BENJAMINR. SHORE

Coexistence of Cancer and Tuberculosis of the Breast and of the Axillarp Glands, E. VILLARDAND J. F. MARTIN. Coexistence de cancer et de tuberculose du sein et des ganglions axillaires, Bull. Assoc. franp. p. 1’8tude du cancer 22: 128- 139, 1933. A woman of iifty-aeven years had a small tumor of the right breast with no palpable nodes in the axilla. There was a history of pleurisy at the age of eighteen, and for five years the patient had had a polyarthritis, apparently of a tuberculous type. A radical removal of the breast tumor and axillary glands was done. Histologic examination showed that the breast cancer was of the scirrhous type. Tuberculous nodules were also present, usually separated from the cancer cells by a band of collagenous tissue; but occasionally the malignant cells extended into the tuberculous nodules. .In the axillary nodes, also, both cancer and tuberculosis were present, but the cancer was of a different type from that of the breast, showing an adenomatous structure. 196 ABSTRACTS

Mummification of Left Arm Following Mammary Carcinoma, OTTO VAN DER VELDE. J. A. M. A. 100: 1236-1237, 1933. A woman of sixty-five with an early carcinoma of the left breast with no gross evidence of metastasis was treated by amputation without axillary disseotion. Three years later axillary metastases developed. A year thereafter the hand began to swell, and this was followed by edema of the entire arm and bleb formation. Dry gangrene with mummification ensued. Amputation was done without the need of an anesthetic and without bleeding. The patient died two months later of pulmonary metastases. Tumor tissue was found to have grown around and completely accluded the axillary artery and vein. GRAYH. TWOMBLY Present Status of Management of Carcinoma of the Breast, L. 0. BAUMGARDNER. Am. J. Surg. 17: 233-236, 248, 1932. The author cites statistics to the effect that the average duration of life in untreated cases of breast cancer is three to four years after the discovery of the tumor, and that about 20 per cent of all patients with untreated cancer are alive at the end of five years. He stresses the point that we should not speak of cure, but only of arrest, by treatment, since recurrences may take place at any time. Statis- tics simply giving the average results for all cases are of little value. Such factors as presence or absence of affected nodes, type of growth, use of radiation preoperatively or postoperatively, have a bearing upon the outlook and should be included in all statistical studies. " The statistics that are needed are those compiled from the best men covering a large number of cases treated by surgery, by preoperative or postoperative irradiation, and by both combined. One group of stat.istics should cover strictly comparable cases, and there should be further modifications of groups to include cases with axillary gland involvement and possibly other features. Also, each pathologic or prognostic group of breast cancer should have it@own statistical tables. This is an enormous undertaking, but until it is accomplished there should be less controversy over the unknown." F. CAVERS

Rational Management of Tumors of the Breast, T. J. IRISH.J. Iowa M. SOC.22 : 534-537, 1932. This is an excellent review of the chief symptoms, signs, gross and histologic characteristics, prognosis, and treatment of the commoner breast tumors. Local removal is advised for lipomas, discrete fibro-adenomas, the disarete large cysts of chronic mastitis, and single duct papillomas with bleeding nipple. Diffuse mastitis and multiple duct papillomas deep in the breast may be only kept under observation; but near the menopause simple mastectomy is preferable. The three. main types of carcinoma and sarcoma are handled by the radical operation with postoperative irradiation. For inoperable cases simple mastectomy is oc- cssionally justified as a palliative measure. NELSONB. SACEETT Tumors of the Breast. The Stewart Incision for Radical Amputation, E. J. KLOPP. Surg. Clin. North America 12: 1485-1499, 1932. Fifteen years ago approximately one-fourth of the cases of cancer of the breast that were seen in large clinics were inoperable. Klopp rarely sees a case now that is actually inoperable, although many are far advanced. At Jefferson Hospital, Philadelphia, 80 per cent show axillary node involvement when first seen. [Prob- ably half the patients are still incurable even at Jefferson, though a satisfactory mechanical removal of the tumor and nodes is possible, and is the proper treatment, despite the fact that some 80 per cent of such patients die within five years.] Prior to operation for cancer of the breast at this hospital, the lungs are x-rayed THE BREAST 197

for the detection of pulmonary metastases, and bones are x-rayed whenever there is any pain or tenderness. Patients with rapidly growing tumors and those with extensive involvement are treated with x-rays before operation, the operation being done four weeks later. If the diagnosis of cancer is doubtful, the author makes it a practice to excise the tumor widely for a frozen section report before doing the radical operation. If the frozen section report is doubtful, the wound may be closed and the paraffin section report awaited. The author believes the radical operation may be safely postponed twenty-four or forty-eight hours if necessary. He prefers the Stewart incision. This is a transverse elliptical incision extending from the axillary fold to the sternum. It permits wide excision of the skin; it gives free access to the ada;it enables the operator to remove the upper three or four inches of rectus faicia; it provides excellent subscapular exposure; it can be entirely closed with extensive undermining of the flaps; and it gives satisfactory functional and cosmetic results. Skin grafts were found necessary to close the wound in only 3 out of more than 300 cases. Routine postoperative x-ray therapy is given beginning the third or fourth week.

End-Results of Treatment of Cancer of the Breast by Radical Surgery Combined with Preoperative and Postoperative Irradiation, BURTONJ. LEE. Am. J. Burg. 20: 405-443, 1933. This paper is the report of end-results in operable carcinoma of the breast treated by radical amputation combined with preoperative and postoperative radiation. The number of cases is 217. The majority of patients were between forty-six and fifty years of age. Eight were younger than thirty, the youngest being twenty-seven. The point is emphasized that members of the profession are quite alert to the possibility of mammary cancer in the older age groups, but may miss the disease in young women. Most of the tumors were in the upper and outer quadrant of the breast. Seventy-four per cent of the patients gave as a first symptom the presence of a lump in the breast. Pain was present in only 6.6 per cent. Bleeding from the nipple was observed in 1.4 per cent. Backache, produced by a metastasis to the spine, was the first symptom in 1.4 per cent. The author points out that the diagnosis of cancer of the breast is becoming more and more difficult, since the patients are presenting themselves in an earlier stage, often without any characteristic symptoms except a small movable tumor. It is evident that in such patients an exploratory incision of the breast must be made for a microscopic diagnosis. Such a biopsy should be made by removing the whole growth widely, rather than by cutting into the tumor while still in the breast. Various punch methods which were originally used by Abbe many years ago, and which have been revived by others from time to time, require pathologists experienced in the study of such traumatized material, and cannot be recommended as a general technic. If a wide excision around a localized tumor is made, even though some delay is necessary to obtain the microscopic diagnosis, a cure is still possible. Lee recommends that, if a local excision has been performed and the tumor proved to be malignant, the whole wound should be carbolized and the phenol then removed by alcohol. He is convinced that preoperative radiation-650 roentgen units through the breast and drainage areas in two treatments on each of two successive days-is the proper technic. The operation is carried out two to four days after the last treatment. Primary healing of the wound occurs before the erythema appears. If 800 roentgen units are given, the edges of the wound will be inflamed and healing delayed. [This would not be the case if the radiation were given very slowly.] Postoperative radiation is begun four weeks after the operation, and a cycle of treatments, each of 750 roentgen units, is given over the breast and drainage areas on successive or alternating days. If the nodes are not involved, only one cycle is given. If they are involved, three cycles are given 198 ABSTRAOTS through five portals, one anterior, one posterior, one superior, and two lateral, thus getting three erythema doses into the axilla. The author thinka that more than three full erythema doses cannot be given to the supraolavicular region, the fascia, or the skin over the clavicle, without causing permanent damage to the underlying structures, or even a radiation necrosis of 'the skin or of the clavicle, or an intractable neuritis of the oervical plexus. Of the 217 patients studied, 41 per cent were alive at the end of five years. Of 130 patients, 36 per oent were well at the end of seven years, and of 76 patients, 22 per cent were alive and well ten years after operation. At the end of five years, out of 66 patients whoee nodes were not involved, 72 per cent were alive and well, whereas of 103 patients with nodes involved, only 23 per cent survived five years. The prospect of a permanent cure of the disease in the presence of pregnancy or lactation is remote. Nine patients were malea. Only two survived for five years. The writer finds that the histologio grading of the tumors has some prognostic significance, and the use of the clinical index of malignancy (see Lee and Stuben- bord: Surg., Gynea., & Obst.: 47: 812-814, 1928) has ale0 shown excellent correlation with the grading and the ultimata results. There are no illustrations, but a good bibliography is included. Cases of Amputation of the Breast, VZNCENTEBANET. Casos de amputaci6n de mama, Bol. Liga contra el aincer (Ed. cient.) 7: 289-301, 1932. Banet presents 4 casea of carcinoma of the breast recently operated upon. No unusual features are recorded. Diagrams of the operation and a preoperative and postoperative photograph of one of the cases are appended. JOHN E. WIRTH Restoration of Function of Hand and Arm Following Radical Amputation of the Breast, C. G. ROBERTS. Am, J. Surg. 19: 494-496, 1933. In patients treated by radical mastectomy the author routinely suspends the hand and arm on the operated side by means of adhesive skin traction and a Balkan frame. The traction is so arranged as to keep the humerus at right angles to the body and the forearm flexed to 90°, with just enough weight to keep the elbow off the bed (2 to 4 pounds). The author believes that this results in an earlier and more complete return of function than is obtained by the usual methods. GRAYH. TWOYBLY Spontaneous Dhppeurnce of Meta~taticNodules from Cudnoma of the Breast Following Irradiation of the Ovaries, W. J. HOFFMAN.Surg. Clin. North America 13: 494-498,1933. A woman forty-five years of age, having a breast aarcinorna whiuh WBB considered inoperable, was treated by radiation until the tumor completely regressed, when a radical mastectomy showed only a small residual area of carcinoma. Signs of metastasee in the lungs, the opposite breast, the bones, and the cranium developed. Because of pain in the region of the pelvis, x-ray radiation was given to this area. Menstruation ceased, and a year later the patient was improved in health; there was no evidence of diseaee in the breast, chest, neck, or scalp, and symptoms of intraaranial involvement had disappeared. There was, however, a liver metastasis. Fibro-adenoma of the Breast, ALFILEDOPrarar~~. Consideraciones sobre un tumor adenoconjuntivo-mamario, Prensa m6d. argent. 19: 374-379, 1932. A girl seventeen years old had a greatly enlarged breast, which contained numerous cysts so that the preoperative diagnosia was between fibro-adenoma, THE THYROID GLAND 199 cystosarcoma phylloides, and a cystic adenosarcoma. The breast presented none of the physical findings usually associated with a malignant tumor. A biopsy showed fibro-adenoma, and a local mastectomy was performed. The article is illustrated by a photograph and three photomicrographs and contains a short bibliography. JOHNE. WrRTH Neuroma of the Nipple, F. W. STEWART.Surg. Clin. North America 13; 434-436, 1933. A woman thirty-two years of age, in whom inversion of the nipple developed after her first pregnancy, showed no gross pathological evidence of malignancy. Microscopic sections revealed a subcutaneous neuroma made up of large nerve trunks in irregular arrangement, most of them heavily or finely myelinated. A few showed edema, mucinous degeneration of Schwann cells, and separation between the nerve fibers and perineurium, characteristic of early plexiform neuroma. The neuroma was probably the cause of the inversion.

THE THYROID GLAND Relations of Thyroid Gland Adenomas to the Tumor Capsule and the Blood Vessels, J. DOEPFNER.tfber das Verhalten des Schilddriisenadenoms und der wuchernden Strums zur Kapsel und zu den Blutgefassen, Frankfurt. Ztschr. f. Path. 44: 461-489, 1933. The author points out that the malignancy of an epithelial tumor is by no means always associated with a definite histologic picture, but seems to depend largely, if not mainly, on the biologic behavior of the tumor cells. Metastasis may occur not only in thyroid adenomas, but also in typically " benign '' tumors of other types, fibromas, lipomas, chondromas, angiomas, myomas, and myxomas. Doepfner regards the proliferating struma of Langhans as forming a connecting link between the pure adenomas and the typical carcinomas of the thyroid gland. [Haagensen (Am. J. Cancer 15: 2063, 1931) has proposed a reasonable and adequate classification, in place of the more elaborate schemes put forward by some previous writers.] Histologic study was made of 17 adenomas and 4 Langhans strumas, with special reference to tumor cell invasion of the capsule and oE the intratumoral and intracapsular blood vessels. In 4 of the adenomas there were metastases to distant organs, while none of the Langhans tumors showed such metastases. In each case the nodule was microtomed in series, and either the entire serics (112- 172 sections) or parts of it (every fourth section) mounted for examination. In 18 of the 21 tumors there was clear evidence of invasion of the connective-tissue capsule. In only one case of non-metastasizing sdenoma, which had recurred seven years after strumectomy, the tumor had perforated the capsule, and its strands extended into the adjacent muscles. In 3 cases of non-metastasizing adenoma and in 3 of the 4 Langhans tumors free tumor cells, usually in small groups, lay within the veins of the tumor itself and those of the capsule. The author's results lead him to agree entirely with the conclusions of Warren [See Abst. in Am. J. Cancer 15: 2928, 1931],who, working on much larger material, considered invasion of the capsule and the blood vessels by the tumor tissue a sign of vigorous growth of the adenomatous nodule and of increased capacity of proliferation of the tumor epithelium, and believed it to be of great importance in prognosis. Doepfner has collected from the recent literature 86 cases of metastasizing thyroid adenoma which have been histologically investigated and in which the age and sex have been given in the case reports. These are tabulated as follows: 10 200 ABSTRACTS

AKe Male Female Total 1st decade - - - 2nd '' 2 - 2 3rd " 1 7 8 4th 'I 6 6 12 6th " 7 15 22 6th " 8 21 29 7th 'I 5 6 11 - 8th 'I 2 2

29 57 86

Wegelin, in whose institute at Berne Doepfner worked, found that the ratio of thyroid adenomas in males as compared with females was 73 : 84, roughly 6 to 7. The author compares this with the ratio of 29 males to 57 females, roughly 1 : 2, in the collected series of metastasizing adenomas, though he does not emphasize the influence of fe.male sex alone as a factor in determining whether the early signs of histologic malignancy which are shown by the great majority of otherwise benign adenomas will develop into unmistakably malignant characters. Age is Auggested as an important factor, since invasion of capsule and blood vessels has been found fairly frequently in the first and second decades, though metastasizing adenomas occur most frequently in the fifth and sixth decades. Five photomicrographs are given. F. CAVERS

Case of Carcinoma of Thyroid Gland with Metastatic Thrombosis of the Internal Jugular Vein, P. VALDONI.Metastasi endogiugulare da pregresso tumore malign0 della tiroide, Arch. ital. di chir. 32: 749-762, 1932. A woman of forty-five, first admitted to the surgical clinio of the University of Rome in January 1929, had about a year previously noticed a soft lump, some 2 cm. in diameter, in the right thyroid lobe. She had pain in this region, with periods of profuse sweating and constipation. On admission there was found a slight diminution in basal metabolism. At operation a nodule was discovered in the right lobe; this was removed with part of the surrounding thyroid tissue, and diagnosed by the pathologist as an adenoma. Three months after this the patient noticed a small, round swelling in the right side of the neck, accompanied by palpitation as well ns excessive perspiration. This time the basal metabolism was raised and there were other signs of hyperthyroidism, as bilateral exophthalmos, positive Mobius, Graefe, and Stellwag signs, tremor of the hands, a pulse of 90. The spherical lump, half of which lay under the anterior border of the sternomastoid, was harder than that removed at the first operation and was ndherent to the muscle, part of which was resected in removing the entire right thyroid lobe. The pathologist again reported " adenoma." The symptoms mentioned rapidly disappeared, but a few months later the patient again returned, complaining of continuous severe pain in the right half of the face and head, especially in the orbital region. Extensive x-ray examination of head, neck, and thorax was negative. A hard, irregular swelling was palpated in the carotid region, with an extension down to about the middle of the sternomastoid. At operation, retraction of this muscle revealed a thick, reddish spindle- shaped mass which proved on dissection to terminate above in three branches, corresponding to the internal jugular and its tributary superior thyroid and facial veins, while the enlarged jugular was traced downwards to its junction with the innominate vein. The jugular was cut just above this point, and a portion of THE THYROID GLAND 201 thrombus was pulled up from the innominate; the patient made a deep inspiratory movement, causing the hemorrhage to cease and air to enter the vein, but the latter was at once ligated and sutured. The upper ends of the jugular and its two tributaries were ligated, and the thrombosed mass dissected from its adhesions to the sternomastoid. During the stormy convalescence which ensued, there appeared edema of the right arm, right purulent pleurisy, which was successfully dealt with, and a Horner syndrome. The latter was still present when the patient was seen at the time of reporting, twenty-one months after the third operation. She was otherwise in good health, had no pain, and, judged by the negative results of clinical and x-ray examination, was free from recurrence and metastasis. The specimens removed at the first and second operations were re-examined and compared with sections of the thrombotic metastasis. The author gives a detailed account of the histologic findings and his interpretation of these. The first tumor removed was a diffuse solid carcinoma. In the second tumor there were denser masses of mainly cylindrical cells (colloid adenocarcinoma), but in places the architecture was that of malignant papilliferous cystadenoma. Finally, the endojugular metastasis consisted of malignant papilloma. The author emphasizes the relation between these histologic changes and the symptomatology in this case. The author believes that this is the first reported case in which the entire internal jugular vein has been successfully removed for thrombotic metastasis from a malignant thyroid tumor. He found in the literature five cases, all coming to autopsy, of similar extensive carcinomatous thrombosis of the large veins secondary to thyroid tumor. The most striking of these was that described by Clute and Smith (Arch. Surg. 18: 1, 1929), in which the. tumor had invaded the internal jugular and the innominate and extended into the right auricle. In other cases the jugular, subclavian, and axillary veins have been similarly invaded. There are eight good illustrations. F. CAVERS Carcinoma of the Thyroid with Unusual Metastases to the Heart, M. A. KOPELO- WITSCH. Krehs der Schilddruse mit seltener Metastase im Herzen, Virchows Arch. f. path. Anat. 288: 652-659, 1933. The author reports II case of carcinoma of the thyroid with extensive metastafies to the regional lymph nodes, lungs, left kidney, and left ventricle of the heart. Photographs of the pulmonary and cardiac metastatic tumors are included. BEYJAMINR. SHORE Carcinoma of the Thyroid with Skeletal Metastases, W. W. MAVER. J. M. SOC. New Jersey 30: 318-320, 1933. One of the most frequent sources of bony metastases is carcinoma of the thyroid gland. The primary tumor of the thyroid may be so small as to cause no symptoms, and it may escape discovery until pain, disability, or pathologic fracture calls attention to the process and excites a search for the origin of the metastases. Such a clinical setting was presented by two cases reported by the author. In one case the symptoms suggested a tumor of the spinal cord until further study disclosed the true nature of the process. WILLIAMJ. HOFFMAN

Carcinoma of the Thyroid; Thyroidectomy; Postoperative Myxedema Without Tetany, M. DUVOIR,G. Kttss, J. PCRISSON,J. BERNARDAND KIEPFER. Cancer du corps thyrofde. Thyroldectomie totale. Myxoeddme post- operatoire sans tetanie. Absence actuelle de recidive nCoplssique, Bull. et m6m. SOC.m6d. d. hbp. de Paris 49: 457-466, 1933. A man of sixty-two about five months previously had had a sudden feeling of constriction of the throat, his voice became raucous, and he noticed a swelling in 202 ABSTRACTS the neck, which grew rapidly in size. Two days before admission he had an attack of asphyxia, during which he fainted. The left thyroid lobe contained a hard, irregular tumor, and the entire thyroid was removed. The histologic diagnosis was epitheliolymphosarcoma, lymphocytic masses occurring among the epithelial cords. [The histologic description is very brief and is not illustrated.] Soon after operation the patient showed signs of myxedema, but these disappeared with thyroid extract medication. The absence of tetany is attributed to the fact that the parathyroids were not removed. Photographs show the appearance of the patient’s face and neck before and after treatment with thyroid extract. Fourteen months after operation there was no sign of recurrence or metastasis. F. CAVERS

Sarcoma of the Thyroid Gland, ANGELC. GALLOAND AMADEOMARANO. Sar- coma de la glhndula tiroides, Prensa m6d. argent. 19: 497-504, 1932. An Argentine male fifty-nine years old developed a large, rapidly growing tumor of the thyroid associated with an hematocele of the thyroid. The hematocele was aspirated at least twice, and on one occasion as much as 300 C.C. of sanguineous fluid was obtained. Symptoms progressed in a short time from evidence8 of local pressure, as dysphagia and dyspnea, to cerebral anemia, vertigo, ringing in the ears, and finally delirium for a short period before death. At autopsy the disease process was found to be limited to the neck. There werc no metastases to distant organs, and only moderate local infiltration was noticed. The tumor is classified histologically as a sarcoma of the thyroid because of the large multinucleated cells and the apparent limitation of the process to the connective tissue rather than the glandular elements of the thyroid. Three photomicrographs aceompany the article. There is no bibliography, but the authors give a brief discussion of the literature on the subject of sarcoma vs. carcinoma of the thyroid. [From the photomicrographs and the description of the histologic structure it seems probable that the authors are dealing with a giant-cell carcinoma, referred to so frequently as sarcoma.] JOHNE. WIRTH

THORACIC TUMORS Cyst-like X-ray Shadows of Non-hydatid FMmary Tumors of the Pleura and Lung, J. W. Tosfas,. Sombras quisticas de 10s tumores primitivos no hid&ticos de la pleura y del pulmh, Semana m6d. 1: 1183-1195, 1933. Histologic Characters of a Primary Sarcoma of the Pleura, J. W. Tosfas. Con- firmaci6n anat6mica de la observaci6n clinica de tumor malign0 voluminoso primitivo de la pleura: sarcoma primitivo de la pleura, ibid. 1: 1929-1931, 1933. The greater part of the first of these papers is occupied by an account of three cases in which the autopsy findings confirmed the clinical and radiologic diagnosis made during life. In each case the x-ray shadow was hemispheric in outline, with its base on the pleura and its dome projecting far into the thoracic cavity, though not actually involving the lung except by compression. The skin reactions for hydatid disease were negative in two cases. In one case the mass was a tuberculoma. In the other two it was a sarcoma (verified histologically in one case). Both of these were voluminous tumors causing displacement of the esophagus, and in one case also of the stomach, colon, and kidney, but no metastases were found. In the case of the larger sarcoma, the hydatid skin reaction was positive, and at autopsy a hydatid cyst was found in the liver. The author discusses the differential diagnosis of tuberculoma, hydatid cyst, and primary malignant tumors of the pleura. One of the chief points emphasised THORACIC TUMORS 203 is the more rapid extension and greater density of the shadow in cases of sarcoma than in hydatid cyst, This is further illustrated by an account of a case of bronchial carcinoma, represented at first by a rounded shadow, the rapid extension of which is strikingly shown in a series of seven radiograms taken over a period of four months; there were no superficial metastases, and autopsy was not permitted. There are twenty-four radiographs, mostly of good quality. The second paper contains further details of the case in which autopsy revealed an hydatid cyst in the liver. This finding led to a further investigation of the affected left hemithorax, and at the upper end of the tumor there was found a small hydatid cyst, the wall of which was invaded by the round-cell sarcoma. Four illustrations are given. F. CAVERS

Primary Mucus-cell Carcinoma of Lung, R. HUQUENINAND J. DELARUE. Re- marques sur les Bpith6liomas primitifs du poumon & cellules mucipares, Ann. d’anat. path. 10: 440-444, 1933. Epitheliomas originating in bronchial or mucous glands constitute one of the rare forms of primary carcinoma of the lung. Study of the authors’ four cases suggests that two typical features of this type of neoplasm are its location near the hilum of the lung and the occurrence of a peculiar gelatinous expectoration which in typical cases looks like currant jelly. The characteristic 1ocalil;ation may he clinically masked by secondary deposits or inflammatory complications. The gelatinous type of expectoration may be absent or obscured by a concomitant bronchopulmonary infection. In addition, it may be encountered in other types of pulmonary cancer as well as in non-cancerous affections of the lung. The variable color of the sputum depends upon the amount of local hemorrhage present and changes in the color of the blood due to stagnation. WILLIAMJ. HOFFMAN

Three Cases of Primary Cancer of the Lung, NAVARROBLABCO. Tres casos de chcer primitivo del pulmbn, Arch. d. med. cir. y especial. 36: 181-183, 1933. Navarro Bla~coemphasizes the difficulty of correct diagnosis in primary carcinoma of the lung and presents 3 cases which certainly showed most of the signs said to be characteristic of the condition. From the time of diagnosis to death only five months had elapsed in two of his cases; the third patient died in six months. In none of the cases was the diagnosis confirmed by biopsy or autopsy. A discussion by various physicians mentions cases which clinically resembled primary carcinoma of the lung. JOHNE. WIRTH

Primary Cancer of the Lung, CARLOSDOMiNQUEZ. Cancer primitivo del pulmon, Dia med. 5: 19-21, 1932. A single case of probable carcinoma of a bronchus is described, with a biopsy report upon a supraclavicular node. No treatment is recorded. There is a discussion of the symptomatology of primary carcinoma of the lung, but no bibliography. JOHNE. WIRTH

Case of Cancer of the Lung, E. BERNARDAND FRIED.Un cas de cancer du poumon, Tunisie mCd. 26: 447-449, 1932. A single case of cancer of the lungs is described with autopsy findings. The tumor, which was composed of columnar cells, obstructed one of the large branches of the main bronchus of the left lung. 204 ABSTRAOTS

Case of Primary Lung Tumor (Alveolar Carcinoma), G. SAYAQO.Sobre un caso de tumor primitivo de pulm6n (carcinoma alveolar), Prensa m6d. argent. 19: 545-550, 1932. A Syrian thirty-three years old, who had lived in Argentina for twenty years, had a hacking cough for a year. The cough at first was non-productive, but later mucus appeared and became abundant and frothy. There was never any fever, and the patient’s general condition remained good. During the next three months he became dyspneic, began to lose weight, and expectorated as much as a liter of mucus a day. Radiographs taken two months later showed a uniform dense shadow involving the lower half of each lung. Death occurred six days after admission to the hospital and at autopsy the lower half of each lung was found to be solidified by a diffuse growth. Nodular growths appeared only at the upper margins of the hepatized portions of the lungs. No extrapulmonary metastases were observed. Histologically these diffuse areas, as well as the upper nodular areas, showed a papillary alveolar carcinoma. Because of this structure and the bilateral involvement the authors believe that the primary lesion arose in the alveoli rather than a bronchus. The article is illustrated with .radiographs, photomicrographs, and a photograph. There is no bibliography. JOHNE. WIRTH

Case of Latent Carcinoma of the Lung with Rapidly Fatal Metastasis to the Peri- cardium, P. SAVY,P. DELOREAND H. NAUSBAC.Asystolie aigue libe il un cancer pulmonaire latent, Lyon m6d. 151 : 605-608, 1933. A man of fifty-seven waA admitted to the hospital in a state of cardiac collapse, with syncope, convulsions, cyanosis of the extremities, and a feeble pulse. He waN given injections of various stimulants (camphor, caffein, adrenalin, etc.), which afforded considerable relief. The present symptoms had begun only a week previously, with a feeling of extreme weakness, but a month before that the patient had coughed up some blood. He died two days after admission. At autopsy there was found a firm tumor near the hilus of the left lung, diagnosed histologically as an adenocarcinoma of bronchial origin, with nodules of similar structure in the pericardium and also cancerous mediastinal nodes. Evidently the primary lung tumor had caused no symptoms, apart from the single hemoptysis, but by metastasis it had produced rapidly fatal neoplastic pericarditis. The serosa was much thickened and the cavity contained 200 C.C. of hemorrhagic exudate; the myocardium was intact. F. CAVERB

Case of Carcinoma of the Lung with Hemorrhagic Pleurisy, PUlmonqf~Infarction, and Acute Pericarditis, PALLABSEAND DAMEZ. Sur un cas de cancer du poumon avec pleurbie hbmorrhagique, infarctus pulmonaire et pbricardite aigu&, Lyon m6d. 151 : 227-229, 1933. A man [age not stated] had noticed, three months before, increasing weakness and loss of weight, with a slight cough. Within a month dyspnea set in and became increasingly severe, and recently his physician had withdrawn 350 C.C. of blood-stained fluid from the left pleural cavity. There was dulness over the whole left side of the chest, and the heart showed asystole and arhythmia. X-ray showed uniform shading of the entire left hemithorax. Withdrawn exudate contained 85 per cent lymphocytes and 15 per cent polynuclears, the latter being mostly eosinophile. At each of two further tappings about 1500 C.C. were withdrawn, and death occurred fifteen days after admission. At autopsy the left lung showed a tumor as large as the head of a newborn child, arising in the hilar region of the lung and apparently of bronchial origin. There was a large infarct, quite separate THORACIC TUMORS 205 from the tumor, also typical cat’s-tongue pericarditis, with large fibrinous masses and blood-stained liquid; there were two cancerous lymph nodes encircling the esophagus but hot invading it. F. CAVERS

Carcinomatous Lymphangitis of the Lungs, Causing Dyspnea, A. COSTEDOAT. La lymphangite canc6reuse des poumons 8. forme suffocante, Presse m6d. 41 : 745-748, 1933. The author states that carcinomatous pulmonary lymphangitis is a rare condition, only 17 cases having been hitherto reported [his brief bibliography consists solely of French references]. He reports a single case, in a somewhat unusual fashion: instead of giving a straightforward account of his clinical and other findings, he writes a general account of the lesion, and under the different headings. states whether or not this or that feature was observed in his own patient. Cancerous lymphangitis of the lung is said to occur in fairly young subjects and to be, as a rule, secondary to gastric carcinoma (his patient had been operated upon eight years before for prepyloric cancer), or sometimes to cancer of the breast. In advanced cases the x-ray picture is characteristic, presenting a network with thickenings at the points of intersection of the fibers. The outstanding symptom is dyspnea, but it is often late in appearing, and may precede death by a few months or even a few days. There are nine illustrations, mostly radiographic. F. CAVERB Pulmonary Abscess Secondary to Bronchial Carcinoma, J. W. TOBIAS.Absceso del pulmbn, secundario a un chncer bronquial, Semana m6d. 1: 1859-1883, 1933. A man of forty-eight had a sudden attack of coughing, with hemoptysis two months before admission. He repeatedly brought up blood-stained mucus; then the character of the expectoration changed, becoming purulent and fetid. There was severe pain in the right chest and over the sternum. While in the hospital the patient was not feverish, though he sweated a good deal both day and night. A firm mass was felt below the skin over the lower part of the body of the sternum. X-ray examination showed a diffuse shadow occupying the base of the left lung; this was denser in its upper portion, near the heart apex. Together with the profuse purulent expectoration, the general appearance of the shadow led to a diagnosis of pulmonary abscess. The ninth rib was resected in the posterior axillary line, and an abscess cavity discovered, which, on being probed, was found to end above in a dense mass of tissue. The patient died soon afterwards, and at autopsy the abscess was found to have arisen in the parenchyma of the lower left lobe and to communicate with the left main bronchus, where it became continuous with a tumor of bronchial origin, histologically a squamous-cell carcinoma. The tumor had broken down at the point of origin of the abscess and had caused necrosis of the adjacent lung tissue. It had invaded the peribronchial nodes, and the subcutaneous sternal mass was also carcinomatous, but no other metastases were found. There are six excellent, illustrations. F. CAVERS

Saturation Doses in the Treatment of Pulmonary Cancers, N. PUENTEDUANY, M. VIAMONTEAND F. PADR6N. La dosis de saturacih en el tratamiento de 10s chnceres pulmonares, Rev. de med. y cir. de la Habana 37: 520-529, 1932. This is an interesting case of an apparent cure, after eight months, of a primary carcinoma of the lung by roentgen therapy. A white male, forty years of age, had had neuralgic pains in his left arm for six months. One month before admission to the hospital a left supraclavicular node appeared, which rapidly increased in size. The patient had lost 10 pounds of weight and was in poor general condi- 206 ABSTRACTS tion. Radiographs of the chest showed a dense shadow in the median portion of the left apex extending down to the second interspace. Biopsy of the supraclavicular node showed a group of undifferentiated cylindrical and cuboidal epithelial cells believed to be somewhat radiosensitive. The patient was given daily roentgen-ray treatments of 240 T over alternating anterior, lateral, and posterior fields for a total of six exposures to each field [18 treatments of fifty minutes each in twenty-two days]. Each area treated showed an intense erythema following the fifth exposure to a field, eighteen days after the beginning of treatment. During and after the course the patient showed no ill effects from this amount of treatment to the lung. Eight months after the beginning of the treatment (or seven months from the end) there were no nodes palpable in the supraclavicular space, the lung shadow had undergone marked regression, and the general condition had improved markedly. Although this is probably not a definite cure, the authors believe it is one of the most gratifying results they have had with roentgen therapy in lung cancer. The article contains a series of radiographs and two photomicrographs. JOHNE. WIRTH Pulmonary and Spinal Tumors in a Year-old Child. WEILL-HALLE,C. VOQT, DUHEMAND DUBOST. Tumeurs pulmonaire et medullaire (sarcome probable) chez un enfant de un an. Traitement radiotherapique efficace, Bull SOC.de p6diat. de Paris 30.: 513-522, 1932. A yesr-old child was brought to the hospital on account of paralysis of the lower extremities. When about six months old he began to be restless and to have feverish attacks; the mother noticed that his weight remained stationary, that he waH unable to use his legs, and that the right side of the chest was enlarged. Pal- pation revealed absolute dulness of the lower two-thirds of the right hemithorax, and auscultation showed complete absence of breath sounds over this area. X-ray examination was Confirmatory, showing a dense homogeneous shadow. There were no symptoms of pulmonary dysfunction, in particular no dyspnea. So far as could be judged in so young a child, there was complete anesthesia to needle pricks and to heat in the legs, abdomen, and lower part of the thorax, up to the level of the eighth dorsal segment. Simple x-ray pictures of the spine showed nothing abnormal, but lipiodol, injected suboccipitally, was arrested at the level of the tenth dorsal vertebra. Lumbar injection of lipiodol was not done because of the feverish reaction, with vomiting, which followed the suboccipital injection. X-ray treatment was given, the child receiving in four weekly sittings 2400 Solomon unite to the spine, and in eight sittings 4800 to the thorax. Six weeks after the beginning of treatment the intrathoracic mass had completely disappeared. The neurologic troubles also gradually cleared up. The authors regard the case as one of primary pulmonary sarcoma with extradural metastasis. They refer to other French reports of spinal tumors in children which were mostly sarcomas and were generally secondary to a visceral tumor. There are four roentgenograms. F. CAVERS Primary Polymorphous Alveolar Sarcoma of the Lung with Early Lymph Node Metastasis, 1'. A. BOROIOLI. Sarcoma alveolare polimorfo primitivo 'del polmone con precoci metastasi linfoghiandolari, Tumori 7: 26-46, 1933. The author discusses the twenty-three cases of primary sarcoma of the lung (as distinct from lymphosarcoma) which he finds in the literature of the last thirty years. These tumors in general occur in young individuals and show more rapid development than carcinoma of the lung. They tend to masclive growth, often occupying an entire lobe and the mediastinum, but true metastases are of rare occurrence. Histologically they are of three types, fucliform-cell tumors, round- cell tumors, and polymorphous-cell sarcoma#. THORACIC TUMORS 207

An interesting case of the polymorphous-cell type is reported. A woman of thirty-five showed grave dyspnea, pallor, hemoptysis, and a diastolic murmur. The first x-ray shows clear lung fields and an apparent enlargement of the descending arch of the aorta. Four months later fever and signs of consolidation over the right lower lobe appeared. Autopsy showed the right lower lobe occupied by an enormous neoplasm, with involvement of the peribronchial, medisstinal, and perigastric nodes, as well as a small nodule in the right middle lobe. The appearance of aneurysm in the first roentgenogram was due to a group of involved nodes surrounding the descending aorta and pulsating with it. The histologic picture was that of an alveolar polymorphous-cell sarcoma. Many areas resembled a simple fibroma. There was an extraordinary variety of cells of mesenchymal origin intimately connected with the fibrillar structure, and many of them in the process of forming fibrils. The author concludes that the tumor of the right lower lobe was the primary growth, although he remarks that it was not seen in the first x-ray plate, where the preaortic nodes were already definitely involved. The article is illustrated by photomicrographs and contains a long bibliography. JEANNETTEMUNRO Neoplasm of the Lung, MORROS. Neoplasia de pulmh, Arch. d. med. cir y especial. 36: 305, 1933. Morros presents briefly for discussion the case of a sixty-two-year-old male with a hard, tender, tumor mass in the region of the right sternoclavicular articula- tion and a large tender liver. Radiographs revealed a small circumscribed shadow in the left lung field, large Mar nodes, and bony changes in the right clavicle and in the diaphyRis of the left humerus. As the patient was still living and there had been no biopsy, the question raised was whether the process was a primary lung carcinoma with bony metastases or whether all the lesions were not metastases from an unknown primary focus. JOHNE. WIRTH Primary Endothelioma of the Pleura, GARCIAALONSO AND SANCHEZLUCAS. Endotelioma primitivo de pleura, Arch. d. nied. cir y. especial. 35: 463, 1932. Autopsy of a male fifty-one years old revealed the left pleural cavity filled with bloody fluid, the lung parenchyma free of disease, the parietal and visceral pleurae a centimeter thick in places, and a compact mass on the costal diaphragmatic surface which had extended through the diaphragm and involved, retroperitoneally, the upper left abdomen to the region of the adrenal gland. The diagnosis, on the basis of the gross material and the hiatologic Rtructure of the tumor tissue, was primary endothelioma of the pleura. JOHNE. WIRTH

Pleuropulmonary Endothelioma, A. L. BANYAIAND JOHNGRILL. Am. Rev. Tuberc. 27: 193-199, 1933. It is stated that up to 1925 only 40 to 50 authentic cases of primary endotheliomata of the pleura had been reported. Some pathologists believe that so- called endotheliomata are really secondary metastases from unrecognized or latent primary carcinomata of the lung. The authors report a case occurring in a young woman twenty-six years of age. The illness began with a severe cold and cough, followed by a loss of 18 pounds of weight, There were low-grade fever and night sweats, and a tuberculous empyema was suspected when the chest was found to contain sterile pus. Later the veins of the lower chest and abdomen became dilated, and enlarged lymph nodes were found in the right axilla. A tentative diagnosis of malignant tumor was then made and a second thoracoplavty performed. At that time a pulmonary abscess was 208 ABSTFL4OTS drained and tissue removed from a pulmonary nodule for biopsy. X-ray therapy was instituted. The patient soon left the hospital unimproved, and died three weeks later. Post-mortem examination was not obtained. Microscopic report of tissue removed from the pleural cavity was primary tumor of the pleura, a meso- thelioma. W. 8. MACCOMB Endothelioma of the Pleura and Syndrome of Pourfour de Petit, A. A. RAIMONDI AND R. PARDAL.Endotelioma de pleura y sindrome de Pourfour de Petit, Rev. Asoc. m6d. argent. 46: 385-397, 1932. Also in Arch. de tisiol. 8: 574- 584, 1932. The first Rymptoms of new growth in a fifty-year-old patient consisted of pains in the upper part of the right chest, increasing gradually in intensity in the course of a few months. Retraction of the thorax developed during the same time. During periods when the pain was intense the right eye protruded, the palpebral opening widened, the pupil increased in size, and a flow of tears appeared. The right pupil remained larger than the left and the right palpebral opening was wider than the left, though the other symptoms disappeared. [This is usually designated as Homer’s syndrome.] X-ray examination showed a shadow occupying the first four intercostal spaces on the right side. The diagnosis of endothelioma of the pleura was made. In a few months, a small subcutaneous nodule was noticed some 4 cm. below the right costal border. It gradually increased in size and after removal was diagnosed as a metastasis from a pleural endothelioma. For about one hour after the nodule was removed, the patient showed the same eye symptoms as at the beginning of the disease, the explanation being that the novocain-adrenalin injection, given as a local anesthetic, stimulated the sympathetic system. Further injections of adrenalin showed this to be correct. Four x-ray pictures and three photomicrographs elucidate the description of this interesting case. JOHANNEBP. M. VOGELAAR

Large Mediastinal Tumor Treated by Radiotherapy, DANOAND LAIN& Tumeur mediastinale volumineuse traitbe par radiothbrapie, Gaz. mOd. de Nantes 46: 78-79, 1933. A girl seventeen years of age suffered from increasing dyspnea, associated eventually with insomnia and loss of weight. Radiological examination showed a large round tumor of the mediastinum; the subclavicular nodes were enlarged, Roentgen-ray treatments were given-a total of 7000 roentgen units in two months. A second short series of x-ray treatments was given three months later, and a third two months after that. At that time the mediastind tumor had almost entirely disappeared. The patient has been well for two years. The tumor was evidently Hodgkin’s disease or lymphosarcoma.

Intrathoracic Ganglioneuroma of Sympathetic Origin in a Child, P. F. ARMANU- DELILLP),C. LESTOCQUOYAND H. GAVOIS. Ganglio-neurome d’origine sym- pathique chez une fillette de cinq ans, Bull. SOC.de pediat. de Paris 30: 174-476, 1932. In x-ray examination of the chest of a girl of five years who had a persistent cough and difficulty in breathing, there was seen a rounded shadow with sharp outline, occupying the posterior half of the right hemithorax. After induction of pneumothorax, it was seen that the mass was not adherent to the lung, and at operation it was found easy to remove a hard encapsulated tumor, the size of a cocoanut. Histologically this was a ganglioneuroma, consisting mainly of fibers with small, elongated nuclei, and groups of large ganglion-like cells. Two roent- gellograms are given, but no histologic illustrations. F. CAVERP TUMORS OF THE ABDOMINAL WALL 209

Compression of Superior Vena Cava by a Neuro-epithelioma of the Anterior Mediastinum, L. E. ONTANEDA,E. CRISCUOLOAND J. M. MONSERRAT. Sindrome vena cava superior por neuroepitelioma del mediastino-ant6rior, Rev. Asoc. m6d. argent 46: 1420-1424, 1932. The authors describe a case presenting the clinical picture of obstruction of the superior vena cava due to compression by a mediastinal tumor. There was also ascites, with edema of the penis and scrotum, found at autopsy to be due to lymph- node metastases. The primary tumor, 8s well as the metastases, consisted almost entirely of cells which were arranged in rosettes. F. CAVERS Dennoid Cyst of the Mediastinum, J. BELLE. Kyste dermoide du mediastin, J. d. sci. med. de Lille 51: 317-319, 1933. Belle’s patient, a boy twelve years of age, .upon radiological examination showed a large, round tumor originating in the mediastinurn, and containing calcareous tooth-shaped concretions. At operation a dermoid tumor was found containing sebaceous matter, hair, and teeth.

Undetermined Thoracic Tumor in a Child, H. GRENET,P. I~AAC-GEORQEBAND L. LOUVET. Turneur du poumon, Bull. SOC.de p6diat. de Paris 31: 29-31, 1933. The authors presented a girl of eleven years in order to illustrate the difficulty in the interpretation of rounded, cyst-like roentgen shadows in the thoracic cavity. The child had been under their observation for six years, and the shadow at the right apex had not grown beyond its original size, 3 or 4 cm. in length. The persistent cough was still present, but the child remained otherwise healthy and of normal development. Repeated blood counts and tests for tubercle bacilli and evidence of hydatid cyst have been negative. Before the child was seen by the authors she had been referred by the family doctor to a surgeon, on suspicion of hydatid cyst, but the surgeon, after seeing the first x-ray film, refused to operate. F. CAVERS TUMORS OF THE ABDOMINAL WALL

Fibromas of the Abdominal Wall, F. F. CARRANZAAND N. ARENAS. Fibromas de la pared abdominal, Semana m6d. 2: 1705-1710, 1932. The authors describe 5 cases of fibroma of the abdominal wall, all occurring in women. One of the tumors was a fibromyxoma [two photomicrographs are given]; the others were pure fibromas. All the patients had borne several children, a fact which agrees with the observations of other writers, and which has given rise to the supposition that these fibromas result from the trauma of childbirth. In two of the cases a course of x-ray therapy caused the tumors to become smaller and thus facilitated their removal. F. CAVERS Two Cases of Endometrioma of the Umbilicus, L. AUBERT. Deux cas d’endom6ai- ome de I’ombilic, Rev. frang. d. gyn6c. et d’obs’t. 27: Congrhs 555-563, 1932. Aubert reports 2 cases of endometrioma. In both the umbilical tumor bled at the menstrual periods, and in one it was painful, especially at the periods. Neither patient had had any operation; in one case the genital organs were entirely normal; in the other there was a uterine fibroma. The umbilical tumor was removed in both cases and proved to be typical endometrioma, with glands resembling those of the uterine rnucosa. The tumors apparently originated in embryonic rests. 210 ABSTRACTS

THE DIGESTIVE TRACT

Carcinoma of the Esophagus, J. C. BECK AND M. R. GUTTMAN.Ann. Otol., Rhin. & Laryng. 41: 1183-1190, 1932. In carcinoma of the esophagus the mortality is practically 100 per cent. The diagnosis rests on esophagoscopy and biopsy. The esophageal bougie is con- denined in Jackson’s words: ‘‘ As a diagnostic instrument it is always negative early, inconclusive later, ineffectual at best, and often fatal.” The usual endo- scopic picture of carcinoma of the esophagus is a bleeding, ulcerated, fungating mass. About 60 per cent of esophageal cancers are still confined to the esophagus at the time of death. This fact suggests that the surgical results should be better than they now are. An unfavorable element is the fact that a high proportion are anaplastic and highly malignant growths. More may be expected from surgery if the lesion is diagnosed early and if it is located in the cervical portion. Irradiation, whether by the Ro-called radium bomb, deep x-ray therapy, radon seeds, or actual radium element, is mainly palliative and aids chiefly in maintaining a patent lumen. [ntubation is an important palliative measure, making existence easier by pre- venting starvation and thirst and thus obviating gastrostomy. Dilatation is used only as a preliminary step to intubation. Gastrostomy is a measure of last resort and is only utilized when irradiation and intubation fail to maintain a patent lumen. WILLIAMJ. HOFFMAN

Experiences with Carcinoma of the Esophagus, C. EWERS. J. Thoracic Surg. 2: 829-246, 1933. The author gives a detailed report with the histories, physical findings, operative procedure, and postoperative course of 17 cases of carcinoma of the esophagus in which he had operated. Five were in the upper end of the esophagus, 9 in the thoracic portion, and 3 at the cardia. Of the 5 patients with the growth in the upper end, 3 died within a few days of the operation, while the other 2 lived four and a half and five months, one dying from hemorrhage from a metastasis and the other from cachexia combined with myocarditis. Of the 9 thoracic growths only 5 were removable at operation. Six patients died shortly after operation, one three months after exploration, and two lived seven and a half and eighteen months, dying of metastases. In all 3 cases in which the growth involved only the lower end of the esophagus, death occurred within two weeks of the operation. The author points to the advanced state of the growth and the cachexia in those who come to operation and emphasizes the importance of early diagnosis, esophagoscopy being the most accurate of the available diagnostic procedures. He believes that the technical difficulties in removal of the growth have been largely mastered. GRAYTWOMBLY

Carcinoma of the Esophaeus. * Case Reports Illustrating Two Methods of Treat- ment, WILLIAM1,. WATSON. Surg. Clin. North America 13: 444-448, 1933. Watson reports two cases of carcinoma of the esophagus. The first patient, a woman of sixty-one years, had been unable to swallow solid food for three months prior to admission. Fluoroscopy, roentgenograms, and esophagoscopic biopsy revealed a squamous carcinoma, grade 11, presumably radioresistant, at the level of the aortic arch. Treatment by bougies was continued for eleven months, twenty-one treatments being given. At the end of that period the lumen had become reduced to 4 mm. in diameter, so that a gastrostomy was necessary for THE DIOESTIVE TRACT 21 1 feeding purposes. The case illustrates what may be expected from the dilatation treatment. The second patient, a male sixty-eight years old, had a history of seven months of dysphagia. Fluoroscopy and esophagoscopy revealed an extensive, annular, ulcerated tumor which proved to be an epidermoid carcinoma, grade 11, presumably radioresistant. Treatment was begun by constructing a Janeway gastros- tomg under local anesthesia, so that nutrition could be maintained. Further treatment was by external irradiation. Under fluoroscopy the upper and lower limits of the tumor were marked out on the skin and four portals, each 14 x 8 cm., were employed, two anterior and two posterior, through which a crossfire of x-rays were directed to the tumor. Two thousand roentgen units were delivered through each portal in units of 500 T. The treatment extended over one month. Nine months after gastrostomy the patient was still alive, in poor condition but with no evidence of metastases. The large dose of radiation was insufficient to destroy all the tumor, but there has been marked slowing of the growth. WILLIAMJ. HOFFMAN Dilatation of Cancers of the Esophagus, GEORCESLOEWY. Dilatation des cancers de l’acsophage, Bull. et mBm. SOC.nat. d. chir. 59: 801-806, 1933. Lcewy describes the beneficial effects produced by dilatation in carcinoma of the esophagus. The average length of life after the onset of dysphagia is about six months, whether one performs a gastrostomy or practises dilatation. The danger of dilatation in good hands is less than the operative mortality of gastrostomy. The retention of nearly normal swallowing confers a great boon on the unfortunate victims of this disease and justifies this valuable palliative procedure. WILLIAMJ. HOFFMAN Resection of a Pharyngo-esophageal Cancer, Suture and Primary Union of the Esophagus, R. INOEBR~OTSEN.Cancer pharyngo-esophagien. RBsection. Suture et reunion primitive de l’oesophage, Acta chir. Scand. 71: 475-481, 1932. Also in Norsk. mag. f. legevidensk. 94: 500-504, 1933. A man tixty-five years of age had a hard, rapidly growing tumor in the left side of the neck. Examination of the excised specimen showed it to be an infiltrating epithelioma. Fifteen months later he returned complaining of hoarseness, at which time the diagnosis of carcinoma of the superior portion of the esophagus was made. A complete laryngectomy and a partial excision of the esophagus was performed, the esophageal defect being closed by primary suture. The patient was well for three and II half years, but succumbed with a recurrence in the neck four years after the extirpation of the primary tumor. BENJAMINR. SHORE

Problem of Gastric Carcinoma, H. C. R. DARLINQ.M. J. Australia 1: 697-704, 1933. The author deplores the fact that, despite educative efforts, it still remains practically unknown to the public that cancer in its early and later stages behaves towards treatment as if it were two entirely different diseases. He bases his paper on 22 cases of gastric cancer seen by him during two years. In only 6 of these was it possible to perform partial resection, and not even these could be termed early caees. In New South Wales the annual number of deaths from gastric cancer during the five years 1928 to 1932 has remained almost constant (603,581,603,625,628), as has also the percentage of cancer deaths (26.4,25,26.3,25.6,24.8). The author discusnes the early symptoms, calling attention to the saddening but instructive report by Alvarez (abst. in Am. J. Cancer 15: 2949, 1931), who found that in 41 consecutive cases of gastric cancer among doctors, Pymptoms had been present for 212 ABSTRACTS an average of eleven months. He adopts Lord Moynihan’s tentative grouping of symptoms into four types: the duodenal ulcer type, the dyspeptic type, the obstructive type, and the hemorrhagic type. Under each of these headings he gives case histories from his own series. In the six cases in which partial gastrectomy was performed the intervals between the onset of symptoms and adequate radiologic and chemical examination were ten monthR, eighteen weeks, ten weeks, ten months, nine months, and two years; in the remaining 16 cases the average time was over eighteen months. After a discussion of the methods of examinat,ion, the author cites statistics from nine published series of operated cases, totalling over 2500, and including Balfour’s 1000 Mayo Clinic series. He points out that Balfour’s groups practically correspond to Steinthal’s stages I and I1 for breast cancer, and states that whereas in breast cancer the average percentages of those. alive slid well after three years are 65 to 80 for stage I and 30 or less for stage 11, the corresponding figures for gastric cancer are 52 and 19 per cent. He believes that with earlier diagnosis and earlier operation the results obtained in gastric cancer in the future may he expected to approximate those now reached in early breast cancer, despite the higher operative mortality. The latter, he considers, should be reduced considerably below the present average of 18 per cent. F. CAVERS

Relation of Chronic Gastric Ulcer to Carcinoma of the Stomach, AUGUETROTH- MANN. Chronisches Magengeschwiir in seiner Beziehung zum Mrtgenkrebs, Arch. f. klin. Chir. 175: 201-215, 1933. Rothmann reports five cases in which carcinoma developed in the base of an old chronic gastric ulcer. These were observed in one year and represented an incidence of 17.2 per cent of 17 carcinomas of the stomach observed at autopsy and 12 specimens removed surgically. In all of these five cases the free hydrochloric acid was present in the stomach in normal or slightly increased amounts. The article is well illustrated by low-power photomicrographs. BENJAMINR. SHORE

Ditferential Diagnosis of Gastric Carcinoma, A. JONA.La diagnosi differenziale del caiicro nello stomaco nella pratica medica, Rassegna internaz. di clin. e terap. 13: 813-823, 855-869, 1932. This is a completely uncritical compilation from textbooks and papers, intended for the information of general practitioners. Numerous writers are mentioned by name., but no references are given. No reference is made to personally observed cases. F. CAVERB

Results of Gastrectomies for Malignant Gastric Tumors, J. A. CAEIRO. Resulta- dus de gastrectomfas por tumores gdstricos malignos, Arch. argent. de enferm. cl. ap. digest. y de la nutricidn 7: 727-736, 1932. Caeiro stresses the point that only early exploratory laparotomy is going to increese the percentage of cures of cancer of the stomach. Vague gastric symptoms are sufficient to warrant exploration, and in his opinion it is not necessary to wait until a positive diagnosis can be made radiographically, for many operable cases will become inoperable during this time. Because the lesion was so advanced, he was able to do extensive resections on only 4 of 16 cases operated upon. One of the 4 patient8 died early. Each of the other 3 was alive one year after a subtotal reRection of the stomach. In one case, in a male forty-three years old with gastric symptoms of three months duration, gastric analysis showed a total acidity of 40 [free hydrochloric acid not given] and there was blood in the stools. The lesion is described as an THE DIGESTIVE TRACT 213

ulcer of the antrum with neoplastic degeneration. In another patient, a woman of sixty with a two-year history beginning with anorexia, there were metastases to the regional nodes. The third patient, a male forty-five years old, had gastric symptoms over a period of sixteen years and showed no free hydrochloric acid and a total acidity of 45. The tumor was 7 cm. in diameter and was ulcerated. There were metastases to nodes along the greater curvature. There are preoperative and postoperative radiographs, but no photomicrographs and no bibliography. A. J. Pavlovsky and R. C. D6novan (ibid., pp. 980-982), commenting on Caeiro’s paper, state that histologic study of the primary gastric lesion and its metastases to nodes makes it possible to predict the ultimate outcome. JOHNE. WIRTH

Conservative Treatment of Inoperable Gastric Carcinomas, P. SZANTO.Zur konservativen Behandlung des inoperablen Magenkarsinoms, Wien. med. Wchnschr. 83 : 401-402, 1933. Improvement of the digestion and general physical condition of patients with itioperable cancers of the stomach are reported following the administration of a preparation called ‘I Carzalin.” In some of the 15 cases studied, improvement has been so marked that the effect was thought to be not only local, on gastric digestion, but also systemic. BENJAMINR. SHORE

Trauma and Gastric Carcinoma, 1’. HORN. Unfall und Magenkrebs. hled. Klin. 28: 1572-1574, 1932. A man of fifty was injured, in an automobile accident, about the mouth, arms, and legs. He vomited several times, and his attending physician attributed this to nervous shock, since there was no evidence of injury to the epigastric or other abdominal regions. In writing a statement in support of the patient’s claim for compensation, he refused to make any reference to abdominal injury. The patient continued to vomit blood and bile, and a few months later a second physician diagnosed gastric cancer and referred the patient to a surgeon, who confirmed this diagnosis and performed partial gastreetomy. This second physician was em- phatic in his belief that the accident had been the cause of the cancer, and made a statement to this effect to the insurance company. The surgeon was invited to report, and he as emphatically denied the possibility of any causal relation between the injury and the carcinoma. The tumor was as large as an adult hand, was ulcerated in the centre, had a hard, thickened marginal wall, and according to the surgeon’s opinion and that of the author, who is a pathologist, it must have been present for a considerable time, probably at least a year, before the accident occurred. The shock which induced vomiting was considered as very unlikely to have increased the rate of growth of the tumor. The author reports the case mainly as a warning against dogmatism on the part of physicians who have insufficient knowledge of pathology to justify them in making positive statements in cases like the one here reported. F. CAVERS

Post-traumatic Epigastric Pain ; Gastric Carcinoma Discovered at Operation despite Negative Clinical and Radiographic Findings, V. PAUCHETAND G. LUQUET. Traumatisme Bpigastrique. Cancer tr&s douloureux de I’estomac, meconnu cliniquement, trouv6 B I’op6ration; gastrectomie large; gubrison, Bull. et m6m. SOC.d. chirurgiens de Paris 24: 552-555, 1932. A man of sixty-six stated that nineteen months previously he was knocked down by an automobile, rendered unconscious, and taken to the hospital. On recover- ing consciousness his first feeling of pain was in the epigastric and right lumbar 214 ABSTRACTS regions, and a few minutes later he vomited blood-stained material. This occurred several times before he left the hospital, two months after the accident, and had continued at intervals since then. Also the pain had become more acute and laeting, and was not now relieved on taking food. The authors could find no tumor on palpation, and chemical and radiographic examinations gave negative results. The patient demanded operation because of severe pain. At laparotomy the stomach showed, on the posterior surface of the pyloric antrum, what appeared to be a callous gastric ulcer, but examination showed this ulcer to be carcinomatous. The authors add that several physicians who had previously examined the patient had regarded the case as one of post-traumatic pyschosis. They claim credit only for having realized that their patient’s agony was obviously too great to be a psychic phenomenon, and that such an explanation was inadequate to account for the persistent hematemesis. They also state that this case shows once more that when doubt exists regarding a gastric condition which is causing severe symptoms, there should be no hesitation in operating even in the absence of positive physical tumor findings. They suggest that in this case there was a simple ulcer, which began to bleed following trauma, and that later on, probably without reference to the injury, the ulcer assumed a malignant character. F. CAVERS Large Pyloric Carcinoma With Negative Radiographic Findings, J. LANOB. Cancer du pylore, Bull. et m6m. SOC.d. chirurgiens de Paris 25: 182-184, 1933. A woman of forty-seven complained of having recently felt a lump in the abdomen which moved up and down. A hard mobile mass was found, and was diagnosed as a tumor of the greater curvature. On x-ray examination, with manipulation of the barium-filled stomach, the tumor could be felt, but there was no filling defect or other abnormality. At operation there was found an intramural tumor of the pyloric region, the sire of an orange, hardly bulging into the gastric cavity. The lower end of the stomach was resected and gastrojejunostomy done. The tumor was diagnosed histologically as a carcinoma of the ‘I linitis plastics ” type. The tumor cells were disseminated in small groups which infiltrated the muscular bundles and were surrounded by hypertrophied connective tissue. No illustrations are given. F. CAVERS Absence of Symptoms in Cancer of Stomach with Extensive Pulmonary Metas- tases, F. SECCOAND G. S. ORTIZ. Chncer de estomago en cuadro metastasico prodominante, Semana med. 2: 1560-1562, 1932. The authors describe a case in which x-ray examinations revealed a filling defect in the pyloric antrum and multiple shadows in the lungs and mediastinum; also enlarged nodes in the region of the lumbar aorta. There were several hard, enlarged right supraclavicular nodes; histologic examination of one of these showed the presence of adenocarcinoma. The authors interpret the case as one of primary gastric carcinoma with metastases. For about two years the patient had been losing appetite, had a sensation of epigastric pressure after food, and had been losing weight. Therefore, as pointed out by a speaker in the subsequent discussion, the title given by the authors to their paper is misleading. There are two illustrations. F. CAVERE THE DIGESTIVE TRACT 215

Case of Gastric Carcinoma, Clinically Unrecognized, HAUTEFORT.A propos du cancer de l’estomac meconnu cliniquement, Bull. et m6m. SOC.d. chirurgiens de Paris 24: 567-568, 1932. A man of sixty was operated upon for carcinoma of the pyloric antrum, and was, at the time of this report, eighteen months later, in good health. A year after the operation his wife, aged fifty-five, complained of epigastric pain, nausea, and occasional vomiting, such as her husband had suffered. The author could find no tumor on palpation and believed that the symptoms were of psychic origin. Four months later the woman returned, complaining of repeated vomiting. Again no tumor could be felt, and a complete radiographic examination showed nothing abnormal. Four months after that she was again seen, with obvious signs of emaciation and with a hard palpable epigastric tumor. The x-ray investigation, made by the same radiologist as before, showed a large irregular filling defect in the prepyloric region. At laparotomy it was found impossible to perform gastrectomy on account of the extension of the growth into neighboring regions, with adhesions and numerous enlarged lymph nodes, and palliative gastro-enterostomy was done. The author regrets not having made an exploratory laparotomy when the woman first complained, or at any rate when she came the second time, despite the lack of physical evidence of a tumor. He is determined to advise laparotomy in every future case in which there are persistent symptoms suggestive of gastric tumor irrespective of the radiographic and laboratory findings. F. CAVERB

Carcinoma of the Stomach in a Child Aged Three Years, CORNELIUSS. HAGERTY AND STANLEYGIBBON. Arch. Path. 14: 289-290, 1932. Only 6 cases of carcinoma of the stomach have been reported in children under ten, and in two of these there is some doubt as to whether it was primary or second- afy. After giving references to those cases, the author reports his own case in a girl of three, who had had loss of appetite and anemia for three months and enlargement of the abdomen for four days. Death occurred three days after exploratory incision, which revealed metastatic tumor nodules in the liver but failed to disclose the primary growth. At autopsy an ulcerated glandular carcinoma of the cardia of the stomach was found. A photomicrograph shows the structure of the growth. In the ensuing discussion, Dr. Jaffe suggested the possibility that this may have begun as a teratoma with proliferation of the epithelium.

Right Upper Quadrant Mass in a Boy of Eighteen, CABOTCASE 18282. New England J. M. 207: 90-91, 1932. Adenocarcinoma of the stomach in a boy of eighteen was discovered at necropsy, with metastases to the liver and retroperitoneal lymph nodes. -Death was due to hemorrhage into the peritoneal cavity. The principal clinical feature was the greatly enlarged liver.

Fatal Icterogenic Spirochetosis in a Patient with Latent Gastric Carcinoma, BARIBTYAND ALBEAUX-FERNET.Spiroch6tose ict6righe mortelle chez un malade porteur d’un cancer latent de l’estomac, Bull. et m6m. SOC. m6d. d. h6p. de Paris 56: 166-172, 1932. A man of sixty-six died from spirochetal infection producing the following symptoms : jaundice, followed by meningeal manifestations; first hypertrophy and later diminution in size of the liver; slight pyrexia; persistent albuminuria; well marked hemorrhagic syndrome (hemorrhagic herpes, hemoptysis, hemsturia), and 216 ABSTRACTS a scarlatiniform rash. At autopsy there was found a pyloric carcinoma which had apparently caused no symptoms and had therefore not been suspected or looked for. F. CAVERB

Clinical Observation, as a Useful Contribution for the Differential Diagnosis Between a Gastric Neoplasm and Intestinal Tuberculosis, RUBXNA. GARCIA AND VICENTEN. GARCIA. Una observaci6n clfnica, como contribucih fitil, para el diagnbtico diferencial entre un neoplasms g&strico y una T. B. C. intestinal, Repert. d. med. y cir. 23: 170-174, 1932. A woman, six years after the menopause, complained of continuous pain in the stomach, gas, and loss of appetite. She was pale and had a cough but no hemoptysis. There was a hard, slightly movable, tender mass in the epigastrium. Liver and spleen were not enlarged. There were enlarged, tender nodes in the left supraclavicular region. A blood count showed 3,300,000 red cells and 1,200 white cells, of which 75 per cent were polynuclears and 25 per cent lymphocytes. Radiography revealed a normal stomach except for slight rigidity in the prepyloric region and a deformed duodenal bulb. While the patient was under observation her cough became worse. A slight temperature developed, ascites became marked, and the whit,e blood count rose to 14,400, with 93 per cent polynuclears. No tubercle bacilli were found in the sputum, but Amoebae histolyticae were found in the stools. Death occurred six weeks after admission. Autopsy showed the abdominal condition to be due to tuberculous peritonitis with extensive adhesions and a secondary abscess. JOHNE. WIETH

Metastatic Infection of Bone and Joints as the Initial Clinical Manifestation of Gastric Neoplasms, H. A. SINGERAND L. W. SHABAT.J. Bone and Joint Surg. 15: 491-493, 1933. The authors report three cases in which suppurative lesions of the bones and joints had their origin in relatively asymptomatic gastric neoplasms. In one case suppurative arthritis of the knee was traced to an infected leiomyoma of the stomach and in’ two other cases osteomyelitis and purulent arthritis of the spine were believed to be secondary to infected carcinomas of the stomach. In patients of cmcer age thorough examinations of the gastro-intestinal tract should be made for a carcinoma as the primary focus in cases of osteomyelitis or suppurative arthritis of obscure origin. BBNJAMINR. SHORE himary Intramural Sarcoma of the Stomach; Clinical and Roentgenographic Diagnosis, S. KADRNKAAND A. SIERRO. Le sarcome primitif de l’estomac. Diagnostic clinique et radiologique, Arch. d. mal. de l’app. digestif 23: 51-87, 1933. The authors give full reports of two cases of gastric sarcoma. (1) A man of seventy-one, who had never been ill previously, was seized with vertigo and vomited blood. During the next few days he had epigastric pain after meals. On examination he was found to be anemic, and the spleen was enlarged. The abdomen was somewhat distended, but no tumor was palpated. X-ray showed a rounded defect in the antral region. Operation was deferred on account of the patient’s poor state of health, and a fortnight later he died from pneumonia. At autopsy the stomach showed a soft rounded tumor, 5.5 x 3 x 3 cm., on the anterior surface of the antrum, with ulceration at its upper pole. Histologically it was a round-cell sarcoma. (2) The second patient, a man of fifty-six, for two months before attending hospital, had attacks of epigastric pain about half an hour after meals. During the past month the pain had been accompanied by vomiting, and the patient had THE DIQESTIVE TRACT 217 lost appetite and weight. A hard mass was felt in the epigastric region, and the liver was enlarged. The gastric contents showed absence of hydrochloric and lactic acids, and the presence of blood. X-ray examination revealed marked pyloric stenosis and stasis (30 hours); peristalsis was exaggerated in the upper two thirds, and absent in the lower third. At operation the stomach was hard and much thickened in its lower third, including the pylorus, and the surface here was of greenish-black color. The lower two-thirds were resected. The tumor was a round-cell sarcoma (Ilymphosarcoma) which had left the serosa unaffected but had destroyed the entire wall of the stomach, including the mucosa. The patient recovered and gained in weight, but returned six months after operation in a state of extreme cachexia, with jaundice, ascites, melena, and large, hard palpable masses in the epigastric region. He died a few days later. At autopsy there was found a large recurrent retrogastric tumor with metastases in the liver, kidneys, and retroperitoneal glands. The authors conclude that it is practically impossible to distinguish intramural sarcoma from carcinoma. They also conclude that intramural sarcoma8, owing to their usually slow growth and metastasis, respond more favorably to surgical treatment than do gastric carcinomas. It may be noted that in their discussion and in the appended bibliography, which contains about seventy references, a remarkably small number of French publications are included, and a large proportion (about thirty) of American ones. There are ten good illustrations. F. CAVERS Primary Lymphoblastoma of the Stomach with Metastasis to the Ovaries, F. MUSCATELLO.Linfoblastoma primitivo dello stomaco con metastasi ovariche, Tumori 7: 175-188, 1933. A woman was admitted to the hospital with no gastric symptoms but indefinite pelvic complaints. Autopsy disclosed a large invasive tumor of the pyloric region of the stomach, no stenosis, and tumors of both ovaries. Microscopically the tumors appeared to be lymphoblastomas. The stomach tumor seemed to be of longer standing, showing areas of degeneration and retrogression. No other metastases except those to the ovaries were found. The author discusses the histogenesis and development of the tumors and believes that the only plausible method of diffusion of the tumor was by direct transplants from the stomach to the ovaries. The article is illustrated by photomicrographs. JEANNETTEMUNRO

Benign Polypoid Tumors of the Stomach, 0. SUBANI.Tlber gutartige polypbse Magentumoren, Chirurg 5: 378-381, 1933. Susani reports 6 cases of benign polypoid tumors of the stomach; two were myomas of the submucosa or muscularis, one the cystic degeneration of an adenoma of a misplaced pancreatic rest, and three were true polypoid adenomas. Conserva- tive surgical measures are permissible in all but the true epithelial polyps, for which subtotal gastrectomy is indicated. The operative mortality associated with the latter operation is considered low compared to the much higher mortality should carcinoma develop in a polyp. There are no illustrations. BENJAMINR. SHORE

Subserosal Leiomyoma of the Stomach, NICOLASG~MEZ DE ROSAS. Leiomioma sub-seroso del estomago, Rev. de med. y cir. de la Habana, 37: 590-593, 1932. clinical Case of Leiomyoma of the Stomach, PEDROLE6N. caso clinic0 de leiomioma del estomago, Rev. de med. y cir. de la Habana, 37: 594-597, 1932. A woman forty-six years of age complained of constant dull pain in the right flank and right upper abdomen, with occasional attacks of severe pain, constipa- 218 ABSTRACTS tion, and loss of weight for five years. For a short while there had been a slowly growing, round, firm, movable tumor in the upper mid-abdomen. Gastric analysis revealed free hydrochloric acid and a small amount of blood. Radiographs showed a gastric tumor extending from the fundus to the pylorus. At operation the tumor and part of the stomach were excised. The tumor waa found histologically to be a subserosal leiomyoma. The overlying mucosa was ulcerated and there was a large cavity in the tumor which connected with the lumen of the stomach. The article contains a summary of 3 similar cases found in the literature during the last three years. Le6n discusses at length the gross and histologic features of the case reported by G6mez de Rosas. There are two photomicrographic illustrations. JOHN E. WIRTH Polymorphic Schwannoma of Lesser Curvature of Stomach, C. BONORINOUDA- ONDO AND D. BRACHETTO-BRIAN. Schwanoma polimorfo de la pequefla curva- dura del est6mag0, Prensa m6d. Argent. 18: 1025-1038, 1932. The authors report a schwannoma of the lesser curvature of the stomach of a man aged forty-one, who for about fifteen years had had repeated attacks of pain in the right hypochondrium, with vomiting (blood and bile present). Roentgen examination showed a filling defect at the upper end of the lesser curvature, which is the site of the majority of these tumors. At operation a tumor some 3 cm. in diameter was removed. The tumor was examined by serial section, and found to consist of a considerable variety of cells. In one portion these had a tendency to palisade formation, while in some portions there were myxomatoid and in others sarcomatoid areas. There are twelve illustrations including some excellent photomicrographs. F. CAVERS

Unusual Cause of Hematemesis (Neuroflbroma), CABOTCABE 18283. New England J. M. 207: 91-93, 1932. A man of sixty-one had repeated rectal bleeding and hematemesis at rather long intervals. In the left upper quadrant of the abdomen, near the midline, was a firm round tumor the size of an orange. Roentgen plates showed this to occupy the middle two thirds of the stomach. The patient died of peritonitis three days after removal of the tumor mass. This proved to be a neurofibroma of unusual size. In the stomach wall a few centimeters from the main tumor mass was a small nodule which proved to be a myoma.

Radiologic Diagnosis of Tumors of the Small Intestine, A. AKERLUND.Zur direkten Rontgendiagnostik der Diinndarmtumoren, Acta chir. Scand. 71 : 1-22, 1932. ' The author believes that the radiologic diagnosis of tumors of the small intestine is possible in the early stages before marked obstruction has taken place. Obliteration of the normal rugae, a filling defect or niche formation, prestenotic formation of pseudo-diverticula, and a stiff and unyielding segment of intestine when viewed with the fluoroscope are the primary local radiologic signs. Contrast media are given by mouth, although it is possible to fill the small intestine almost completely by the administration of an opaque enema. Persistent nielena and symptoms of gastro-intestinal obstruction in the absence of demonstrsble radiologic evidence of pathologic processes in the stomach and colon constitute the special indications for careful radiologic examination of the small intestine. The histories of 4 patients with malignant tumors of the small intestine are THE DIQESTIVE TRACT 219 given. One had an hemangiosarcoma of the jejunum, one an adenocarcinoma of the colon and ileum with an ileocolic fistula, one a diffuse adenocarcinoma of the peritoneum and intestine, and the last a lymphogranuloma of the small intestine with perforation. The article is illustrated by a photograph of the hemangiosarcoma, photomicrographs, and excellent roentgenograms of all the cases. BENJAMINR. SHORE Cancer of the Small Intestine, SANTIAQOCARRO. CAncer del intestino delgado, Progresos de la clin. 40: 7-9, 1932. A woman seventy-nine years of age suffered suddenly from cramps and vomiting, followed by loss of appetite, a sense of fullness and slight pain in the stomach, and rapid loss of weight. A mass was palpable in the abdomen and radiographs revealed a partial obstruction in the small intestines, somewhere in the region of the ileum, with dilatation of the proximal bowel and partial collapse of the distal bowel. Because of the patient's age, poor nutrition, anemia, loss of appetite and weight, palpation of the tumor, and radiographs, a diagnosis of cancer of the small intestine was made. The diagnosis is not verified by operation or necropsy. The article contains a reproduction of one of the radiographs, but no bibliography. JOHNE. WIRTH

Lymphosarcoma of the Jejunum, E. H. TAYLOR.New England J. Med. 208: 642-644, 1933. Sarcoma is less frequent in the small intestine than carcinoma. The most common histologic variety of jejunal sarcoma is lymphosarcoma. This tumor originates in the submucous lymphoid follicles, extends along the long axis of the intestine, invades the muscular coat, and causes paralytic distention. It may ulcerate, bleed, and perforate, although it seldom infiltrates the peritoneal coat. With regard to the symptomatology, there is a peculiar disproportion between the rapid impairment of health and the frequent absence of local symptoms. The usual clinical picture is weakness, general debility, and occasional alternation of diarrhea and constipation. An illustrative case report is given. CEORQET. PACK

Lymphosarcoma of the Cecum: Report of a Case, C:F. DIXONAND P. R. IMES. Proc. Staff Meet., Mayo Clinic 8: 117-119, 1933. Lymphosarcoma is twice as common in the small as in the large intestine. The order of frequency of its occurrence is as follows; ileum, cecum, jejunum, and rectum. Only four malignant gastro-intestinal tumors have been found in children under fifteen years of age at the Mayo Clinic; two of these were sarcomas of the stomach and the other two were lymphosarcomas of the large bowel. The authors relate the case history of a twelve-year-old boy who had suffered for fourteen months with vague, cramping abdominal pain, simulating appendicitis and frequently associated with vomiting. An appendectomy performed elsewhere had not relieved these symptoms. On admission to the Mayo Clinic, a fixed tumor 15 cm. in diameter was felt in the right lower quadrant. X-ray studies showed it to involve the ascending colon, cecum, and terminal ileum. A resection of the terminal ileum, cecum, ascending colon, and hepatic flexure, with lateral anastomosis, was done in a single stage following blood transfusion. The patient recovered and at the time of the report was receiving postoperative prophylactic x-ray treatmen t. CEORQET. PACK 220 ABSTRAOTS

Enterogenous Cyst: Record of a Cam, A. C. FORRESTIR.Glasgow M. J. 119: 202-205, 1933. The author considers that enterogenous cysts, though not rare, are worth reporting, especially as their etiology has not yet been definitely established and they are seldom diagnosed before operation. A boy of five years, six months before admission to the hospital, developed colicky abdominal pains, followed by vomiting. Similar attacks recurred every two or three days for nearly five weeks, the boy gradually becoming lethargic and frequently sweating at night. During the week before admission the attacks occurred several times daily. The abdomen was distended] with increased fullness below the left costal margin, and was everywhere rigid and tender to palpation] the maximum tenderness being at the umbilicus and to its left. On a diagnosis of acute intestinal obstruction of unknown cause, the abdomen was opened and found to be nearly filled by a tense cystic swelling. This was attached to the ileum, which was incorporated in the cyst wall, the whole being twisted on its axis and forming a mild volvulus. The cyst with the involved loop of bowel was excised and end-to-end anastomosis made, with good recovery. The cyst communicated with the intestinal lumen by an opening admitting an ordinary pencil. Histologic examination of a piece of tissue from the junction of cyst wall and intestinal wall showed that the mucosa of the intestine was intact; the subjacent tissues showed considerable infiltration, and the cyst wall at this site consisted of the muscular coat of the intestine lined by polymorphonuclear leukocytes, while away from the opening it consisted of fibrous tissue with muscle strands running circularly and longitudinally, The tissue of the cyst wall was very vascular, and hemorrhages had occurred into the cyst; the epithelial lining of the cyst wall had disappeared. Lewis and Thyng (Am. 3. Anat. 7: 505, 1907) showed that the formation of diverticula of the Rmall intestine was a regular occurrence during human embryonal and fetal life, and it seems reasonable to suppose that such diverticula may persist and form enterogenous cysts. Cases of Meckel's diverticulum have been described which have given rise to similar cysts. On the other hand, cysts may arise in the intestinal wall or the mesentery, and by rarefaction and disappearance of tissue may later open into the lumen of the intestine. In most cases, including both types, the intestine is involved] and bowel resection is necessary. There are no illustrations. F. CAVERS

Cancer of the Large Bowel, L. J. CARTER.Canadian M. A. ,J, 29: 167-171, 1933. After twenty years] experience in x-ray work the writer emphasizes the danger of allowing seemingly trivial gastro-intestinal symptoms to go without thorough investigation, especially such symptoms as gas in stomach or bowel, vague indiges- tion] lass of weight and strength, and oonstipation not readily responding to treatment. The investigation must be made by an expert radiologist. " No one who is not investigating gastro-intestinal conditions from day to day, and thus securing familiarity with the early signs of cancer, can possibly recognize those small departures from the normal which indicate early malignancy.J1 One negative examination must not be regarded as conclusive; repeated examinations should be rnade at regular intervals. The author cites three personal cases, two illustrating the value of repeated or routine radiologic examinations when the clinical diagnosis does not point to bowel malignancy, and the third as an example of the unbelievable obtuseness of some people regarding their own physical condition.,' The first and second patients are alive nine and two years respectively after operation; the third, who presented herself with great abdominal enlargement said to have dated back only two weeks, was found on surgical exploration to have a massive inoperable malignant growth involving the cecum and ascending, descending, and sigmoid colon. TEE DIOEBTIVE TRACT 221

The author analyzes 60 consecutive cases of colonic carcinoma observed at the Bigelow Clinic, Brandon. Of 54 coming to operation, 24 were found to be resectable and 30 not. In the former the average duration of symptoms was ten months, in the latter it was only five and a half months. The short time interval in the non-resectable cases, in which the tumor had shown more rapid growth and invasion of nodes and surrounding tissues, is regarded by the author as the strongest reason for early and thorough investigat'ion of suspicious symptoms. Of the 24 patients in whom resection was done, 10 are living six years after operation. Of 30 with non-resectable growths, 3 are untraced and 27 are known to be dead. Twelve received x-ray therapy and lived on an average eleven months, but the condition of the remaining patients who survived exploratory operation was too grave to admit of any further treatment. F. CAVERS

X-Ray Diagnosis of Cancer of the Colon, BYRLR. KIRKLIN. Med. Arts 35: 211- 212, 1932. A brief description of methods of x-ray diagnosis of colonic cancer. Curability of Carcinoma of the Colon and Rectum by Radical Operation, E. S. JUDDAND E. A. WILKINBON.Proc. Staff Meet., Mayo Clinic 8: 15-16, 1933. The authors report three cases illustrating the curability of carcinoma of the colon and rectum by radical operative procedures, which have given to each patient a quarter of a century of life. These patients are still living without signs of recurrent cancer, The ages of the patients at the time of operation were thirty-one, thirty-four, and forty-one years. Recent histologic grading of these cancers showed them all to belong to group 1. With the improvements in operative procedures which have taken place since these operations and the reduction in operative mortality, the results are even more gratifying. GEORQET. PACK

Two Cases of Obstruction of the Colon by Neoplasm, J. M. MADINAVEITIA. Do8 casos de obstrucci6n del colon por neoplasia, Progresos de la clin. 40: 451- 454, 1932. A woman sixty-six years old had epigastric pain an hour and a half after each meal for a year, and then began to have severe hematemesis. Radiographs showed evidence of a carcinoma of the pylorus and obstruction of the transverse colon in the region of the splenic flexure. The author believes that the patient had a carcinoma of the stomach and of the colon. There is no operative or necropsy verification. A second woman, forty-six years old, had intestinal obstruction after years of severe diarrhea. Radiographs showed a mass extending from the cecum to the ascending colon. At operation an ileotransversecolostomy was performed. The patient died one week after operation, following severe hematemesis. The nature of the cecal mass was not determined by biopsy or autopsy, but it was thought possibly to have been tuberculous. JOHNE. WIRTH

Surgery of Cancer of the Rectosigmoid Segment, V. PAUCHET.Chirurgie du gros intestin. Cancer du segment recto-sigmoidien, Rev. tech. chir. 24: 225- 233,1932. In rectosigmoid cancer, the author has not found the perineal operation satisfactory, as it does not permit the removal of all nodes involved, and also endangers the ureters. For this reason he prefers the combined abdominoperineal operation ; with this technic, in the course of the abdominal operation the ureters are dissected out with great care; the rectosigmoidal segment is carefully freed from above downwards and sectioned below the tumor; a Mikulicz drain is used. If the patient is 222 ABSTRACTS

in good physical condition, the sphincter may be preserved at the perineal operation, but as a rule this is not advisable. Illustrations showing the technic of the operation are given.

Eight Colon Cases, c. D. BROOKB,w. R. CLINTONAND L. B. A~HLEY. Am. J. Surg. 20: 86-94, 1933. Five of the eight patients described by Brooks and his amociates had neoplasms of the colon. A fifty-four-year-old man had a large pedunculated lipoma which almost occluded the lumen of the sigmoid. An early adenocarcinoma of the transverse colon in a sixty-one-year-old woman produced symptoms and objective sign8 Rimulating an acute gangrenous appendicitis. A forty-four-year-old woman had a resection of the cecum for carcinoma one year after a complete hysterectomy for carcinoma of the fundus uteri. An adenocarcinoma of the splenic flexure of the colon in a thirty-eight-year-old man was removed in two stages, the first being a preliminary cecostomy. A twenty-three-year-old woman had a rectal resection for carcinoma and remained well for seven years, when a recurrence developed secondary to polyposis. GEORGET. PACK Cyst of the Transverse Colon in a Boy of Two and a Half Years, W. H. IRVINE. Canadian M. Assoc. J. 28: 536-537, 1933. In a child of two years and a half a tumor was present which was first taken for the distended bladder; by having the patient held upside down during palpation it was found to belong to the upper part of the abdomen. At operation it was found to arise from the free margin of the transverse colon by a firm, thick stalk about two inches long. The cyst itself, about the size of a baseball, was thin-walled and contained thick, tenacious, dark grayish liquid. Unfortunately no histologic examination was made. It was probably of congenital origin. The patient had been seen again recently, eighteen years after operation, and was a robust young man. F. CAVER8

Method for Roentgenographic Diagnosis of Cancer of the Rectum, 0. FRICKE. Eine neue Methode der rontgenologischen Darstellung des Rektumkarzinoms, Rijntgenpraxia 5: 365-368, 1933. The author states that he has often found it difficult to make a precise diagnosis of the site of a rectal cancer, chiefly because the pubic symphysis interferes with manual palpation and compression during x-ray exposure. He has tried with 8ucceHH a method of which the principle is inflation of the healthy portion of the rectal wall after opaque filling. He introduces into the rectum one or two duodenal sounds, constructed as follows. One end of a piece of thin rubber tubing is tied around the terminal olive of the sound, and the other end is tied round the middle of the sound, the whole resembling a long-handled, closed umbrella. The tubes are inflated into balloon shape above the site of the tumor as revealed by the opaque filling, and the pressure thus set up causes the filling material to come into close contact with the affected bowel wall. Six illustrations are given. F. CAVERB

Cancer of the Rectum, DUDLEYSMITH. California and West. Med. 37: 223-226, 1932. Perineal resection of the rectum has a low primary mortality, but is followed by recurrence in a considerable percentage of cases. Its use should be restricted to patients who are considered unfit for a more radical procedure. The two- stage abdominoperineal resection of the rectum can be accomplished with a primary mortality of only 10 per cent. The factors contributing to this low mortality THE DIGESTIVE TRACT 223 are: spinal anesthesia, careful preoperative preparation of the patient, blood transfusion, vaccination against peritonitis, establishment of good drainage. If the patient is in poor condition, it is essential to secure proper functioning of the colostomy prior to the major operative procedure. Smith prefers the Sistrunk type of colostomy, in which the two arms of the gut are separated by a segment of the entire abdominal wall. If the patient with an inoperable carcinoma is in good condition and the local tumor not completely fixed, it is questionable if it should not be removed, even though metastases to the liver and lymph nodes are present. This procedure is justified if the patient gets six to twelve months of comfort. GEORQET. PACK Technic of Low Amputation of the Rectum for Cancer, G. LUQUET. Quatre observations d’amputation du rectum canc6reux avec gu6risons op6ratoiresI Bull. et m6m. Soc. d. chirurgiens de Paris 24: 415-421, 1932. Technic of High Amputation of the Rectum for Cancer, G. LUQUET. Amputa- tion du rectum pour cancer par la voie haute (opbration de Hartmann), Rev. tech. chir. 24: 234-244, 1932. Both of these papers are devoted to detailed descriptions of operations used by the author for the resection of the carcinomatous rectum. In the first he deals with the technic of amputation for cancers located low in the rectum, and reports three-year cures in four cases. Two of these were operated by the coccygoperineal route, with conservation of the sphincter, and two by the abdominoperineal route. The author prefers the latter procedure for the majority of rectal tumors. In the second paper the author reports no cases, but describes the technic of Hartmann’s Rmputation, which he practises for cancers of the lower sigmoid colon, the rectocolic junction, and the higher part of the rectum. This high route operation has the advantage of being less grave and less mutilating than the abdominoperineal procedure but it has the disadvantage of leaving the patient with a permanent iliac anus. A series of clear illustrations is given showing thesuccessive stages in these operations. F. CAVERS

General Practitioner’s Relation to Rectal Cancer; Prevention of Cancer, C. J. DRUECK.Internat. J. Med. & Surg. 46: 67-68, 1933. The author points out the prevalence of rectal cancer and emphasizes the importance of thorough examination of the rectum by the general practitioner in the making of early cancer diagnoses and in finding and eradicating causes of chronic irritation. GRAYTWOMBLY

Myoma Matignum of the Rectum: a Case Report, F. S. WRIQHTAND M. W. HALL. Military Surg. 71 : 527-531, 1932. A man of forty-eight suffered from itching of the anus and noticed a small protrusion. This grew larger until, six months afterwards, its prolapse with de- fecation led him to consult a surgeon, who removed a tumor about two inches in diameter, attached to the anterior rectal wall about two inches above the sphincter muscle. The pathologic report was spindle-cell sarcoma. Later the patient had an attack of fever, attributed to paratyphoid, following which he did not re- gain his usual health. He was referred to the authors because of cachexia, abdominal pain, and a rectal tumor. The latter was a large, irregular, multiple mass; proctoscopic examination was difficult owing to the continuous bleeding, but roentgenography after a barium enema showed a filling defect on the right side of the rectum. The prognosis was considered bad, but the man requested operation. Low colostomy was followed five weeks later by abdominoperineal resection. Five months after operation the patient returned home, having gained about twenty pounds weight. 224 ABSTRAOTS

From the histologic appearance and multiple character of the growth, the long history, and the presence of lymph node metastases, the authors conclude that the tumor was originally a leiomyoma and had undergone malignant change. At the time of reporting, nearly four years after the second operation, the patient was in good health and had gained forty-one pounds weight. There are two illus- brations. F. CAVERS

Anatomical and Clinical Characteristics of Polypoid Tumors of the Rectum, H. JUNOHANNB.Anatomie und Klinik der Zottengeschwlilste des Mastdarms, Arch. f. klin. Chir. 175: 45-65, 1933. The author reports the histories of four patients with polypoid tumors of the rectum. In all of these malignant changes in at least a portion of the growth were demonstrable, and in all radical resection of the rectum by the abdominosacral route was performed. The author stresses the fact that histologic examination of many areas may be necessary before malignant changes are observed, and for this reason many biopsy specimens should be taken from all polypoid growths. The article is well illustrated by photographs of gross specimens and photomicrographs. BENJAMINR. SHORE Primary Carcinoma in the Vermiform Appendix: Report of a Case, MARIAN FRAUENTHALAND R. I. GRAUSMAN.Am. J. Surg. 19: 118-119,1933, The authors report a case of a very small adenocarcinoma of the appendix diagnosed following routine histologic study of the excised organ. The patient has remained well for two years. There are two photomicrographs. BENJAMINR. SHORE Carcinoid Tumor of the Appendix, P. B. AYRES. Univ. of Toronto Med. Jour. 10: 1.52-156, 1933. This is a short review of the histology and pathology of carcinoids of the appendix. The author gives a brief account of the theories of histogenesis of this tumor but fails to include any adequate summary of the work of Masson. The article records no original observations. GRAYTWOMBLY

THE PANCREAS Punch Biopsy in Neoplasms of the Pancreas, ANTONINOPEREZ ARA. La biopsia por punci6n en las neoplasias del pSncreas, Rev. de med. y cir. de la Habana, 37: 509-519, 1932. The author describes and advocates the use of a punch biopsy for large tumors of the pancreas. The punch consists of a trocar to which a 20 C.C. syringe can be attached. The trocar is introduced anteriorly and the procedure is carried out under the fluoroscope with a barium meal in the stomach and small intestine. The article includes a short bibliography. JOHNE. WIRTH Tumor of the Head of the Pancreas Causing Duodenal Obstruction. E. S. JUDD AND J. R. PHILLIPS.Roc. Staff Meet., Mayo Clin. 8: 28-29, 1933. Tumors of the head of the pancreas, most often carcinomas, are frequent causes of obstructive jaundice. Von Bunger (Beitr. z. klin. Chir. 39: 131, 1903) studied 58 cases and found in 55 that the common bile-duct passed through the pancreas for a distance of 0.8 to 4.5 cm. and that a layer of 0.2 to 2.0 om. of pancreatic tissue surrounded this duct. A short-circuiting operation, usually a cholecystogastrostomy relieves the obstructive jaundice, but if the patient survives the disease long THE PANCREAS 225 enough to permit the carcinoma to involve the duodenum, a gastro-enterostomy may be necessary. Dehne and Walters (Arch. f. klin. chir. 167: 506, 1931) in 113 cases of pancreatic cancer causing jaundice, found 5 in which there was duodenal involvement or obstruction. Obstruction of the common bile-duct usually ante- dates that of the duodenum. In previously reported cases, the operations of cholecystogastrostomy and gastro-enterostomy have been done at separate times and in the order in which they were needed. The author’s patient had all the signs of duodenal obstruction, and the operation revealed in addition a marked dilatation of the common bile- duct and gallbladder, although insufficient to cause jaundice. Therefore both operations, i.e., a cholecystogastrostomy and a gastro-enterostomy, were performed. In cases of cholecystogastrostomy for obstructive jaundice due to lesions in the ampulla or head of the pancreas, it should be borne in mind that a gastro- enterostomy may be necessary later, and it may be advisable to perform this at the same time. A gastro-enterostomy has been done as late as six years after cholecystogastrostomy was carried out for carcinoma of the lower end of the common bile-duct. After gastro-enterostomy for this complication of pancreatic cancer, some patients have lived a year or more in comparative comfort. GEORQET. PACK

Pancreatic Tumor with Hypoglycemic Status Epilepticus, T. H. BAST, E. R. SCHMIDT,AND E. L. SEVRINQHAUS.Acta chir. Scandinav. 71: 82-102, 1932. A man forty-four years of age had suffered for two years from frequent convulsions. He was often stuporous in the early morning and always improved after breakfast. Examination of the blood showed the sugar to be less than 40 mg. per cent, and the diagnosis of a hypoglycemic origin for the convulsive state and coma due to a pancreatic adenoma was made. Improvement was marked after intravenous administration of glucose, and operation was advised. A tumor one inch in diameter was removed from the tail of the pancreas. It was firm, encapsulated, and calcified at the center. Histologic study showed the growth to be composed mainly of cells with a granular cytoplaflm, resembling the granules of duct cells, and only occasional island cells. The invasive tendency auggested that the tumor had passed beyond the stage of an adenoma and should be classified as a carcinoma. Studies of the blood sugar following operation show an increasing tolerance for sugar. However, the low levels suggest that the hyperinsulinism was not altogether checked by removal of the tumor and that a return of the symptoms at a later date, due probably to B diffuse process in the pancreas, is likely. No evidence of confusion or hypoglycemia was seen in the patient during the second month after operation, which is the last observation reported. The article is illustrated by photographs of the gross specimen and photomicrographs. BENJAMINR. SHORE

Two Cases of Huge Multilocular Cysts of the Pancreas, J. M. BERKMANAND E. G. BANNICK. Proc. Staff Meet., Mayo Clin. 8: 185-188, 1933. Huge multilocular pancreatic cysts may occur in various positions in the upper abdomen and present great difficulties in diagnosis. A previous history of chole- cystitis or pancreatitis may be of diagnostic aid. A malignant tumor may be suspected preoperatively and may not readily be excluded at operation. Because of the possibility of malignancy, the poor general condition of the patient, and the apparently high surgical risk, the outlook often seems quite hopeless, but the patient should be given the benefit of exploration. The results of drainage of 226 ABSTRACTS these pancreatic cysts are often very satisfactory, even though extensive destruction of the pancreas has taken place. GEORGET. PACK

LIVER AND BILIARY TRACT Primary Carcinoma of the Liver, J. F. BRIGGB. Minnesota Med. 16: 230-234, 1!)33. nriggs reports two cases of primary carcinoma of the liver of the hepatoma type. The hepatomas are more frequent in males and occur chiefly in the fourth decade. There are no pathognomonic signs of this tumor, as the history may suggest cirrhosis of the liver or gastric or gallbladder disease. Jaundice occurs in 61 per cent of cases and ascites in 59 per cent. The diagnosis is made by the process of elimination, as the condition must be differentiated from other diseases of the liver such as syphilis, amyloid degeneration, echinococcus cyst, cirrhosis, pylephlebitis, liver abscess, and secondary or metastatic carcinomas. The length of life is seldom longer than six months. The hepatomas are grossly classified into three types, nodular, massive, and diffuse. GEORGET. PACK Case of Hydropericardium from Multiple Cardiac Metastases of Primary Liver Carcinoma, Y. JONOAND K. MATBUOKA.Ein Fall von Hydroperikard aus der multipleri Herametastase vom primaren Leberkarainam, J. Oriental Med. 19: 115-121, 1933. A report of a primary tumor of the liver in a man thirty-two years of age, who died of cardiac failure caused by hydropericardium and ascites. From clinical and pathological findings this tumor was diagnosed as a primary bile-duct carcinoma of the liver. It was associated with a massive pericardial effusion from the multiple cardiac metastases. K. SUGIURA White Stool and Painless Jaundice in Metastatic Carcinoma of the Liver, P. MERKLEN.Selles blanches, Presse m6d. 41 : 41-42, 1933. A woman of sixty showed symptoms of retention jaundice, first noticed a few months before admission to the hospital. For two weeks the stool had been greasy and white. There was a hard tumor of the left breast, without enlargement of axillary nodes but with increase in size of the liver. Death occurred a few weeks later, and autopsy confirmed the clinical diagnosis of primary scirrhous carcinoma of the breast with metastases in the liver; the biliary passages and the pancreas were free from invasion. F. CAVERS

Primary Carcinoma of Intrahepatic Bile Ducts, L. W. JOHNSONAND W. W. HALL. U. 5. Naval M. Bull. 31: 31-33, 1933. A fifty-four-year-old man complained of progressive painless jaundice of five weeks’ duration. The liver was slightly enlarged but was not irregular nor tender. The differential diagnosis was between chronic pancreatitis, carcinoma of the head of the pancreas, carcinoma of the Vaterian ampulla, and a silent stone in the common bile-duct. At autopsy the biliary obstruction was found to be due to biliary cirrhosis with gradual constriction of the tributary hepatic bile ducts by a scirrhous carcinoma primary in these intrahepatic ducts. GEORGET. PACK Differential Diagnosis of Cholelithiaeis and Neoplasms, G. LEPEHNE. Zur Differentialdiagnose Cholelithiasis oder Tumor, Deutsche med. Wchnschr. 59: 916-919, 1933. The differential diagnosis between cholelithiasis and carcinoma of the gallbladder and extra-hepatic bile-ducts is made with difficulty and in many cases can be LIVER AND BILIARY TRACT 227 arrived at only after laparotomy. The author has divided his cases into those with and without jaundice and discusses selected cases in each group. BENJAMINR. SHORE

Primary Carcinoma of the Gallbladder, BERQERET,BRODIN AND A. R. SALMON. Un cas de cancer primitif de la v6sicule biliaire avec lithiase, Arch. d. mal. de l’app. digestif 23: 105-109, 1933. A woman of fifty-two, previously in good health, suddenly felt severe epigastric pain radiating to the spine. She had had no vomiting, constipation, or diarrhea. A hard, tender tumor was felt below the edge of the liver. X-ray examination showed several biliary calculi below the tumor. At operation the gallbladder was removed, with several enlarged nodes at the hepatic hilus, also part of the liver near the tumor. The patient died three months after operation; autopsy was not permitted. The tumor was a scirrhous cylinder-cell carcinoma. The authors have reported the case because it shows that a gallbladder cancer may grow to such an extent as to be palpable and to have produced metastases in the adjacent lymph nodes and liver, and yet give rise only to late symptoms of biliary colic. There are three illustrations. F. CAVERS

Case of Squamous-cell Epithelioma of the Gallbladder, RUBENA. GARCIAAND VICENTEN. GARCIA.Un caso epitelioma espinocelular de la vesfcula biliar, Repert. d. med. y cir. 23: 231-235, 1932. A jaundiced female of sixty, with clay-colored stools and a firm, tender tumor mass in the right upper quadrant of the abdomen, died two weeks after admission to the hospital. At autopsy the stomach was found to be dilated and to contain an ecchymotic area on the serosal surface of the greater curvature. The mucosal surface of this latter region contained large areas of destroyed and ulcerated mucosa. The gallbladder was completely surrounded by adhesions; its walls were thickened and it contained numerous stones. No other definite abnormalities were noted. The authors describe the process histologically as a squamous-cell carcinoma of the gallbladder (due to a metaplasia of the mucosa) with metastases to the stomach. There are no photomicrographs, and the histologic findings are meagerly described. There is no bibliography. JOHN E. WIRTH

Anatomo-pathological Contribution to the Study of Carcinoma of the Ampulla of Vater, FRANcESCOMOLFINO. Contributo anatomopatologico allo studio del carcinoma della papilla di Vater, Pathologica 25: 158-165, 1933. The author reviews the literature, discussing the histological structure, pathogenesis, and clinical results of tumor of the ampulla of Vater, and gives a detailed autopsy report of a case. The patient was icteric and marasmic. A small carcinoma of the ampulla of Vater was found, centrally ulcerated, with undermined edges. There were periduodenal infiltration, stenosis ‘of the bile and pancreatic ducts, suppurative cholangeitis, and numerous hepatic metastases. The histologic picture was that of adenocarcinoma probably derived from the intestinal mucosa. JEANNETTEMUNRO

Cancer of the Ampulla of Vater with the Symptoms of Gallstones, N. FIESSINQER. La forme pseudo-lithiasique du cancer de l’ampoule de Vater, Rev. g6n. de clin. et de th6rap. 46: 529-531, 1932. A woman fifty years of age had had repeated attacks of severe biliary colic for seven months, with digestive disturbances and a low degree of jaundice in the 228 ABSTRACTS intervals; the gallbladder was tender on pressure. The radiological examination showed no stones in the common bileduct. The patient refused operation and died. At autopsy a cancer of the ampulla of Vater was found, but there were no node or liver metastases.

Carcinoma of the Papilla of Vater, J. M. GODFREYAND S. W. SAPPINOTON.Hahne- mannian Monthly 67: 337-341, 1932. A man of seventy, with symptoms for ten months, presented the classic picture of carcinoma of the ampulla of Vater, namely jaundice, acholic stools, distended gallbladder without stones, but no metastases. About seven weeks after the onset of symptoms a diagnosis of possible pancreatic carcinoma was made and operation waR done. The ampulla of Vater was described at that time as not blocked with stone, but no further comment was made. The diagnosis was cirrhosis of the liver and ascites. Autopsy showed the papilla of Vater enlarged, indurated, and protruding into the duodenum as a definite knob 12 x 12 mm. Microscopic examination showed carcinoma apparently arising from the ducts or ampulla.

PERITONEAL AND RETROPERITONEAL TUMORS, MESENTERIC CYSTS Pseudomyxoma, HANSGANQL. Zur Pseudomyxomfrage. Deutsche Ztschr. f. Chir. 240: 788-790, 1933. The author reports the case of a forty-eight-year-old man with a pseudomyxom- atous process of the peritoneal cavity. It apparently arose in an acutely inflamed ruptured appendix which was not the seat of a mucocele. No follow-up of the case is given, and there are no illustrations. BENJAMINR. SHORE

“ Pormes frustes ” of Endothelioma of the Peritoneum in Gynecology, L. FIRRAO. Le forme fruste dell’ endotelioma peritoneale nel campo ginecologico, Poli- olinico (sez. chir.) 39: 141-154, 1932. The author presents an elaborate and specious classification of “ mesothe- liornas ” arising from the peritoneum. In one case which he describes he found at operation an extensive pelvic tumor of undeterminable origin and widespread peritoneal metastases. Three biopsy specimens removed at the time from the cul-de-sac, an adnexal maas, and from a peritoneal nodule, respectively, showed different histological pictures. To judge from the photomicrographs which the author presents these represent carcinoma, possibly of ovarian origin. The author, however, believes that they are three different forms of (I mesotheliome.” C. D. HAAQENSEN Case of Retroperitoneal Teratoma, with Limited Carcinomatous Change, M. WATANABE.uber einen Fall von retroperitonealem, teilweise krebsig entarte- tem Teratom, Okayama-Igakkai-Zasshi 45; 687-688, 1933. ,4 child of two years had a tumor in the retroperitoneal tissues of the left kidney region, which had no relation to either testis. The tumor weighed 660 grams and was rough and irregularly oval in shape. The cut surface showed many cysts of various sizes. Histologic examination revealed a tridermal teratoma with cancerous change. Metastases were found in the liver and pancreas. Micro- scopic study of the metastases revealed mainly degenerated carcinoma simplex and adenocarcinoma K. SUQIURA THE SPLEEN 229

Lymphosarcoma of the Mesentery, C. M. PINTOSAND J. J. MURTAQH. Linfo- sarcoma de mesenterio, Semana m6d. 2: 1531-1535, 1932. A female infant of two and a half years had apparently been in good health until two months before admission, when she lost appetite and became increasingly yellow, with rapid enlargement of the abdomen. After admission the child was apathetic and somnolent; she vomited food and bile, and the.skin and mucosae took on a greenish hue. The abdomen was tense and painful on touch, especially in the right lower quadrant, where there was a hard mass; smaller nodules were palpated also in other parts of the abdomen. Death occurred five days after admission. Autopsy showed enlargement of the mesenteric lymph nodes, with invasion of various organs; the histologic features were t,hose of lymphosarcoma. There are four' illustrations. F. CAVERS Mesenteric Cysts in Infancy, ANDROMARTIN. Kystes du mesentere chez le nourrisson, Semaine d. hbp. de Paris 8: 323-325, 1932. Tumors of the mesentery are usually observed in adolescence or early adult life. The majority are congenital and manifest themselves relatively late. Mar- tin's patient was a male infant aged eighteen months, whose abdomen was distended by a cystic mass extending from beneath the left costal margin to the umbilicus. At operation a pedunculated, multilocular mesenteric cyst was discovered and easily removed. Histologic study of a portion of the cyst wall revealed a lymphan- giomatous structure. WILLIAMJ. HOFFMAN

THE SPLEEN Primary Sarcoma of the Spleen with Metastasis to Pleura and Lung, J. PARAF AND A. AB~ZA.Splenome h metastases pleuro-pulmonaires, Bull. et m6m. SOC.m6d. d. hbp. de Paris 49: 480-487, 1933. A girl of sixteen years was sent to hospital with a request from her physician for immediate thoracentesis. She was very pale, with dyspnea and with slight cyanosis of the extremities. There was a large collection of fluid in the left pleural cavity, and the spleen was greatly enlarged. The illness had begun three weeks previously with increasing weakness and dyspnea. Aspiration yielded 1500 C.C. of clear yellow fluid; this was followed by injection of 600 C.C. of air, and the patient was much relieved. The exudate contained, per c. mm., 3,800,000 erythrocytes and 17,000 leukocytes, with a practically normal differential count. Death occurred a few days after admission. At autopsy there was found a large amount of left pleural exudate; the right lung was normal, but the left lung contained a nodule about the size of an orange in the lower lobe, and there were similar but smaller nodules in the pleura. These nodules were traced downwards through the diaphragm into the spleen as cords which led through the spleen capsule into a large rounded mass in that organ. The small round cells of the tumor had invaded the reticular tissue of the spleen, of which only traces remained, and had destroyed most of the splenic corpuscles. The authors do not think the tumor cells were of reticulo-endothelial type, for they approximated closely to the mononuclear cells of the spleen pulp. Four illustrations are given. F. CAVERS

Multilocular Cystic Lymphangioma of the Spleen, C. W. MCLAUHGLINAND J. S. P. BECK. Arch. Path. 15: 655-664, 1933. A case is reported of a large non-parasitic cyst of the spleen occurring in a man of forty-two, treated successfully by splenectomy. The specimen weighed 1620 gm., and was made up chiefly of one large trabeculated cyst with two smaller 230 ABSTRACTS groups of cysts on the surface of the organ. The authors conclude that this and similar cysts are neoplastic in origin and can best be classified as cavernous lym- phangiomata. GRAYTWOMBLY

THE FEMALE GENITAL TRACT Every Woman Who Bleeds after the Menopause Has a Cancer of the Uterus, DUCUING.Toute femme qui perd aprhs la m6nopause B un cancer de l’utbrus, Bull. SOC.d’obst. et de gyn6c. 21: 607-612, 1932. In support of the contention heading this article, Ducuing reports a series of 326 cases of postmenopausal vaginal bleeding observed from 1920 to 1931. His clamification of these cases is as follows: 256 cases of cancer of the cervix; 34 caws of cancer of the corpus; 3 cases of cancer of the ovary; 33 conditions other than cancer. The 33 conditions other than cancer were metritis in 23 cases, uterine fibroid in 9, and a cervical polyp in one. In 6 of these supposedly benign cases, however, cancer was subsequently proved to be present. The proportion of malignant cases, therefore] is 299 out of 326 or 92 per cent. If the cases of cancer of the cervix, which are recognizable as a rule by external examination] are eliminated, as well as the 3 cases of cancer of the ovary, then 60 per cent of the remainder were cancer of the corpus. [In the discussion the point is brought out that since these statistics come from an anticancer center, they are obviously weighted with an unusual number of malignancies. The presence of only one case of cervical polyp and no cases of endometrial polyps among 326 cases of postmenopauRa1 bleeding is almost sufficient evidence in itself that this is not an average sample of such cases. Other investigators have found the relative frequency of malignancy in postmenopausal bleeding as follows: Fahmy, 43.12 per cent (J. Obst. & Gynaec. Brit. Emp. 40: 506, 1933); Kantner and Klawans, 68.4 per cent (Am. J. Obst. & Gynec. 24: 192, 1932); Zweifel, 87 per cent (Deutsch. med. Wchnschr. 56: 1388, 1930). HOWARDC. TAYLOR,JR. Diagnosis of Post-Menopausd Metrorrhagias, A. ALBENQUE.Le diagnostic des metrorragies post mthopausiques, Toulouse m6d. 33 : 577-590, 1932. After a general discussion of post-climacteric menorrhagia the author reports the statistics of the Toulouse Anti-cancer Center for the period 1924 to 1931. Of 326 clinic patients, 299 (91 per cent) had cancer; 8 out of every 10 patients complaining of post climacteric bleeding showed cancer. Of the 299 cases, 78 per cent were cervical, 12 per cent corporeal and 0.9 per cent (3 cases) ovarian in origin. The other 27 cases included one cervical polyp, 6 fibromas, and 20 cases of senile endometritis. The fact is emphasized that, excluding the cervix cases, cancer of the corpus occurs in 60 per cent of the remaining patients with metrorrhagia. NELSONB. SACKETT Unusual Gynecological Conditions; Their Diagnosis and Treatment, R. T. FRANK. Surg. Clin. North America 13: 271-294, 1933. In the rarer complications following pregnancy diagnostic curettage is important, with careful investigation of the curettings. This is especially true for the diagnosis of chorionepithelioma. The author advocates biopsy for the diagnosis of lesions of the vulva and cervix, where carcinoma is suspected, and in his opinion exploratory curettage is not harmful. If desired, the electrocautery knife can be used for biopsy. Pathological studies must be carefully made and correlated with clinical findings. THE FEMALE OEXITAL TRACT 23 1

Intravenous Mesothorium Therapy in Female Genital Carcinoma, GUNTHER 8CHAEFER. Die Stellung der intraveposen Mesothortherapie in der Reihe der Heilfaktoren beim weiblichen Genitalkarzinom, Zentralbl. f. Gynak. 56: 1822- 1890, 1932. In this report of the treatment of cancer by mesothorium intravenously, 29 cases are considered, of which 15 were cancer of the cervix, 11 cancer of the ovary, one a malignant ovarian tumor of undetermined type, one a carcinoma of the vagina, and one a carcinoma of the cecum. In all cases the mesothorium injections were given in addition to other methods of therapy, such as operation, radium, or x-rays; the dose amounted to 3 micrograms per C.C. Injections were given, as a rule, about every other day, the total number varying between ten and fifty. In one group were those cases which had previously received radium or x-ray treatment. In 2 of these cases mesothorium appears to have exerted a favorable effect. The injections were very badly borne, however, by all who had received combined radium and x-ray therapy three to six months previously. The second group included those patients, 15 in number, to whom radium or x-ray treatments were given simultaneously with the mesothorium. Untoward results were fewer here than in the first group. In conclusion, the author admits that mesothorium can have only a secondary place in the treatment of female genital carcinoma, for local healing was never attained and improvement of the general condition was observed in only a few cases. In many cases there were definite signs of a general intoxication, such as rise in temperature with chills, vomiting and diarrhea. In three cases bleeding followed the treatment, but whether the mesothorium was responsible cannot be mid with certainty. [The present trend of opinion is against administering any radio-active substance intravenously.] HOWARDC. TAYLOR,JR.

Some Data on Uterine Cancer, NORMANF. MILLER. J. Iowa M. SOC.23: 132- 136, 1933. This is a short paper reviewing statistically 219 consecutive cases of cancer of the female genital tract. Seventy-nine per cent were cancer of the cervix, 11 per cent cancer of the fundus, and 7 per cent cancer of the ovary, while the remaining 12 cases included cancer of the vulva, vagina, and fallopian tubes. The most common and consistent early symptom in cancer of the cervix was bleeding, progressive in amount, prone to follow trauma, and intermenstrual in time. The average amount of time between the onset of symptoms and the seek- ing of medical advice was six months, while a similar average period ensued between the first examination and the first treatment. This is of interest, since in this particular series parametrial involvement was found in about 20 per cent more patients for each month which had elapsed from the onset of symptoms. In cases of carcinoma of the fundus the average time between examination and operation was over two years. No data are given as to results. GRAYTWOMBLY

Some Aspects of Cervical Pathology, G. I. STRACHAN.J. Obst. & Gynaec. Brit. Emp. 40: 460-471, 1933. The author discusses various well known lesions which have been observed in the uterine cervix, as infections, erosions, tears, and leukoplakia, and which have been regarded as possible predisposing causes in cancer development. The paper contains nothing new. There are four illustrations. F. CJVERS

11 232 ABSTRACTS

Frequency of Cancer of the Cervix of the Uterus in Relation to Parity, J. DUCUINO, AXD P. GUILHEM.Frbquence du cancer du col de l’utbrus en fonction de la paritb, Bull. SOC.d’obst. et. de gyn6c. 21: 612-613, 1932. Among 510 patients with cancer of the cervix observed at the Anti-Cancer Center of Toulouse from 1924 to 1931 there were 56 nulliparae and 454 women who had had children. Division of the latter cases into groups according to the number of pregnancies resulted in the following table.

.__- Inter- Major Minor mediate Multi- Parity Primi- Multi- Multi- parae parae parae parae VII and 11, I11 IV v VI more Cancer case...... 100 114 85 49 30 34 42 Percentages...... 22% 43 % 24.8% 9.2%

Comparison of these figures with the incidence of the different degrees of parity in the obstetrical clinic showed that cancer in women of the minor degrees of milltiparity was 2.4 times as frequent as in the primiparae, whereas in the women of the major degrees it was 2.6 times as frequent. It appears, therefore, that an increase in the number of pregnancies does not have a direct effect in increasing the frequency of malignancy. HOWARDC. TAYLOR,JR. Cancer and Irritative Lesions of the Cervix, F. C. BEALL. Texas State J. Med. 28: 8-11, 1932. Erosion and infection rather than laceration of the cervix are the essential etiologic conditions which lead to cancer. The author has given up amputations in favor of cauterization of the cervix. He removes the cervix in hysterectomy case8 only when it is infected, or cauterizes it before the patient leaves the hospital in cases where removal is not feasible. NELSONB. SACKETT

Histological Classification of Cancers of the Uterine Cervix, and the Relation Between Cellular Structure and Prognosis after Radium Treatment, R. G. MALIPHANT.J. Obst. & Gynaec. Brit. Emp. 40: 444-459, 1933. The author has reviewed the histologic preparations belonging to 236 cases of carcinoma of the cervix admitted to the Royal Infirmary, Cardiff, in the past ten years. The cases were taken consecutively, those being omitted in which the material was unsuitable for reliable histologic grading, as in cases with superadded inflammatory or degenerative changes. Setting aside the adenocarcinomas, Schottlaender and Kermauner divided the solid cancers of the cervix according to the degree of anaplasia, into mature, semi-mature, and immature types. The author gives reasons for preferring Martzloff’s grading, which’ is based on the appearance of the individual cells of which the main mass of the tumor is composed. Of the 236 cases, 10 were glandular cancers. In the remaining 226 solid or epidermoid cancers it was possible to recognize the cell types which Martzloff has named spinal, transitional, and spindle. Most of the solid cancers contained all three cell types, only 21 per cent consisting solely of one type; 9.7 per cent of the spinal-cell-and 11.5 of the transitional-cell tumors were pure cell forms, while no pure spindle-cell tumors were found. Classified according to the predominant cell type, 30.9 per cent of the solid tumors belonged to the highly differentiated spinal form. At the other extreme was a small group (13.3 per cent of the cases) in which the tumor consisted of closely packed spindle cells, usually mixed with THE FEMALE GENITAL TRACT 233

small round and polyhedral cells. Between these two extremes was a large inter- mdiate group (55.8 per cent) in which the tumors consisted mainly of transitional cells and showed moderate anaplasia. This class is large because there is a tendency for it to receive all cell types which are not typically spinal or spindle in character. Although the occurrence of cornification could usually be taken as evidence of a mature cancer, pearls were occasionally Reen in immature growths. In a consecutive series of 100 advanced cases it was found that the histologic type which showed the best immediate response to radium (local healing within three months) was the spindle-cell cancer (50 per cent), the radiosensitivity of the other three histologic types being equal (25 per cent each). The more permanent results were shown in 151 cases which had been treated for more than three years at the time of reporting, as follows:

I Early Cases Advanced Cases (Stages I, 11) (Stages 111, IV) Three- Three- Total Cell Typo Canes Year Canes Year Three-Year Treated Survivals Treated Survivals Survivals

Spinal...... 7 z8.6Y0 30 1o.0yo 13.6% Transitional ...... 20 . 30.0% 68 6.0% 11.0% Spindle...... 6 4.0% 10 12.6% 1e.oyo Adenocarcinoma. .... 2 W.O% 6 20.0% 28.0%

TOTAL...... 34 32.40/0 117 8.6%

Clinical Observations of the Stromr Reaction in Carcinoma of the Portio Vaginslis, J. TOYOSHIMA.Jap. J. Obst. & Gynec. 15: 203-205, 1932. A Rtudy has been made of the type of stroma reaction in relation to the clinical findings and operative mortality in 30 cases of carcinoma of the portio vaginalis. All of the patients had squamous-cell epithelioma; in 2 there was dense and in 3 moderately dense eosinophilic infiltration of the stroma; in 6, infiltration mainly of lymphocytes (in one case associated with moderately dense eosinophilic infiltration) ; in 9, dense plasma-cell infiltration (one mixed with eosinophilic infiltration) ; find in 12, only slight cellular infiltration of the stroma. Having compared these findings with the average time from the first hemorrhage to operation, the incidence of cachexia, involvement of lymphatics, and operative mortality, the author concludes that eosinophilic infiltration of the stroma occurs earlier than any other form of cellular infiltration. The carcinomatous invasion is less marked in cases with eosinophilic infiltration than in any other group, and in the author's cases with this type of infiltration there was no operative mortality. Carcinomatous invasion was more intensive and the operative mortality higher in those cases with slight cellular infiltration than in any other group; of the cases with cellular infiltration, the prognosis was the least favorable in those with plasma-cell infiltration.

Biophysical Factors Concerned in the Clinical Course of Carcinoma of the Uterine ' Cervix, F. E. NEEF. Am. J. Surg. 17: 259-269, 1932. The author emphasizes that so far it has not been proved that the atypical proliferations occasionally seen in inflammatory lesions of the cervix can acquire the continued autonomous urowth find cell division which are the keynote of 234 ABSTRACTS malignancy. Nor is it easy to see how the development of malignancy in the cervix can be related to cervical tears, since cancer rarely begins in or near the actual site of injury. There is no direct evidence that ovarian function has a determining influence on the incidence of uterine cancer. On the other hand, cancer is essentially a disease of the tissue-forming cells, not of the formed tissue cells, and it must therefore arise from those cells which, even under physiologic conditions, respond to the call for cell division, or by which the epithelium is normally replaced. The restoration of squamous epithelium takes place primarily from the basal layer, and when there is a coincidence of heterotopia with downward growth and disruption of the basal layer, then extension and metastasis begin and the tissue has become malignant. The author discusses the histologic types of epidermoid carcinoma as to degree of anaplasia, size and shape of tumor cells and interepithelial spaces; the lymphatic drainage of the cervix and upper vaginal segment; the mechanism of extension and metastasis, etc. F. CavBRs

Early Diagnosia of Carcinoma of the Cervix, J. BEATTIE.St. Bartholomew’s Hosp. Rep. 65: 151-176, 1932. The author describes examples of abnormal conditions of the epithelium of the uterine cervix following recent or acute inflammation, erosion, or prolapse, which histologically simulate malignancy. Only in a really well developed case of cervical carcinoma is the histologic diagnosis easily determined. Such advanced cases show ulceration and massive proliferation of solid groups of squamous epithelial cells, which can fairly easily be classified into Broders’ four groups. Most cases show such poor differentiation that the more adult type of cell is rarely represented (group 3 of Brodera); many also fall into the fourth group. The author is mainly concerned with the histologic diagnosis of early cervical carcinoma, and formulates the following rules upon which such a diagnosis must be based. (1) Rapid and abnormal cell division and nuclear mitoses which are not normal in type but are irregular in size and shape must be present. (2) The basal layer of cells, if present, may be many layers thick and have replaced to a greater or less degree the more adult layers of cells present in normal squamous epithelium. (3) There must be infiltration into the atroma. Finally, the stroma reaction is so variable that as a means of diagnosis of malignancy or otherwise it shouId be treated as of no value. The author has employed the Lugol solution test as used by Schiller (Am. J. Cancer 16: abst. p. 643, 1932) and by a few other writers, and believes he is the first English-speaking investigator who has carried out control research on this test. He has examined 200 cases, in 106 of which histologic examination was made of sections taken from the cervix. In 21 cases the findingR were “ possibly positive,” and the patients have been re-examined from time to time. Two case8 of early carcinoma were discovered by this test when there were no clinical signs to suggest malignancy. In one case amputation of the cervix was performed, and serial sections of the removed cervix showed early carcinoma with some local infiltration of stroma. In the second case, in which there was a small papillary erosion, biopsy showed a developed carcinoma which, as in the fir& case, conformed to the three histologic rules and gave a strongly positive Lugol staining, and pan- hysterectomy was performed. Seventeen diagnostic sections taken from the author’s Lugol-positive material were sent to Vienna for a histologic opinion from Schiller. He returned these with a full histologic description of each, and in only two cases did he claim that a carcinoma was present; these sections were from the two cases which had bden subRequently proved to be true carcinomas. The author believes that the results obtained with the Lugol test, though somewhat disappointing, justify its further trial, combined with biopsy. He has already re-examined several of the patients, THE FEMALE GENITAL TRACT 235 and intends to continue the investigation until at least 400 cases have been examined and, where considered advisable, followed up closely. There are thirteen excellent photomicrographs and several diagrams. F. CAVERS

Early Diagnosis of Carcinoma of the Cervix, C. G. THOMAS.J. IOWAM. SOC. 22: 528-529, 1932. While there is no pathognomonic symptom, irregular vaginal bleeding and unusual vaginal discharge in parous women of early middle life should incite a suspicion of cancer until histologic evidence has proved the contrary. In the concealed inverted type the only finding may be a sense of induration and a retraction of the cervical lip about the external 0s. Only the microscope can successfully distinguish between cancer and (1) ectropion with erosion and granuloma, (2) ulceration in a prolapsed uterus, (3) polyps with necrosis or bleeding, (4) induration due to nabothian cysts, (5) uterine and cervical myomata, (6) sarcoma of the cervix, (7) gonococcal condylomata, syphilis, chancroid, and tuberculosis. NELSONB. SACKETT

Early Diagnosis of Cancer of the Cervix, W. P. GRAVES. Clin. Med. & Surg. 39: 853, 1932. Graves describes the method of Schiller for the early diagnosis of carcinoma of the cervix and recommends a colposcope for the study of the unstained areas. If there is any doubt as to diagnosis, tissue for biopsy should be obtained with a sharp curet.

Carcinoma of the Cervix of the Uterus after Previous Amputation of the Corpus, K. BENDS. Uber Karzinom des Collum uteri nach vorausgegangener Kor- pusamputation, Monatschr. f. Geburtsh. u. Gyniik. 91 : 79-84, 1932. In the Cologne University Clinic from 1925 to 1930 there were observed 515 cases of cancer of the cervix, of which 7 were cancer of the cervical stump remaining after supravaginal hysterectomy. The conditions for which previous operation had been done in these 7 cases were as follows: fibroids (3 cases), tubo-ovarian cyst, inflammation of the adnexa, interruption of pregnancy, and one unknown cause. The interval between the earlier operation and the diagnosis of cervical cancer varied from nine months to eighteen years. Of the 7 cases, 2 were classed as operable, 3 as borderline, and 2 as inoperable. The histologic structure was of the squamous type in 6 cases and of the glandular in one case. The treatment is the same as for other types of cervical carcinoma. In the writer’s clinic radium is given and four to six weeks later the case is reviewed and operation considered. Two of the 7 cases of the present group were operated upon, each by the vaginal technic. No technical difficulties were encountered except in the separation of the bladder from the top of the cervical stump. Of the 7 patients, 2 are already dead, 1 has a recurrence, while 4 are still living, 2 of these having been treated by operation and 2 by radiation only. HOWARDC. TAYLOR,JR.

Pyloric Stenosis Caused by Cancerous Adenopathy Secondary to Uterine Carci- noma Removed Nine Years Previously, LACOUTUREAND POUYANNE.Stbnose du pylore par nboplasme ganglionnaire secondaire A un cancer du col utbrin gubri chirurgicalement depuis neuf ans. Gastro-entbrostomie, J. de mbd. de Bordeaux 109: 725, 1932. A woman of fifty-seven had symptoms of six months’ duration: loss of appetite, vomiting after food, increasing constipation, and gradual loss of strength and weight. The stomach was greatly dilated; x-rays showed that the greater part of 236 ABSTBACTS a barium meal remained in the stomach seven hour8 after ingestion, but no filling defect was detected. An old, healed midline Iaparotomy scar was noticed, and it was learned that the patient had been radically operated upon nine years previously for cervical cancer. There were no signs of local recurrence or palpable metastases. Operation, on a diagnosis of probable pyloric tumor, showed that the stomach was normal, but was pushed forward by an enormous hard lobulated retroperitoneal mass, apparently consisting of enlarged and coalescent lymph nodes, and obviously inoperable. Posterior transmesocolic gastro-enterostomy was done, and the patient left the hospital relieved of symptoms. Part of the inass, on histologic examination, showed features considered characteristic of carcinoma of the uterine cervix. There are no illustrations. F. CAVERS

Case of Carcinoma of the Body of the Uterus with Unusual Clinical Features, A. A. GEMMELL.Liverpool Med-Chir. J. (pt. 1) 41: 118-120, 1933. At operation for bleeding piles on a woman of forty-seven, a purulent discharge from the vagina was observed. The patient stated that menstruation had ceased a year previously, but that for two years before that, and also during the past year, she had noticed a continuous ‘‘ discharge ” and occasional passage of clots. The discharge persisted despite vaginal douching with various antiseptics. At the second of two curettings the intra-uterine material showed malignant tissue, and hysterectomy was done. An adenocarcinoma of undifferentiated type was found in the posterior wall of the uterus and a similar smaller nodule in the isthmus of the left fallopian tube. At the time of reporting, less than a year after hysterectomy, the woman was well and free from discharge. The postmenopausal bleeding had evidently been anal, not vaginal. The author points out that any discharge, whether or not blood-stained, occurring after the menopause should be suspected as a sign of malignant disease until the contrary is proved; also that if a woman complains of bleeding and proves to have hemorrhoids, the physician should ascertain whether or not there is also a discharge from the vagina. F. CAVERM Necrotic Uterine Fibroma and Carcinoma of the Uterine Body, C. MARTIN. Un cas complexe de fibromes ut6rins nbcrobios6s et d’6pith6liomas de la muqueuse du corps, Rev. franc. d. gynbc. et d’obst. 27: Congrhs 549-551, Dec. 1932. The patient at the age of forty-five years had a large uterine fibroma causing severe bleeding. Treatment with x-rays resulted in cessation of the hemorrhages, and of normal menstruation, and a considerable diminution in the size of the tumor. In a few months a bloody and purulent discharge and attacks of pelvic pain developed, and hysterectomy was done. Examination of the uterus showed notJ only an intramural fibroma, partially necrotic, but also a carcinoma of the body of the uterus.

Carcinoma of the Corpus Invading the Pelvic Bones, PHILIPP. Patientin mit Korpuskarzinom, das in die Beckenknochen eingewachsen ist, Ztschr. f. Geburtsh. u. Gynak. 102: 209-210, 1932. A case is reported of extensive metastatic lesions in the pubis and ischiom, arising from a primary carcinoma of the corpus. The patient had remained in relative health and comfort, a condition characteristic of invasions of the anterior and lateral part of the pelvis and offering a marked contrast to the erosion of the sacrum and vertebra. HOWARDC. TAYLOR,Jrt. THE FEMALE GENITAL TRACT 237

Unusual Metastases of Carcinoma of the Uterus, J. A. KELLY. Surg. Clin. North America 13: 468-471, 1933. A woman forty-three years of age had a lump in the right breast and a growth in the left arm about two years after x-ray treatment for a lesion of the uterine cervix, probably carcinoma. Biopsy showed both the breast and the arm tumors to be carcinoma of identical structure, and both probably metastases from the cervix.

Treatment of Carcinoma of the Cervix Uteri, ROYWARD AND A. J. D. SMITH. Annual Report, Radium Inst. London, 1932, pp. 13-16; 32-35. In the treatment of cervical carcinoma some technical improvements have been made at the Radium Institute. While the intrauterine tube applicators remain the same, the vaginal radiation has been greatly increased in the past year by increasing the secondary screening from 1.0 to 5.0 mm. Thus the vaginal vulcanite spheres are 17 mm. in diameter and contain a cylindrical channel in which is placed the platinum cell 7 mm. in diameter, 7 mm. long, with walls 1.5 mm. thick. Radon glass tubes are inserted in amounts up to 15 millicuries. Another form of applicator is the cylindrical bakelite capsule, again providing 1.5 mm. platinum primary and 5 mm. bakelite secondary screening for the radon. Two forty-eight-hour combined intrauterine and vaginal treatments are given one week apart, but between them a further vaginal application is made forty-eight hours after the first. Thus the total intrauterine dose is 2880 mg. hrs., and the vaginal dose 5,500 to 7,300 mg. hrs. Of 194 cases seen in the four years 1925-1928, two were untreated and 42 untraced. Five-year survivals total 30 cases, giving absolute and relative cure rates of 15.5 and 15.6 per cent. When figured on the 154 traced cases, these rates rise to 19.7 and 19.87 per cent respectively. NELSON€3. SACKETT

Prevention and Treatment in Cervical Uterine Cancer, F. I. SHROYER.Radiology 20: 136-142, 1933. This article consists of a series of vague generalities aiid questionable statements such as the following: “ Immediate operation should never be performed upon any malignant condition. The unfortunate individuals should be put upon a detoxicating diet, with colonic irrigations of two quarts of hot sodium bicarbon- ate solution morning and evening until there is a noticeable softening of the mass and a reduction of the surrounding inflammation.” GRAYTWOMBLY

Cancer of the Uterus, J. A. CLARK.Cancer del utero, Rev. de m6d. y cir. de la Habana 37: 278-314, 1932. This is a general discussion of uterine cancer from the control aspect. The ignorance, indolence, and timidity of the patients, and their late recourse to medical attention are discussed, and emphasis is placed on the lack of medical service in such countries as Russia, China, and Brazil. JOHANNESP. M. VOGELAAR

Experiences with Radiological Treatment of Cancer of the Uterus and the Ovaries, JAMESHEYMAN. Acta radiol. 13: 329-333, 1932. Owing to a number of local conditions, which need not be enumerated here, the Swedish cancer material offers more accurate statistics on the results obtained than that of any other country. The Swedish authorities have long insisted upon the necessity of completeness of figures in enumerating what have been termed “ absolute cures,” in order to make possible comparisons between the results of radiation by different clinics and between the results of radiation and of surgery. The absolute cure rate means the number of patients who are still alive and free 238 ABSTRACTS from symptoms five years after treatment compared to the tota2 number of patients with the same disease who had applied for treatment; in other words, no elimination of inoperable or hopeless patients, but the inclusion of aZ2 the material. The records show that the total number of patients with cancer of the cervix applying to the Radiumhemmet during the thirteen years preceding Jan. 1, 1927, was 1237. Of these, 259 are alive and well, an absolute cure rate of 20 per cent. The ten-year absolute cure rate of those treated from 1914 to 1921 was About 16 per cent, but all patients who died of intercurrent disease are reckoned as having died of cancer, so that while the ten-year figures are interesting, as has recently been pointed out, with the expectation of life being relatively low at forty-five to fifty-five years of age, the five-year cures of cancer ought to be considered very satisfactory by the possessor. Of those who did not survive five years, some 60 per cent were greatly improved and were able to return for a shorter or longer time to their occupations. The number of patients refusing treatment was about 6.5 per cent of all applicants. The basis for such refusal was advanced cachexia, distant metastases, or fistulae. If the cure rate is computed on the basis of the treated cases alone, the percentage rises from 20 to 22. Of the 1157 treated cases, some 73 per cent were inoperable. Of these inoperable and borderline cases the five-year cure rate was 16 per cent; with the operable cases 41 per cent. Almost all these patients were treated by radium inserted into the uterus and vagina. During the last three years additional x-ray or teleradium exposures have been given to the parametria, but as yet it is too soon to draw conclusions. With-the improvement in technic which comes from experience, injuries following treatment are rare. Rectovaginal fistulae are still occasionally produced. A serious aspect of the treatment, however, is mortality from sepsis and embolism, which amounts to about 2 per cent. Heyman differs from most of the other workers in this field in that he treats carcinoma of the body of the uterus with radiation instead of surgery. With 80 cases he has had a five-year cure rate of 42.5 per cent, but he states that in many of his patients the disease is extremely advanced. These figures are considerably better than those obtained at the Curie Institute, which led to a discussion as to technic. The only suggestion which could be made by Heyman was that possibly he used much larger quantities of radium than was the practice at the Institute, and that this may account for the better results. In cancer of the ovaries four groups have to be considered. Of 24 hopelessly inoperable patients, only 2 survived five years. Of 36 patients operated upon but not radically, 22 per cent went five years. Of 28 patients with recurrences after operation, 25 per cent went five years, and of 46 rayed prophylactically after operation, 54 per cent remained alive. In inoperable cases and those incompletely operated upon, a palliative result is often obtained which permits the patient to return to work and which often may be maintained for several years. There is no question as to the value of postoperative prophylactic radiation. It is also probable that surgical intervention should be preceded by radiation. In closing, the writer emphasizes the importance of two things in the successful treatment of cancer of the female pelvic organs: especially organized clinics for the purpose and ample radium and x-rays. Some Aspects of Radiotherapy in Relation to Gynaecology, J. B. KING.Tr. Edinburgh Obst. Soc., pp. 33-43, 1932-1933, in Edinburgh M. J., April 1933. The greater part of this discussion is devoted to the radiotherapy of uterine carcinoma. The author recalls that, although palliative results had been obtained by the use of x-rays in inoperable cases as early as 1902, six years after Roentgen's discovery, their use was thereafter practically abandoned for at least ten years. In 1927 Heyman wrote: " Radiological treatment of cancer of the cervix uteri has, THE FEMALE GENITAL TRAUT 239

since its first searching efforts, scarcely fifteen years behind it. During these years it has fought its way through the difficulties appertaining to the technique of the treatment no less than those of a financial and social order. Many a one who has seen the great expectations of the first few years crumble up has retreated dis- heartened. That is the reason why there are only six clinics that are able today to submit a fairly large number of radiologically treated cases which have been under observation for at least five years.” Since 1927 there has been great activity in the realm of radiotherapy, and in some spheres, though not in that of the uterus, the old story of non-fulfilment of too great expectations is recurring. After referring to recent reports from Munich, Paris, and Stockholm, of 49.5, 56, and 48 per cent five-year cures, the author raises the question why it should be possible to cure 50 per cent of cases and no more, since radiation is not bounded, as is surgery, and the cervix is, by its form, its Rite, and the type of carcinoma to which it is liable, almost ideal for the local application of radium. The problem of the radium treatment of the primary lesion may be regarded as virtually solved. The minor variations of technic now used in different clinics apparently do not matter greatly so long as the cervix receives some 4000 to 5000 mg. hours with suitable filtration, and routine care is taken of the patient. Apparently the patients who die despite radiotherapy are those with infiltration of the parametrium and involvement of nodes not detectable clinically and lying beyond the field which has.been effectively radiated. It is not easy to find accurate statistics relating to this involvement in fairly early cases. Ewing’s collected series of parametrial involvement gives 53 per cent, and it is a striking coincidence that the percentage of five-year cures comes to nearly the same figure. The unsolved difficulty thus seems to consist in the treatment of regional node and parametrial involvement, and the author believes the problem can be attacked only by x-ray therapy. Various reports have shown a rise in the five-year cure percentage when x-rays were used as an adjunct to radium. The question of x-ray technic is largely a physical one. With apparatus giving 200,000 volts, using four fields of application and cross-fire action, it is not possible to get with certainty a dosage lethal to cancer cells at a sufficient depth; but recently machines have been constructed which will give 400,000 volts, and with their use it should be possible to obtain homogeneous radiation throughout the pelvis with every chance of eradication of carcinoma in this region. [See, however, Editorial in Am. J. Cancer 17: 790, 1933.1 The author believes that skin cancer has never developed in patients receiving the highest dosages so far used. It is confined to a very different type of skin reaction, the chronic x-ray dermatitis, which is an occupational lesion following numerous small doses over a long period. The adage “ the minor evil for the major good ” should hold in radiotherapy as in surgery; radiologists are often limited in their dosage by the dread, both on the part of doctor and patient, of the mildest skin reaction, yet no objection is raised to mutilating surgery. F. CAVERS InffsmmAtory Complications of Radium Therapy in Cervical Cancer; Technic of Radium Application, R. BERNARD.Les complications inflammatoires de la curietherapie dans les cancers du col de l’utbrus; technique des applications de radium, Bull. SOC.d’obst. et de gyn6o. 21: 731-741, 1932. Also in Presse m6d. 41: 71-72, 1932, and Gynbcologie 32: 96-99, 1933. In treating cancer of the cervix by radium, by the protracted method, requiring an application of eight days, the customary procedure has been to remove, cleanse, and reinsert the apparatus daily. Bernard, in agreement with Petit-Dutaillis, has arrived at the conclusion that it is better to leave the radium in place during the entireitreatment, since he believes that the rise in temperature is due to the 240 ABSTRACTS trauma of the operation rather than to the radium itself. It has been observed that the temperature and pain following the application occur on the first day and are especially marked if a dilatation of the cervix is necessary. When the radium is removed and reinserted every other day, the temperature often rises on the day of application and falls during the day of rest. When the radium is left in place for eight days, it frequently happens that there is a steady fall in temperature from the beginning to the end of treatment. Bernard has therefore adopted a technic in which the radium is not disturbed. This method, however, requires certain precautions. Irrigations are begun with Dakin's solution several days before the radium iR inserted, and exuberant growth is treated by electroooagulation. When the application is made, two small drains are placed to the vaginal vault, and these are irrigated daily. Packing is changed each day, but the radium itself is not removed. By this method Bernard believes that he has eliminated trauma to a large extent and has reduced the incidence of inflammatory complications. Where there is the special complicating infla.mmation found in a definite salpingitis, the adnexa should first be removed by a surgical operation and the radium treatment of the cervix then carried out in the usual fashion. Following presentation of this paper, Madame Simone Labord discussed the infectious organisms cultured in 70 cases of cancer of the cervix and emphasized the r8le played by the enterostreptococcus, the anaerobic streptococcus, and Bacillus perfringens. Reference was made, also, to the viruIence test of Ruge and Philipp and the possibility of an increased virulence resulting from radium treatment. A diminution in the risk from infection is not, in Madame Labord's opinion, obtainable by any local treatment suoh as the cautery, and vaccine therapy has not been very successful. Some hope is found, however, in the preliminary we of radium on the outside of the cervix and in the use of x-rays externally, When inflammatory complications are especially to be feared, a preliminary dilatation may be carried out, and the temperature observed for twenty-four hours before radium is applied. Petit-Dutaillie also took part in the discussion, speaking in favor of the surgical preparation for radium treatment by curetting and cauteridng growths. These procedures, in hie opinion, decrease infection, decrease the intoxication from tissue to be destroyed by radium, and allow a more efficient application nearer the periphery of the growth. HOWARDC. TAYLOR,JR.

Pelpic Irradiation in Cancer of the Cervix, PALMERFINDLEY. Arch, Physical Therapy 13: 405-406, 1932. After commenting on the variety of procedures, surgical and radiotherapeutic, favored by different authorities for cervical carcinoma, the author expresses his own preference for irradiation alone.

Results of Radium Therapy of Uterine Cancer, A. OSTR~IL.Les r6sultat.r de le radiumthbrapie du cancer utbrin, Gas. m6d. de France (Supp. radiol.), pp. 145-148, Jan. 15, 1932. At the Second Gynecological Clinic in Prague, cervical cancers are grouped according to the League of Nations classification and treated by radium. After chloramine douches, excochleation, and cauterization of the cervix, the radium is given in a tandem of three tubes placed in the uterocervical canal. The middle tube contains 20 mg. and the others 10 mg. each. A 10 mg. applicator is placed in each vaginal fornix. One hundred hours gives a dose of 6,000 mg. hours. During the period in which this method of preparing the patient for the radium treatment has been used, pelvic peritonitis has not developed in a single caw. THE FEMALE GENITAL TRACT 24 1

During the past five years the author has also injected an oil emulsion of silver, tungsten, and radon into the parametria and uterosacral regions. Class 11, 111, and IV cases also receive a roentgen treatment to each of four pelvic fields, each field receiving 750 r. Five-year cures are reported in 7 out of 16 class I11 and IV cases, and in one of the two class I and I1 cases treated. C. I). HAAQENSEN

Late Recurrence after Radium Treatment of Cancer of the Uterus, W. KOLDE. Uber 8p:itrezidive bei Strahlenbehandlung des Gebarmutterkrebses, Mo- natschr. f. Geburtsh. u. Gyniik. 91 : 214-224, 1932. Reference is made to numerous cases in the literature in which late recurrences were observed after treatment of uterine cancer with radium or mesothorium Several new cases of this type are reported, one of particular interest being the case of a woman who developed cancer of the body of the uterus seventeen years after treatment of a precancerous condition by mesothorium. Kolde considers that these late recurrences represent a special disadvantage of radium treatment. He discusses, also, a second difficulty in radium treatment, namely the problem of determining when a primary cure has been obtained, due to the similarity of residual tumor tissue to radiation fibrosis. HOWARDC. TAYLOR,JR.

Radical Hysterectomy with Bladder Extirpation in Uterine Carcinoma, SERDUKOFF AND LEVITSKIYA. I)e l’utilitb de l’hyst6rectomie radicale au cours du cancer de l’utbrus avec l’extirpation de la vessie et transplantation des urethres dans le gros intestin, Cancer, Bruxelles 9: 248-261, 1932. The authors state that owing to lack of radium or mesothorium at the pediatric and gynecologic institute in Moscow, they have operated in many cases of uterine cancer which would otherwise be considered inoperable. Since 1924 operation has been done in 80 out of 97 cases admitted (82.4 per cent). Except in early cases, radical hysterectomy has been done, with resection of the bladder and transplantation of the ureters into the sigmoid colon, as a routine method. The sole contra- indications to the latter procedure have been nephritis, pyelitis, and metastases to the rectum or to distant organs. Operation is preceded by injection of B. coli vaccine, antigangrene serum, and Besredka antivirus, with curettage and cauterization of the cervix. Notes are given on seven cases, in two of which the bladder was resected and the ureters were transplanted. Two of the patients are said to show complete cure, with ability to resume work, though one survived only six months and the other just over a year after operation; four (including the two subjected to the extended opera tion) died of postoperative peritonitis; and the remaining patient, who had carcinoma of the ureter and bladder following an earlier operation for cervical cancer, died before the intended second operation was done. [The authors claim to have obtained 30 per cent “ good results,” laying strem on ability to resume work, but they give no information regarding the after-history of the remainder of their 80 operated cases.] F. CAVERS

Mikulicz Drainage in Operation for Cancer of the Uterus, H. ALCORTA.A propos du drainage de Mikulicz dans l’opbration du cancer utbrin, Rev. franp. d. gynbc et d’obst. 27: Congrhs 564-566, December 1932. Prior to the year 1924 the writer had a high postoperative mortality in total abdominal hysterectomy. After 1924 he employed the Mikulicz drain in all such operations except where the procedure was absolutely uncomplicated and of short duration, and peritonealization was perfect, With this technic 44 total hysterec- tomies for uterine cancer have been done, with only 3 deaths, a mortality of 2.56 per cent, as compared with an earlier 85.5 per cent. To combat infection, such 242 ABSTRACTS measures are advocated as preoperative vaccination and treatment to build up the patient’s resistance ; diathermic coagulation of the cancerous cervix, and more complete peritonealization by the use of a second row of sutures according to the Opitz technic.

Criticism of the Operative Result 8 in Cervical Carcinoma as Reported by Schniz, E. VON SCHUBERT.Zur Beurteilung der Operationsresultate des Zervixkar- zinoms durch Schinz, Strahlentherapie 46: 780-781, 1933. Schinz has recently reported (Strahlentherapie 46: 7, 1933. Abst. in Am. J. Cancer 19: 881, 1933) comparative results of surgery and radiotherapy in cancer of various organs based on his own statistics and an extensive literary survey. He classifies malignant tumors as to suitability for surgery or radiation treatment or a combination of both. In carcinoma of the cervix he bases his conclusions on a comparison of results in 380 cases treated with radium at the Radium Institute in Paris and 90 cases treated surgically by Faure at the Broca Hospital. The author maintains that this is not a fair comparison, first, because of the discrepancy in the total number of cases in the two series; and secondly because, while the Radium Institute’s results are unusually good, those of Faure are not as good as those reported by other surgeons. Thus Weibel’s statistics (Arch. f. Gynak. 135: 1, 1928) for the Wertheim operation in 1500 cases of cervical carcinoma show a lower operative mortality than that of Faure, and a higher percentage of five-year cures-40 per cent as compared with 33 per cent, and 56 per cent for stage I cases as compared with 40.7 per cent. Schinz has also made an error in calculating percentages in the statistics he did use, giving 24 per cent for five-year cures by operation and 87 per cent cures by radium in stage I, while the percentages should be 40.7 and 79.3 per cent. The author maintains that the radium treatment of cervical carcinoma is so well established that it is not necessary to defend it by such comparative statistics as those given by Schinz. Operative Complication in a case of Cancer of the Uterus, A. LORCARUIZ. Com- plicaci6n paraoperatoria en un caso de chcer uterino, Rev. de cir. de Barce- lona 3: 555-558, 1932. A forty-year-old woman, pregnant seven times, had been suffering during the past year from menorrhagia and metrorrhagia. Examination revealed an extensive carcinoma of the cervix, vagina, and labia. A Wertheim operation was performed, but the patient died on the fifth day. Autopsy revealed that two loops of the small intestine were surrounded by masses of fibrin and immobilized, apparently causing an ileus and localized peritonitis. JOHANNESP. M. VOQELAAR Some Practical Points in Prevention of Cancer of the Cervix, IVANPROCTER. Southern Med. & Surg. 94: 507-512, 1932. The North Carolina Board of Health Cancer Bulletin is authority for the statement that 300 to 400 women in that state die each year from cancer of the uterus, 80 per cent from cancer of the cervix. Reduction of this mortality depends upon accurate diagnosis in the initial stage and on cure of the lesions which precede cancer. Diagnosis is aided by Hinselmann’s kolposcope and the iodine test, and is decided by a biopsy. Eradication of precancerous lesions assumes examination six weeks post partum and later semiannually, by competent gynecolo- gists, repair of gross lacerations at the time of delivery, cauterization, and excochleation or amputation of diseased cervices. NELSONB. SACKETT THE FEMALE QENITAL TRACT 243

Conservative Treatment in Gynecology with Special Reference to Cancer, ARTHUR L. BROWN. Amer. Med. 38: (n.s. 27): 252-255, 1932. This article has to do solely with endocervicitis and its treatment. Sarcoma of the Utcrus, G. POUCHET.Un cas de sarcome pour de’l’utbrus, Bull. SOC.d’obst. et de gyn6c. 21 : 620-623, 1932. A patient of fifty-four years was examined twenty months after the menopause on account of several attacks of uterine bleeding. The uterus was enlarged, the cervix dilated and thinned out by a mass of grayish, discharging tissue. Biopsy led to a diagnosis of interstitial hyperplastic metritis without malignancy. A total hysterectomy was, however, performed. Higher up in the cavity and quite inaccessible to the curet was a second tumor which examination showed to be a sarcoma. The patient died one year later in spite of x-ray therapy. The case illustrates, in the author’s opinion, the limitation of diagnosis by curettage. HOWARDC. TAYLOR,JR.

Case of Chorionepithelioma, RAZEMONAND BOURY. Un cas de chorio-6pith6liome Bull. SOC.d’obst et de gyn6c. 21: 472-474, 1932. A forty-two-year-old married woman, never pregnant, came under observation for a two-and-a-half-months period of irregular bleeding terminated by a severe hemorrhage. Since the uterus was large and the external 0s somewhat open, a diagnosis of abortion and fibroid was made and a curettage was performed, but no examination of the tissue was undertaken. In spite of temporary improvement, the bleeding recurred and a hysterectomy was performed some weeks later. The gross examination showed a small fibroid in the anterior wall with a diffuse tumor below it. The histologic structure lay between chorionepithelioma and destructive mole, for syncytial cells were not found invading the wall of the uterus. The patient was clinically well four months after treatment and the Brouha test for anterior pituitary hormone was negative. HOWARDC. TAYLOR,JR.

Benign New Growths, F. C. WALKER. Med. Arts 35: 429-433, 1932. A general discussion of uterine fibromyoma and benign cystic tumors of the ovaries, without illustratione or case reports. Treatment of the Adnexa in Operations for Benign Tumors of the Uterus, C. DE FERMO.Sul trattamento degli annessi nella cura operatoria di tumori benigni dell’utero, Boll. e mem. SOC.piemontese di chir. 2: 1494-1506, 1932. This is a plea for conservation of the ovaries in hysterectomy. NELSONB. SACKETT Lipomata of the Uterus, with Report of a Case, F. B. LUND. New England J. Med. 208: 536-537, 1933. Lipoma of the uterus usually occurs at an advanced age; it is usually intramural and subserous, but may project into the cavity of the uterus. These tumors are benign, both histologically and clinically; only one case with sarcomatous degeneration has been reported. The author’s patient was a woman seventy- one years of age, with a large fluctuating tumor in the right lower quadrant and symptoms of appendices1 abscess. At operation a soft fluctuating uterus with atrophic cervix was removed. The tumor was intramural and encapsulated; on section it was of uniform structure resembling adult fat. 244 ABSTRACTS

Dependence of Menopausal Symptoms Upon the Type of Radiation in the Roent- gen Therapy of Myomas, L. GUSTAFSSON.Uber die Abhiingigkeit der kli- makterischen Erscheinungen von der Art der Bestrahlung bei der Myome, Monatschr. f. Geburtsh. u. Gynak. 91 : 238-250, 1932. From 1926 to 1930, 250 cases of myoma and metrorrhagia were treated, under the author’s direction, with x-rays according to the technic of Seitr and Wintz. The voltages amounted, in three different groups, to 180 kv., 155 kv. and 107 kv. respectively. In practically all cases complete control of bleeding was obtained. It was noteworthy, however, that in the group of cases treated by the lower- voltage machine menopausal symptoms were distinctly more frequent and more marked. This Gustafsson attributes to the necessary increase in the size of the field and unavoidable radiation of structures around the ovary. The x-ray dosage should be the least amount which will cause a cessation of the bleeding. More than 34 to 35 per cent of a skin erythema to the ovary causes not only a cessation of the menses but also a complete atrophy of the ovaries and distressing symptoms. On the other hand, with a dose amounting to less than 26 to 28 per cent of a skin erythema, the effect on the ovary is only temporary. Doses limited to 150 to 190 R units are within the range in which menstruation iR stopped and the interstitial gland suffers the least injury. The dose to the ovary for high-voltage radiation averages 175 R units. HOWARDC. TAYLOR,JR. Fibroid8 and &Rays: Some Unfortunate Instances of Radiation Treatment of Pelvic Tumors Incorrectly Diagnosed as Fibroid, R. BERNARD.Fibromes et rayons X; quelque cas malheureux de radiothhrapie sur des tumeurs pelviennes prisea h tort pour des fibromes, Bull. SOC.d’obst. et de gynhc. 21: 394-399, 1932. Seven cases are reported in which x-ray treatment was given incorrectly on account of a supposed fibroid of the uterus. These cases were a unilocular cyst, 2 encysted hematoceles, 2 carcinomas of the corpus, a dermoid, and a fibroid associated with carcinoma of the ovary. In two of these cases a previously unnecessary hysterectomy had to be performed and in three radical surgical treatment of. a pelvic cancer was delayed. The disadvantages of the radiation treatment of pelvic tumors are summed up ‘as follows: (1) a lopger time is required; (2) an artificial menopause is produced; (3) if an operation becomes necessary it may be more difficult on account of adhesions; (4) there is a distinct danger of erroneous diagnosis of a fibroid for a malignant condition. Surgery, then, should be employed in all doubtful conditions and should be adopted at once if the apparent fibroid does not diminish rapidly in size. In discussion Siredey reported the case of a young woman, married for twenty- one months, who, although actually pregnant, was radiated for amenorrhea in the hope of stimulating supposedly inactive ovaries. HOWARDC. TAYLOR,JR.

Diathermy of the Pituitary Body in Uterine Congestion; Its Application in the Diagnosis and Treatment of Fibromas, M. FERRIER.Action de la diathermie hypophysaire sur la congestion uthrine. Son application au diagnostic et au traitement des fibromes, Bull. de 1’Acad. de mhd., Paris 109: 411-414, 1933. The author reports the application of diathermy to the pituitary for its effect upon uterine congestion and fibromas. Thirty-one patients with menorrhagia have been treated by this method, in all but one of whom menstruation became normal. Eighteen fibromyomata were definitely reduced in size; in 8 cases the tumor remained large, necessitating surgical or irradiation treatment. THE FEMALE OENITAL TRACT 245

Opermtion for Myoma during Pregamcy, A. MAYER. Vber Myomoperationen in der Schwangerschaft, Zentralbl. f. Gynak. 56: 1922-1925, 1932. For uterine myomas in the presence of pregnancy three courses are open. (1) The avoidance of all active treatment will, in many cmes, permit the pregnancy to continue to a normal spontaneous delivery. Should this course be followed and the myoma offer obstruction to labor, the delivery may be accomplished by cesarean section. (2) The second method leaves the fetus entirely out of Consideration, and consists in hysterectomy. (3) The third method, consisting in myomectomy, takes into consideration the interest of both mother and child. Mayer reports that in 13 recent myomectomies during pregnancy, he has had no deaths and only one resultant abortion. He emphasises the necessity of careful handling and believes that the danger of Btimulating contraction is less in the earlier months. HOWARDC. TAYLOR,JR. Gigantic Fibromyoma of the Uterus, R. CHIAROLANZA.Miofibroma gigante dell'utero, Boll. e mem. d. SOC.piemontese d. chir. 2: 1005-1006, 1932. The author removed a 19.5 kg. tumor from a forty-year-old woman weighing 57 kg. There was some cystic degeneration. NELSONB. SACKETT

Fibromyorrm of the Cervix Uteri, Y. IKEDAAND K. IKEDA. Zur Ksauistik der Fibromyome der Portio vag. uteri, Japanese J. Obst. & Gynec. 15: 184-186, 1932. A woman of fifty-two years came for treatment on account of metrorrhagia. A tumor could be palpated on the vaginal wall, and R preoperative diagnosis of carcinoma of the cervix was made. The tumor was completely extirpated and found to be a fibromyoma. K. SUQIURA

Mmidve Intrrperitonerl Hemorrhage from Ruptured Subaerous Veins on the Surface of Uterine Fibroids, ALBERTA. SHAPIRAAND ARNOLDSTARR. New England J. M. 207: 827-829, 1932. Two cases are reported in which alarming intra-abdominal hemorrhage nc- curred 8s a result of the rupture of subserous varices on the surface of uterine fibroids. Hysterectomy was done in both cases with good results.

Intraperitoned Hemorrhage Following Rupture of m Bloodvessel on a Uterine Fibroid, V. NEBBMANNAND 8. TASBOVATZ.Hhorragie intrapbriton6ale par rupture vasculaire sur un fibrome utCrin, Bull. SOC.d'obst. et de gyn6c. 21: 406411, 1932. Also in Strasbourg mCd. 92: 475-477, 1932. A forty-four-year-old woman, having been seized in the middle of the night with sudden pain in the right iliac fossa, radiating to the right shoulder, was operated upon with a diagnosie of acute appendicitis. The first incision showed blood in the peritoneum and a normal appendix. Through a second lower abdominal incision, the uterus was discovered the size of a three months pregnancy; upon its upper pole was a small fibroid nodule, from the summit of which a fine stream of blood was spurting with arterial pulsations. The cause of such rup- tures has usually been assigned to trauma, but in this case, with the onset of symptoms occurring during sleep and the injured vewel being obviously an artery, it is suggested that hypertension, from which the patient suffered, was at leaet a contributing factor. HOWARDC. TAYLOR.,JR. 24G ABSTRAUTS

Edematous Fibromyoma, W. A. MORRISON.Burg. Clinics North America 13: 175-178, 1933. Thb is a report of a rapidly growing pelvic tumor in a woman forty-five years of age. Enlargement of the abdomen was noticed only about a month before admission to the hospital. Growth of the tumor was rapid, causing marked distention of the abdomen, dyspnea, and fatigue. At operation a tumor weighing twenty-three and a half pounds was found occupying the entire abdominal cavity. It was attached by a small narrow band to the posterior surface of the uterus. Microscopically it was found to be an edematous fibromyoma. Apparently edema had been caused by a twisting-of the pedicle. W. 8. MACCOMB Torsion of Fibromyomatous Uterus, A. DUJOVICH.La torsibn del uMro fibro- matoso, Semana m6d. 1: 1377-1390, 1933. The author describes a cam of torsion of a fibromyomatous uterus in which he was able to perform myomectomy with good results. He gives a good general account of this oomplication, and adds a bibliography. F. CAV~RS Fibromyoma of the Uterue, Cardiac Failure, Anemia and Edema, Report of Care, H. BRANDMAN.Arch. Int. Med. 50: 306-318, 1932. A single case report of a woman thirty-nine yeare of age with a fibromyoma of the uterus, anemia, and cardiac decompensation. Good recovery followed hysterectomy. Problem of the Lymphocystofibroma Uteri (Robert Meyer), HANSDWORZAK. Zur Frage des Lymphocystofibroma uteri (Robert Meyer), Arch. f. Gynilk. 151: 601-611, 1932. Lymphocystofibroma of the uterus belongs to the so-called uterine hamarto- blastomas and has been described only during the last few years. Reexamination of the laboratory material of the German University Clinic in Prague disclosed such a case operated upon several years ago. The patient was a woman of forty- five, suffering from dysuria, increase in size of the abdomen, sacral pain, and increased menstrual bleeding. Examination of the uterus following hysterectomy showed a cyst in the right lateral wall, the size of a child’s head. The cyst lining was a soft, mucoid-like tissue, 2 to 10 mm. in thickness, which was movable against the underlying uterine tissue. Microscopic examination showed the outer layers of the cyst to consist of parallel stratified muscle bundles. The inner layers consisted of a fibromatous tissue containing cell nuclei and a finely branching fibrillar network. In a11 sections of the tumor were numerous thick-walled blood vessels with dilated lumina, which often Iay directly under the lining of the cyst cavity itself. This inner lining of the cyst showed in places only endothelium. The case just described, like almost all of those reported, appears to be of definitely benign character. One case, reported by Mogiloff, was malignant, as proved by a recurrence. HOWARDC. TAYLOR,JP.

Paravaginal and Pelvic Fibromas, E. FERRONI.Tumori fibrosi paravaginali e pelvici, Arch. di ostet. e ginec. 19: 472-486, 1932. The author describes 10 cases of pure and mixed fibromatous tumors, 8 arising in the vesicovaginal septum and 2 from the parietal pelvic fascia. Of the former group, one was not operated upon; 6 of the remaining 7 tumors were examined histologically and diagnosed as pure fibroma, fibromyxoma (2 cases) and fibro- THE FEMALE GENITAL TRACT 247 myoma (3 cases). The two parietal pelvic tumors were pure fibromas which grew inwards so as to compress the vagina. In the first case immediate operation was necessary because the tumor, as large as a full term fetal head, had caused complete urinary obstruction, complicated by cystitis; it was successfully removed from its attachment to the right side of the pubic symphysis. In the second case labor was obstructed by a large pelvic tumor, so hard as to suggest chondroma, arising from the cotyloid fascia in the right obturstor region and displacing the vagina to the left; cesarean section was done, with delivery of a living child, and the tumor was removed later. The author considers that tumors arising in the vesicovaginal partition should be regarded as of Wolffian origin, and cites various Italian and French writers who have advocated this interpretation, but he gives no histologic descriptions or illustrations in its support. More to the point is his stressing of the fact that tumors in this site, though histologically benign, may indirectly, by pressure on various pelvic organs, cause serious disturbances, even endangering life. F. CAVERS Myoma in the Anterior Vaginal Wall, F. REDER. Trans. Am. Assoc. Obst., Gynec. & Abdom. Surg. 45: 41-46, 1932. A myoma of the anterior vaginal wall causing increased frequency of urination was found and easily removed. Fibrous Adenoleiomyoma in a Laparotomy Scar from Tubal Implanted Elements, G. FAYOTAND H. L. GUIBERT. Ad6no-leiomybme fibroiide d6velopp6 dans une cicatrice de laparatomie mbdiane aux d6pens d’616ments tubaires greff6s au cours d’un salpingo-ovariotomie, Bull. Assoc. franp. p. 1’6tude du cancer 22: 140-151, 1933. A tumor developing in a laparotomy scar two years after a salpingo-ovariotomy increased in size during menstruation, was painful, and showed a slight bloody discharge. It proved to be an adenomatous leiomyoma wikh microcysts and fibrous stroma. As the uterus had not been opened at operation, the authors assumed that the epithelium was derived from the tube.

Tumors of the Ovary, H. R. DUDQEON.Texas State J. Med. 28: 536-539, 1932. A general discussion of the various types of ovarian cysts and tumors is given. The impossibility of differentiating these tumors without histological study is the author’s chief reason for early removal of all tumors except the milder varieties of microcystic and endometrial degeneration. NELSONB. SACKETT Three Cases of Ovarian Carcinoma Treated Palliatively by Irradiation, F. R. SMITH. Surg. Clin. North America 13: 463-467, 1933. A report of 3 cases of carcinoma of the ovary treated by irradiation. The first patient remained well for a year before pelvic recurrence developed. In the second no attempt to remove the tumor was made, but treatment resulted in complete regression of the tumor, and the patient is well four and a half years later. In the third an exploratory operation showed so extensive a growth that x-ray treatments were given for over two years; then both papillary ovarian tumor masses were removed; and radiation treatment was continued. The patient has been free from symptoms seven and a half years. 248 ABSTRACTG

Metastases in the Ovary after Resection of the Stomach for Cucinoma, ANNA ~CREPZTINBKY. Krebsmetastaae im Ovarium nach Magenresektion wegen Karzinom, Monatschr. f. Geburteh. u. Gynlik. 91: 457-460, 1932. -4 thirty-nine-year-old woman had been operated upon two years before for cancer of the stomach and subsequently on two occasions for recurrent nodulee in the scar. At a fourth operation there were found two large nodular tumors of the ovary, as well as multiple small implantations on the intestines and liver. The histologic examination showed a mucoid adenocarcinoma. HOWARDC. TAYLOR,JR. Metastatic Ovarian Carcinoma from Carcinoma of the Breast, C. SCARPITTI. I1 cancro ovarico nietastatico a cancro del seno, Tumori 7: 47-70, 1933. Of extra-abdominal tumors, only cancer of the breast is found to give any large proportion of ovarian metastases. Of 37 metastatic tumors of the ovary, two were from cancer of the breast, and these are reported in detail. Both patients had had operations for breast cancer eight yeare before death. In one case the ovarian tumors showed the typical structure of breast adenocarcinoma with ncirrhous elements. In the other the tumors were solid carcinomas with cells of undifferentiated type, their mammary origin not definite. harpitti believes that in both cases the cells probably spread by the lymph channele, one showing metastases to many retroperitoneal nodes, the other probable metastases in the internal mammary chain. In view of the bad prognosis of ovarian metastases and the age of patients generally suffering with carcinoma of the breast, the author is in favor of routine x-ray treatment of the ovaries in all breast cancer cases. He believes that such treatment may have an inhibitory influence not only on the development of ovarian metastases but on local recurrences. The article is illustrated by x-ray photographs and contains a bibliography. JEANNETTEMUNRO Luge-cell Ovarian Cucinoma in F%eudohermaphroditiam, E. KLAFTEN. Bei- trag zur Kenntnis des soliden goesrelligen OvarialkarsinomR bei Pseudo- hermaphroditismus, Zentralbl. f. Gynak. 56: 1989-1996, 1932. A typical case of large-cell ovarian carcinoma occurring in an eighteen-year-old patient is reported. This patient had never menstruated, her axillary and pubic hair was sparsely developed, the breasts were small, the external genitalia un- developed, and the clitoris hypertrophied. The tumor was an extensive one having a retroperitoneal metastasis, and itn removal required the resection of about 40 cm. of ileum. The patient died Rix days after the operation with symptoms of peritonitis. The tumor was of medullary consistency and contained niimerous central necroses. The cells under the microscope appeared as large round units with epithelial characteristics, filled with glycogen. Alveolar arrangement was present, the individual cell groups being surrounded by a stroma infiltrated with lymphocytes. The uterus was strikingly small and atrophic. Two photomicrographs are included. HOWARDC. TAYLOR,JR.

Cystadonoma of the Ovary, W. R. WILLIAYA. M. J. & Record 136: 465-466, 1932. The author discussem the origin of the cystadenomata of the ovary and points out that Poupinel (Arch. de physiol. 9: 394, 1887) conaidered them as teratoid growths in which the cntodermal derivatives dominated the picture, a point of THE FEMALE (fENIT.4L TRACT 249 view to which he believes pathologists have been indifferent. [On the contrary, there has been a good deal of discussion of the matter. For example, Ribbert (Die Geschwulatlehre, 2nd ed., 1914, page 701) says: ‘‘ The close resemblance of the epithelium of the ovarian cystomata to that of the mucous membrane of the intestine has led to the suggestion by Hanau that it actually is of such origin.” Ribbert shows in Figure 610 that this resemblance may be very close because the gland tubules may on occasion be surrounded by smooth muscle. He then goes on to say that the best explanation for this resemblance to entodermal pictures in ovarian cysts is that they consist of a one-sided teratoma, and gives two examples in which a cystadenoma was actually in contact with a so-called dermoid cyst of the ordinary ectodermal type containing hair. This view of Ribbert’s, however, has not been very warmly received by the gynecological pathologists. Kermauner (Veit-Stoeckel’s Handbuch der Gyna- kologie, 3rd ed., vol. 7, page 255) argues that while teratomata of single tissues are known, the best example being the type in which thyroid tissue only is present, the extraordinary rarity of these neoplasms an compared with the great frequency of the pseudomucinous cystadenomata renders the explanation doubtful and other possibilities should be considered. Walthard (Ztschr. f. Geburtsh. 50: 567, 1903) suggested congenital cell dis- placements in the ovary, basing his ansumption on serial sections of ovaries of newborn children and adults. He found in his material small areas of cylindrical or squamous epithelium, goblet cells, and ciliated cells. This suggestion has also had adherents and opponents among the gynecological pathologists. Some support for the idea is given by Akagi (Arch. f. Gynak. 134: 390, 1928), who made a careful study of ovaries in children under twelve years. His paper contains a series of beautiful drawings of the different types of epithelium, small areas of which he found in the ovaries. However, Kermauner himself believes a third explanation is more probable, which is that, inasmuch as the superficial epithelium of the ovary, the lining of the peritoneal cavity, arid the epithelial lining of Muller’s duct are all derivatives of the celomic epithelium, and as the epithelium of Muller’s duct can differentiate for unknown reasons into tuba1 epithelium, corpus and cervix epithelium, and vaginal epithelium, and as the glands of the cervix show the same morphology and the capacity to secrete mucus which is observed in the cystadenomata of the ovary, there is no reason for a more complicated assumption than that the epithelium of the cystadenomata is simply a special differentiation of the same type as occurs in the cervix.] F. CAVERS

Primary Bilateral Tumor of the Ovary,Probably a Seminoma, in a Young Woman; Diagnosis by Lipiodol, G. VINCENT. Tumeur primitive bilaterale des ovaires, probablement seminome, chez un femme jeune; lipiodo-diagnostic, Bull. SOC. d’obst. et de gyn6c. 21: 446-448, 1932. In a young married woman of t,hirty-one years, there was found on examination an abdominal and pelvic tumor. Lipiodol injections showed one tube high in the pelvis on the left side and the other apparently deep in the pelvis. Opera- tion confirmed the presence of ovarian tumors on each side, displacing the tubes in the manner indicated. In spite of the bilateral character of this growth, the histologic sections indicated a seminoma. These are not reproduced. HOWARDC. TAYLOR,JR. 250 ABSTRACTS

Metastases in the Tibia of Bilateral Seminoma of the Ovaries, H. C. KRAFTT. Projections de radiographies de mbtastases dans le tibia d’un sbminome des deux ovaires, Rev. frang. d. gynbc. et d’obst. 27: Congds 563-564, Dec. 1932. A woman complained of pain and swelling of the left leg and a roentgenogram showed a large area of destruction in the tibia, extending to the knee joint. Bi- lateral ovarian tumors were removed and proved to be seminoma. Radiotherapy was given over the tibia, the abdomen, and thorax, and subsequent roentgen examinations showed gradual regeneration of bone. A year and a half after removal of the ovarian tumors, the patient wa8 in good health and had gained weight. Fibrosarcoma of the Ovary in a Child of Three and a Half Years, 0. COPELLO, L. VELASCOBLANCO, AND E. M. ECHEGARAY.Un caso de fibro-sarcoma del ovario (en una chica de 34 anos), Arch. am. d. med. 8: 101-107, 1932. A child of three and a half years had had loss of appetite, polyuria, and a blood-stained vaginal flow for twenty days, and pain in the back and weakness for three days. Physical examination revealed a large, firm, non-tender mass in the hypogastrium, extending downward from the umbilicus into the right iliac fossa. The external genitalia and breasts were over-developed and there was considerable pubic hair. At operation a tumor, arising in the left ovary, was found twisted on its pedicle and extending upward to the right lobe of the liver. There were no adhesions, metastases, or ascites. The right ovary appeared normal. The tumor was excised by severing its pedicle. Five months after operation there was no evidence of recurrence, and the exaggerated sex characters were less pronounced. The tumor was diagnosed histologically as a fibrosarcoma. The article is illustrated by a photograph of the tumor and two photomicrographs, and contains a good bibliography. JOHNE. WIRTH

Piecemeal Removal of Large Ovarian Fibrosarcoma by Colpotomy, A. CHUECO. La reducci6n de 10s tumores malignos por colpotomia; observaci6n de un voluminoso fibrosarcoma del ovario, Semana m6d. 1 : 605-611, 1933. A woman of fifty-six complained of rapid enlargement of the abdomen, with a sensation of dragging. A smooth, hard tumor was felt in the left flank and was diagnosed as ovarian fibrosarcoma. The author performed anterior colpotomy, dragged the ovarian tumor into the vagina, and removed it piecemeal. The patient made a good recovery, and histologic examination verified the diagnosis of fibrosarcoma. The author discusses the advantages of this vaginal operation as compared with laparotomy for the removal of ovarian tumors. There are seven illustrations. F. CAVERB

Granulosa-cell Tumors of the ovary, z. VON SZATBM~RY.tfber Granulosazell- tumoren, Arch. f. Gyniik. 153: 127-154, 1933. After having studied the granulosa-cell ovarian tumors in the rich material of R. Meyer, the author has found 9 examples of these tumors in the records of Budapest University. He describes these in detail, and points out that difficulties in diagnosis and nomenclature have frequently arisen owing to the somewhat widely differing histologic appearances of different tumors and in different parts of the same tumor. He combines his 9 cases with 33 reported from Meyer’s clinic by Habbe (see Abst. in Am. J. Cancer 15: 3009, 1931) and 85 others collected from the literature, as a basis for a general discussion. Granulosa-cell tumors are mostly unilateral, usually in part cystic, with a THE FEMALE GENITAL TRAOT 25 1 smooth thin wall; hemorrhages and necroses occur frequently in the center of the tumor. The tumors are of slow growth, rarely metastasize, and seldom give rise to adhesions. They occur at any age, occasionally in children, but in more than half the cases at ages over fifty years. Amenorrhea is reported in about half the patients of child-bearing age. About 85 per cent of the patients reported irregular bleeding, following a period of amenorrhea in the younger patients, or the menopause in older women. Glandular endometrial hyperplasia is found in the great majority of cases, probably as a hormonic manifestation of the activity of the tumor cells, which have the same origin as follicular epithelium. In two reported cases a positive Aschheim-Zondek reaction was given by the urine. There are fifteen illustrations. F. CAVERS

Epithelium-lined Blood Cysts of the Ovary, E. S. J. KING. Australian & New Zealand J. Surg. 2: 348-359, 1933. The author gives a histological account based on examination of 30 typical examples of bilateral ovarian endometrioma. He discusses the pathogenesis of these tumors and also of the second variety (luteal cyst) of epithelium-lined ovarian blood cyst, which is distinguished by being large and usually single, as compared with the multiple small endometrial cysts. The large single cysts are considered to be derived from the ovarian follicles either by way of the atretic follicles or corpora lutea. The author rejects various views that have been put forward regarding the origin of the multiple small epithelium-lined blood cysts of the ovary. The terms which have been applied to these cysts by Blair Bell (endometrioma) and by Sampson (endometriosis) emphasize the similarity of the epithelium of the cysts to that of the endometrium. “ These names have arisen from the consideration of the epithelium to the exclusion of other components of the structure of the cysts.” The author admits that the evidence for the theory that these cysts arise from the serosa by metaplasia seems in some cases convincing because of the occasional observation that the cyst epithelium may be traced into continuity with the serosal epithelium. He considers that Sampson’s view that the epithelium is actual endometrium which has been transplanted from the uterus to the ovary by way of the fallopian tubes or the veins “ seems a priori an unlikely explanation.” There are seventeen illustrations. F. CAVERS

Vegetating Cyst of tha Ovary Treated by Radium and Surgery, A. GOSSETAND E. WALLON. Kyste de l’ovaire v6g6tant trait6 par radium-chirurgie, Bull. SOC.d’obst. et de gyn6c. 21: 421-428, 1932. Five years before this report was presented, the patient, a woman of sixty-four, was operated upon for a fungating cyst of the right ovary with associated implants in the pelvis. The operation was limited to a salpingo-oophorectomy, but before closure of the abdomen two drains were placed in contact with the area of the peritoneum on which implants had occurred. Beginning on the sixteenth day after operation, radium was inserted through the tubes to the amount of 21 millicuries for six days. Examination of the tissue showed that it consisted of a branching growth of connective tissue covered with a cylindrical epithelium which in certain solid areas was definitely infiltrating. The five-year survival of this patient with malignant implantations on the peritoneum is ascribed to the addition of the radium to the surgical treatment. Following the presentation of this report Petit-Dutaillis discussed the combined use of surgery and radium for cancer of the cervix and Douay cited several 252 ABSTRACTS instances in which intra-abdominal radium was used in cases which had growth at the limit of operability. HOWARDC. TAYLOR,JR.

Thrombosis of the Left External Iliac Artery Secondary to a Left Ovarian Cyst, GILSONC. ENQEL.J. A. M. A. 99: 1343-1344, 1932. A woman of sixty-five had a painful swelling of the left leg of three days’ duration. Two years before the dorsum of the left foot was traumatized. The resulting wound healed, but shortly afterward an ulcer, which had never healed, had appeared on the left ankle accompanied by swelling of both legs. The day after admission to the hospital the lower half of the left leg and the foot were purple and there was 110 pulsation in the extremity as high as the femoral vessels. Believing this to be a case of thrombosis of the femoral artery, the author exposed the artery and removed a small clot above the branoh of the profunda. There wa8 no bleeding and a catheter was passed up through the vessel for 11.5 cm., at which point a definite obstruction was encountered. This could not be dis- lodged and because of the poor condition of the patient the wound was closed. The entire extremity continued to be purple and cold and death ensued on the fourth day after operation. Autopsy revealed a left ovarian cyst, the size of a lemon, that was adherent to the sigmoid and had caused pressure on the external iliac vessels at the brim of the pelvis, at which point the external iliac artery was occluded by a thrombus about 2 cm. in length, while the entire lumen of the external iliac vein was filled with clotted blood.

Ovarian Tumor Complicating a Pregnancy, FRANKABBETT AND ROBERTSTAFF. Med. Arts 35: 227-228, 1932. A large ovarian tumor was found on Caesarean section to be superimposed on the incarcerated pregnant uterus.

Intraligamentous Ovarian Cyst, R. WEILLER. Kyste ovarien intra-ligamentaire, Bull. SOC.d’obst. et de gynkc. 21: 587-590, 1932. In a woman of twenty years there WRS found at operation a bilocular cyst lying within the folds of the left broad ligament, and this was successfully removed. The ovary upon this side was never observed during the course of the operation. The cyst Weiller believes to be of ovarian rather than parovarian origin for the following reasons. The peritoneum lying over it was thick and vascular. The tumor was situated largely in the upper segment of the round ligament. The contents of the cyst was mucilaginous, while that of parovarian Cysts is usually aqueous, transparent, without paralbumin. HOWARDC. TAYLOR,.JR. Voliiminous Sarcoma-like Tumor Developing from a Focus of Chromafin Tissue in the Broad Ligament, LE LORIER,M. MAYERAND P. IBIDOR.Volumineuse tumeur pseudo-sarcomateuse dkveloppke aux dkpens d’un amas de cellules phi-eochromes du ligament large, Ann. d’anat. path. 10: 186-190, 1933. A semicystic intraligamentous tumor the size of a six months’ pregnancy was removed from a woman thirty-one years old, whose menstrual periods had ceased nine months before admission. It was composed of yellow or orange-colored material, although a firmer grayish mass near the uterus resembled a subserous myoma. The authors awribe the tumor, which microscopically resembled a mixed-cell sarcoma, to degeneration of aberrant suprarenal glands, or of chromaffin tissue constantly present along the borders and in the broad ligaments of the uterus. NELSONB. SACKETT THE FEiV6LE GENITAL TRACT 253

An Ovarian Growth Developing in the Pelvis Following Hysterectomy; Surgical Excision; Recurrence; Cure by Roentgen Therapy, M. P. BROCQAND B. Du~aux. Formation ovarienne dkvelopp6e dans Ie petit bassin & la suite d’une hystkrectomie; exkrese chirurgicale; rkcidive; gukrison par roentgen- thkrapie, Bull. SOC.d’obst. et de gyn6c. 21: 399-405, 1932. A woman of thirty-five had been operated upon in 1920 for a right encysted hernatocele and in 1926 for a second tuba1 pregnancy, for which the left tube and ovary were removed and a subtotal hysterectomy performed, In 1930 a third operation was required for a cystic mass developing in the cul de sac, fixed to the rectum and the walls qf the pelvis. When this mass was removed, remnants of corpus luteum showed it to be of ovarian origin. A few months after this last operation a small mass was found in the pelvis. In the helief that this mass was also of ovarian origin, x-ray treatment was instituted and a complete cure resulted. In discussion of the origin of ovarian masses developing after supposed bilateral oophorectorny, the authors consider the possibility of the following: (1) embryonic remnants stimulated to activity by inflammat,ion; (2) fragments of ovary left in place following a difficult operation with adhesions; (3) supernu- merary ovaries hypertrophying after the removal of the normal organ. In the treatment of ovarian masses developing after hysterectomy observation is permissible in women approaching the menopause. An nbdominal operation is better, as a rule, than an attempt at vaginal drainage. In recurrent cases x-ray treatment may be found useful, as in the present instance. HOWARDC. TAYLOR,JR. Squamous-cell Epithelioma of the Vulva Remarkable for the Extreme Rapidity of Its Growth; Onset Three to Four Months before Hospitalization, I. SADIK. Un cas d’Cpith6lioma spino-cellulaire de la vulve, remarquable par I’extrhe rapidit6 de son developpement, Bull. SOC.d’obst. et de gynkc. 21: 590-503, 1932. An unmarried woman of fifty-one years was admitted to the hospital for a growth of the vulva. 1,ocal examination showed a partial atrophy of the clitoris and the labia minora and areas of leukoplakia in the same region. The perineum and the posterior part of the vulva was the site of a large ulceration measuring 4 by 5 cm. in diameter. Histologic examination of the meas of leukoplakia showed a marked hyperkeratosis with a thickening especially of the superficial’ layers of the skin. Sections from the ulcer showed invading cancer tissue of the squamous-cell type. The patient was treated firet with radium and later by surgical excision of the vulva, but died a year after admission to the hospital. HOWARDC. TAYLOR,JR. Contribution to the Clinical Description of Melanomas of the Vulva, A. W. HOCKLOFF. Beitrag zur Klinik dea Vulvamelanoms, Zentralbl. f. Gyniik. 56: 2001-2002, 1932. A case is briefly reported of a forty-seven-year-old nullipara who six months before admission had observed an enlargement of the left labium. Examination showed an ulcerated tumor of dark brown color, the size of a small child’s fist, on the left labium minor. The left inguinal node was the size of a walnut and was fixed and painful. Operation consiAted in excision of the tumor and extirpation of the inguinal node. Microscopic examination showed a richly pigmented polymorphic melanosarcoma. Recurrence in the inguinal region was observed shortly after the patient was discharged from the hospital. HOWARDC. TAYLOR,JR. 254 ABSTRACTS

Erythroplasia of the Vulva and Carcinoma of the Uterine Cervix, M. FABRE. Erythroplasie vulvaire et cancer du col utbrin, Bull. SOC.tranp. dermat. et syph. 39: 897-901, 1932. A woman of fifty-four was referred to the author with a diagnosis of intractable erythema of the vulva, first noticed three years previously. The lesion was extensive and ulcerated, sharply marked off from the healthy mucosa at the edges, and showing somewhat deep infiltration. Histologic examination of an excised portion showed the lesion to be a papillary squamous-cell carcinoma. Solid carbon dioxide was first used and gave considerable relief, then x-ray treatment was instituted. Three months later the vulvar lesion had practically disappeared. Three years after this the patient was found to have inoperable carcinoma of the uterine cervix, which had apparently developed during the interval. Histo- logically the tumor was of mixed-cell type with preponderance of the basal-cell form. The author raises the question whether the two successive growths were related to each other, and the three speakers in the,ensuing discussion agreed with his view that the two tumors were probably of independent origin. The paper is illustrated by photographs of the vulvar tumor before and after treatment. F. CAVERS THE GENITO-URINARY TRACT Cancer of the Genito-urinary Tract, Lure F. AJAMIL. CBncer del tractus gbni- tourinario, Bol. Liga contra el dncer 7: 336-350, 1932. Ajamil gives a fair but general and brief text-book picture of the symptoms, diagnosis, and treatment of several types of tumors of the genito-urinary traot. JOHNE. WIRTH Malignant Tumor8 of the Kidney and Bladder, HOALBAUM.Maligne Tumoren im Harnsystem, KIin. Wchnschr. 11 : 1566-1567, 1932. The author says that practically all the malignant tumors of the kidney are divisible into two types: the mixed tumors found chiefly in childhood and the hypernephromas found in adults, true carcinomas, in his opinion, being extremely rare. The mixed tumors give rise to pain in the back on walking, standing, or continued sitting. In Hohlbaum's experience children with such tumors are usually treated, before a correct diagnosis is made, for SCOliOSiS and other spinal troubles. In malignant renal tumors in adults the first symptoms are frequently due to metastases. The author has seen cases in which the tumor, when on the left side, had been mistaken for an enlarged spleen and treated by x-rays. Hematuria is the most frequent early sign of malignant renal tumor, and in most ca8es leads the patient to seek advice, but too often the physician ignores the rule that every cue of hematuria must be regarded as due to renal tumor until the contrary is proved by thorough investigation. In several of the author's cases the physician had regarded hematuria very lightly or had attributed it to ruptured varices or to " strain." In every case of hematuria there should be immediate cystoscopy, followed by pyelography whether or not anything abnormal is found in the bladder. F. CAVERS Renal Tumors, PASCUAL.Tumores renales, Arch. d. med. cir y especial. 35: 482, 1932. Of 31 patients with renal tumors 11 were operated on, and in 3 of these renal calculi were found associated with the tumor. Pyelograms are advocated in all obscure renal conditions or cases with hematuria. An outline is given of well known defects in the kidney which may be demonstrated by means of pyelograms. JOHN E. WIRTH THE QENITO-URINARY TRACT 255

Diagnosis of Renal Tumors, 0. RUMPEL. Diagnose der Nierentumoren, Med. Klin. 28: 1547-1548, 1932. In this short paper the author discusses the differential diagnosis of renal neoplasms, first pointing out that in his experience hematuria is the first signal of tumor in nearly 90 per cent of the cases. Bleeding is less common in non-neoplastic lesions, though it may occur in tuberculosis, cystic disease, nephritis, and arteriosclerosis. Cystoscopy and dye tests for excretory efficiency have proved to be the chief aids in diagnosis, and the author believes that pyelography with opaque solutions or air should not be used until other means of diagnosis have failed. He has obtained good results from nephrectomy, some of the patients having been alive and well after four and five years or longer. Unfortunately the great majority of patients come for treatment at a late stage, with anemia, fever, and a large tumor, and with a history of repeated occurrence of hematuria, which should have led them to seek advice much earlier. F. CAVERS Hypernephroma. Multiple Metastases: Compression of the Cauda Equina and Jacksonian Epilepsy, JUANM. OBARRIOAND DOMINQO COLILLAS. Suprarre- naloma; mettistasis mliltiples: compresi6n de la cola de caballo y epilepsia jacksoniana, Prensa med. argent. 19: 608-616, 1932. A woman fifty-five years old had mild pain in the lower lumbar region and left leg for eight or nine months. Within another month she had pain in the right arm, a jackmnian epilepsy, and severe cough and hemoptysis. She died shortly after this in a convulsive seizure. Physical examination showed evidence of compression of the cauda equina. There were no palpable masses in the abdomen. Radiographs showed multiple areas of bone destruction in the lumbar and sacral spine, upper end of the left femur, and the right acromion, and metastases in the lungs. Biopsy showed a carcinoma of the adrenal cortex. The article contains numerous roentgenograms and photomicrographs and a good bibliography. JOHN E. WIRTH

Case of Hemangioma of the Kidney, SILVADE ASSIS. Sobre um caso de hemangioma do rim, Brasil-med. 46: 556-561, 1932. The medical literature to date contains reports of 26 cases of hemangioma of the kidney, including the case here reported. The principal and practically only symptom is constant hematuria, total but of variable degree. The treatment of choice is total nephrectomy. The author’s patient, a woman of fifty- four years, had an ulcerated hemangioma open at the upper calyx major, situated at the upper pole of the right kidney. Hematuria was profuse. After operation (right-sided nephrectomy) under spinal anesthesia, the urine was clear and of norma1 character. Histologic examination of the specimen showed “ hematic fibro-angioma.” An exact diagnosis in these cases is regarded by the author as impossible, even in the course of the operation; but he claims that in his own case, as well as the published cases, an assumption of malignancy was justified and total nephrectomy indicated. Angioma does not give rise to progressive asthenia or the cachexia of cancer, with the accompanying rapid emaciation and characteristic pale bronze color. Further than this, a slow painless course, without enlarged nodes and without fever, may suggest a diagnosis of benign neoplasm. The differential diagnosis from essential hematuria is practically impoesible. Tuber- culosis is excluded by cultures and inoculations. 256 ABSTRACTS

Leukoplakia of the Renal Pelvis, M. ARLOTTA. Un caso di leucoplachia del bacinetto renale, Arch. ital. di chip. 32: 525-544, 1932. The author gives an interesting partial review of the literature of leukoplakia of the urinary tract, beginning with the case reported by Ebstein in 1882. In all, he found reports of 46 cases, only 10 of these appearing during the past decade, and he admits that his estimate of the frequency of this lesion is probably too low. * h man of thirty stated that three years previously he had violent pain in the left loin, which radiated to the left half of the scrotum and was followed by oli- guria, but was relieved by provoked vomiting. After a year of freedom from symptoms, he had another attack of pain, which this time radiated from the left loin to the left iliac fofifia,and was followed by urinary dribbling, vesical tenesmua, and burning urethral pain on micturition. During the next six months he had several similar attacks, umally relieved, as before, by induced vomiting. He contlulted a physician, who used the cystoscope and prescribed medicine, which did no good, and after several more attacks he attended the author’s clinic. The kidneys and ureters were not painful on pressure; the urine from the right kidney was normal, that from the left contained some pus cells and abundant sqriamous epithelial cells. The urinary sediment was examined bacteriologically, but no tubercle or other bacilli were found, and the skin reactions for tuberculosis were negative. Indigocarmine excretion was equal (about 90 minutes) on both sides. Cystoscopy revealed nothing abnormal. Pyelography gave a normal picture on the right nide, but the lower half of the left pelvis was flattened and the calyces could not be seen in this region. Nephrectomy was performed. The lower half of the kidney contained several small abscesses, the largest of which was in communication with the apex of a calyx. The epithelium of the lower calyces, the lower half of the pelvis, and the upper part of the ureter was enormously thickened, but the calibre of the passage was about normal. On histologic examination the kidney showed, both in the cortex and medulla, innumerable tubercles with epithelioid and lymphoid cells and occasional giant cells; some of these had coalesced to form caseating abscesses. The thickened epithelium consisted of numerous cell layers, the more superficial ones showing cornification and desquamation, and the basal layer wafi ill defined. The author regards this as a clear case of leukoplskia set up by the irritation of a chronic tuberculous process, and discusses various etiologic explanations of urinary tract leukoplakia which have been put forward. He stresses the histologic fiimilarity between leukoplakia in this site and in others, such as the skin, regards chronic irritation 11s the agent which causes the change from transitional- cell to squamous cornified epithelium, and considers LecAne’s theory of origin from ectopic wolffian reets as both erroneous and unnecessary. Cases have been reported, however, as occurring in early life; one, for instance, in an infant of four months. 111 come reported cases, carcinoma has been found in leukoplakia of the renal pelvis, ureter, and bladder, and the author believes that when the pelvis is involved the only logical treatment is nephrectomy; if the ureter is also involved, nephro-ureterectomy is indicated, on account of the danger of malignant change. There are five illustrations. F. CAVERS Two Large Pararenal Fibrolipomata, M. CHEVASSU.Deux volumineux fibro- li~~cimesparan6phr6tiqueRl l’un op6r6 par M. Robert Didier, l’autre par M. Raymond Leibovici, Bull. et m6m. Soc. nat. de chir. 58: 1068-1078, 1932. Two pararenal fibrolipomata are described weighing 4 and 10 kilos respectively. 1Iven the latter does not heat the record for size; the author found one reported THE OENITO-UIlINAliY TBACT 257 in the French literature which weighed 30 kilos. On account of their size, these tumors are often difficult to remove. The author says their diagnosis is frequently difficult without resort to radiography after peritoneal air inflation and opaque filling of the bowel combined with pyelography. When large, they generally cause compression and stenosis of the bowel, especially the coloii, and various other pressure symptoms which may endanger life. Moreover, they occasionally become sarcomatons. There are two illustrations of the specimens removed. F. (‘AVERS

Some Clinical Considerationson Malignant Neoplasms of the Bladder, Z. CU~LLAR DURAN. Algunas consideraciones clinicas sobre las modalidades de 10s neo- plasmas malignos della vejiga, Repert. d. med. y cir. 23: 215-251, 1932. The three most frequent signs of vesical cancer are hematuria, pain, and frequent urination, but these signs may vary greatly in different cases. In one of the author’s patients, a male fifty-three years old, there had been frequency for a year and then sudden hematuria without pain. He then went along for a year and a half more with intermittent hematuria before he consented to a cgstoscopic examination. He then refused operation until pain became a prominent feature. In a second case, in a male fifty years old, the first sign was a sudden profuse hematuria, which lasted eight days. The tumor was found to be of moderate sire. A third patient, a male fifty-eight years old, complained of frequency and pain and had only a very small tumor. This was treated, but a year later there was a large recurrence, with hematuria. JOHNE. WIRTH

Myxosarcoma of the Bladder in a Child, A. <;. WEISS AND R. MEYER. Myxo- sarcome de la vessie chez un enfant, Rev. franc. de p6diat. 8: 748-750, 1932. A five-year-old boy had complained, a month before his death, of burning pain on micturition, and a few days later of pain in the left hip, which made walking difficult. .4 few days after this he was unable to pass either urine or stool, and showed a tendency to somnolence. Several attempts to pass a catheter failed. A smooth, rounded, hard tumor was palpated suprapubically and extended to just below the umbilicus; on rectal palpation it was found to extend far back in the pelvis, compressing the rectum. On suprapubic puncture the needle passed through a firm mass, but no urine was withdrawn. Nephrostomy was therefore done; the kidney was intensely congested. A tube was inserted into the renal pelvis and the operative wound closed around it, but very little urine escaped. The patient died eight days after operation, in a state of uremic coma. The authors call attention to the rapid course in this case, and cite statistics in which it is stated that the average interval between the onset of symptoms and death in vesical sarcoma in children is about ten weeks. There is a single photomicrograph of poor quality. F. CAVERS

Carcinoma of the Prostate, D. TADDEI.I1 cancro della prostate, Rassegna internal;. di clin. e terap. 13: 1039-1047, 1932. The author reports no cases and gives no references to the literature in this discussion of the etiology, diagnosis, and treatment of prostatic carcinoma, his object being to relate some things he has learned about this disease from his own experience. He points out that while in most cases operation gives quite as good immediate results as those obtained in cancers of the skin, lip, breast, and uterine cervix, the live-year or even three-year results are extremely discouraging. He 258 ABSTRACTS estimates that five-year cure is obtained in only about 5 per cent of cases. Pro- static cancer is rarely diagnosed at a stage early enough to allow of radical extirpation. In the author’s experience, in one out of every seven cases of apparently benign hypertrophy in men over Bty years old, the removed prostate is found on histologic examination to be carcinomatous. The slow development of prostatic cancers (ranging up to seven years) is probably more apparent than real and may be explained by the frequency with which carcinoma arises insidiously in adenomas. In a considerable proportion of his cases [numbers not stated] the disease had spread at a relatively early stage to the bladder and caused hematuria, which led the patient to seek advice. The iliac lymph nodes were found at operation, even in these relatively early cases, to contain cancer tissue; such involvement is impossible to diagnose clinidally. As to treatment, the author has found that in the great majority of cases only palliative measures are possible by the time the surgeon sees the patient. No mention is made of radiotherapy. F. CAVERS

Modem Surgical Treatment of Prostatic Adenoma, J. SALLERAS.Estado actual del tratamiento del adenoma de la prbstata, Semana m6d. 1: 1524-1530, 1933. The author gives a general account of modern surgical technic in prostatectomy for adenoma, emphasizing the fact that the methods now used have largely reduced the mortality and morbidity of the operation. The account is based on about 300 prostatectomies performed by the author. F. CAVERS

Some Cases of Cancer of the Prostate Aggravated by Cystotomy, DUVERQEY. Quelques cas de cancers prostatiques aggrav6s p4r la cystostomie, Assoc. franc. d’urol. CongrAs 32: 462-464, 1932. Some surgeons do a cystotomy in cancer of the prostate as soon as symptoms appear and the diagnosis is made. Duvergey has found, however, that the patient’s condition is sometimes made worse by this procedure. He reports 3 cases in which symptoms of obstruction were relatively slight and the patient suffered no pain and was able to work before cystotomy was done. After operation, the pain became uncontrollable, the general condition grew rapidly worse, and death occurred within a year.

Carcinoma of the Penis, R. C. NICOLINI.C$ncer del pene, Semana m6d. 1: 1598-1616, 1933. The author gives a fairly good general account of penile carcinoma and adds brief notes on ten cases treated at the Buenos Airea surgical clinic. The first 8 patients were treated by diathermy amputation and inguinal node removal ; the last two have been treated by local antisepsis, protein therapy, and radium. One died of postoperative pulmonary edema; two were loat sight of; the remainder lived, free from recurrence, for over five years. The author has treated other cases during the past five years with radium, with equal success. There are ten illustrations. F. CAVERS

Tumor of the Testicle, H. K. WADB. Southern M. J. 25: 1138-1142, 1932. The author gives an excellent summary of the morphology, age incidence, etiology, diagnosis, and prognosis of tumors of the testicle and reports a case. A man of thirty-three had a swelling of the right testis, first noticed fourteen months before hospital admission. There was also a mass in the midline of the abdomen, the nature of which could not be certainly determined, though it was THE NERVOUS SYSTEM 259 suspected to be metastatic. Deep x-ray therapy was given at intervals for thirty days. The teflticular and abdominal tumors became smaller. The affected testis was removed, and the x-ray treatment continued. The abdominal mass showed further diminution, but soon afterwards there was pain, with nausea and vomiting, and a year after admission the patient died. The testicular tumor was diagnosed as embryonal carcinoma. The autopsy report, made elsewhere, described metastases in the liver, spleen, pancreas, and retroperitoneal lymph nodes, consisting of diffuse, infiltrating, rapidly growing carcinoma. In the ensuing discussion, Dr. R. A. Hennessy said that during the past six years he had treated 8 cases of testicular tumor by orchidectomy, preceded and followed by radiotherapy; of 6 patients traced, 4 remained alive and well for two, two and a half, three and a half, and five years respectively. Dr. E. L. Keyes stated that it was a striking fact that if these tumors are treated by radiation before and after castration the histologically more malignant growths will do better than the less malignant ones; that is, the richly cellular growths are more vulnerable to radiation. F. CAVERS

Case of Abdominal Testis Complicated by Tumour Formation and Acute Torsion of the Cord, E. C. CAITTY. Malayan M. J. 8: 203, 1933. A male Chinese of thirty-six complained of pain and swelling of the lower half of the abdomen for six days. At the age of sixteen he noticed a small oval swelling somewhere in the pubic region, which had gradually subsided. The recent pain had come on suddenly. A large, smooth, globular swelling occupied the whole abdomen up to the umbilicus; it was tender and felt cystic. The left testis was absent, from the scrotum and inguinal canal, and on rectal examination a hard irregular mass was felt in front of the rectum. At laparotomy blood-stained fluid was found and a dark bluish-black mass was shelled out easily. It proved to be the much enlarged left testis with a tightly twisted pedicle arising from the left side of the pelvis. The testicular tumor was diagnosed as " a small round cell sarcoma." There are no illustrations. F. CAVERS THE NERVOUS SYSTEM General and Focal Signs of Intracranial Tumors, T. N. SPESSARD.Virginia M. Monthly 58: 797-801, 1932. Among the general signs of intracranial tumors the author discusses headache; vomiting; visual symptoms; mental disturbances, such as impairment of memory, drowsiness, disorientation, or childishness; changes in personality and convulsive seizures. Of localizing signs, the most common are hemiparesis and signs of sensory disturbance, both occurring on the side opposite the lesion and pointing to pathology in the cerebral cortex in the first and second cranial fossae. Cere- bellar tumors give an entirely different set of signs, including incoordination, ataxia, and dysergia, the incoordination and ataxia being more marked on the side of the lesion. Rapidly progressive deafness frequently indicates an.expanding lesion of the cerebellopontine angle. Important localizing signs are also obtained by routine x-ray examination of the skull. Some Evidences of Intracranial Disease as Revealed by the Roentgen Ray, C. W. SCHWARTZ.Am. J. Roentgenol. 29: 182-193, 1933. Films present no more nor less than a collection of shadows, the value of which for diagnosis is in direct proportion to the experience of the interpreter. It is only 260 ABSTRACTS by the checking of cases at operation or necropsy that a solid foundation can be made upon which to base the roentgenographic diagnosis of new cases. It is useless to attempt conclusions from technically poor films. They must be of excellent quality and stereoscopic. What constitutes a normal skull radiographically becomes increasingly difficult to answer when the variations in a large series of films is appreciated. Inter- clinoid bridging, for example, may vary from delicate strands of calcification in the edges of the diaphragm of the sella to massive bony bridges. It occurs in 14 per cent of skulls, and, while probably of considerable significance endocrino- logically, must be considered at present as without pathological significance. Similarly, petroclinoid bridging and calcification in the falx are ‘I normal findings.” Thirteen per cent of patients will show calcification in the choroid plexus. En- largement of diploic veins bilaterally is of no diagnostic significance. The pineal gland, calcified in 50 per cent of all skulls, constitutes an important aid in roentgenologic diagnosis of intracranial tumors. In the presence of a definite ‘I pineal shift,” one is justified in assuming a pathological process, the direction of the shift giving a clue to the location of the lesion. Fifty per cent of intracranial tumors are gliomas, and 13 per cent of these calcify sufficiently to be demonstrable in roentgenograms. Calcification nften occurs in the glioblastoma multiforme in spite of the rapidly growing, malignant nature of the tumor. Such calcification is usually of the amorphous type. The astrocytoma, a much more benign and slow-growing lesion, is often the site of calcification arranged in a punctate fashion. Oligodendrogliomas may be heavily calcified. The Calcification is of an amorphous type, often combined with a string-like type. (Schwartz classifies intracranial calcifications into three chief types : punctate, linear and amorphous.) The medulloblastoma rarely calcifies and is the most radiosensitive of the gliomas. The midline fourth ventricle ependymoma often contains demonstrable areas of calcification. Radiologic signs of pressure may appear quickly, and after pressure has been relieved disappear equally rapidly. Children with posterior fossa tumors often suffer from markedly increased intracranial pressure which is demonstrable radiographically by deepened convolutional markings and separation of the cranial s uturea. Pituitary adenomas rarely produce evidence of increased intracranial pressure. If the tumor is primarily an intrasellar type, it causes a ballooning of the sella with depression of the floor, thinning of the dorsum, and atrophy of the tuber- culnm. The suprasellar tumor usually produces a flattening of the sella with more actual dorsal destruction. There comes a time in the development of pituitary tumors when the sella destruction is so great that a differentiation by the roentgenograms between supra- and intrasellar types becomes impossible. Calcification in the walls of a craniopharyngeal duct tumor often makes a definite diagnosis of this lesion possible. Suprasellar calcification may, however, be found within a chordoma or a meningioma. A type of atrophy of the sella sometimes occurs with temporal lobe tumors. In such cases the clinoids and dorsum on one side will be more atrophic. Atrophy confined to the dorsum with sometimes a slightly atrophic petrous ridge may be caused indirectly by an acoustic neuroma. Meningiomas, being outside the brain tissue itself, cause a pressure displacement, and as the brain is able to accommodate itself to a considerable amount of such abuse, no early symptoms arise. They therefore often attain a very large Hire before coming to operation. Meningiomas often calcify but not character- istically. The very characteristic bony changea they produce depend upon whether osteoplastic or osteolytic tendencies predominate. When the effect iR chiefly destructive, a positive diagnosis is more difficult than when the lesion is THE NERVOUS SYSTEM 26 1 productive. The bone overlying a meningioma will usually show increased vascularity and frequent small spiculations. Parasagittal meningiomas characteris- tically produce increased local vascularity with some slight evidence of bone production. It is often possible by a study of the vascular channels leading to a region supposedly the site of a blood vessel tumor to tell whether the lesion is chiefly venous or arterial. Arterial channels tend to course from below upward and gradually taper in caliber. Venous channels remain of consistent caliber and extend upward and forward. Bone spiculation occurs with both the meningioma and the angioma, but is much more common with meningiomas. In the immediate vicinity of the sella we often see small spicules of calcification in the walls of the carotid artery where it joins the circle of Willis. This produces no change in the sella and is merely an evidence of sclerosis. When, however, we see calcification in crescentic lines beside the sella, particularly in the presence of unilateral sella atrophy, it is likely that an aneurysm is present. Reproductions of roentgenograms show exceedingly well the bony changes discussed. EDWINM. DEERY Radiologic Diagnosis of Brain Tumors, P. DELMAS-MARSALET.Le radiodi- agnostic des tumeurs c6r6brales, Arch. d’6lectric. m6d. 41: 1-42, 1933. The clinical neurological examination should precede all special examinations or tests for the diagnosis of brain tumors. The roentgenographic signs, though aiding in the find diagnosis, are far from absolute in character and their final interpretation can best. be made by those who observe the patient clinically. In taking roentgenograms of the skull it is of the utmost importance to insist upon a standard technic, and a large number of plates taken in various positions. The author has divided his paper into three sections. Section 1 deals with the roentgenographic signs produced by increased intracranial pressure. If such an increase occurs in a young subject it may result in a demonstrable separation of the cranial sutures. Examples of suture separation are given. The so-called convolutional markings on the inner surface of the skull are discussed. These may be considerably accentuated in the presence of increased tension. Dilatation of the veins of the diploe and of the larger venous channels occur with tumors, particularly with the meningioma. Likewise, tumors may indirectly cause the formation of bony spicules on the inner surface of the skull. Section 2 deals with radiologic evidence of direct localizing value, chiefly the hyperplastic bony changes frequently found in association with the meningiomas. Occasional tumors contain sufficient calcification to cast a shadow in the roentgenogram, and several examples are given in illustration (calcified gliomas, cranio- pharyngiomau) . Section 3 deals with the technical details of roentgenography. Among the topics discussed are: correct positions for the visualization of special structures; morphological variations in normal skulls; calcification of the pineal gland; defor- mations appearing in a plate due to distance factors; cranial lesions not related to tumors of the brain, such as Paget’s disease; intracranial calcification other than that occurring within tumors. Radiologic study of the images of brain tumors or of characteristic changes associated with them may constitute a valuable aid in the diagnosis of such cases. In the present day no one should assume the responsibility for the diagnosis and care of brain tumor patients without having recourse to a radiological study. Owing to inexperience in interpretation of a plate or to faulty technic, radiologic evidence of a tumor may be found where none exists. The neurologist accus- tomed to reading plates is always in a better position than the radiologist to obtain 262 -4BSTRACTS a correct interpretation, for the clinical aspects of the case furnish him with the most important data. This is a highly factual paper with many illustrations. In all there are 37 plates to show various radiologic aspects of brain tumors. The illustrations have been made from ‘‘ negative prints,” which give good details, The author omits a discussion of gas encephalography and arterial encephalography, as he has seen but little of either procedure. [The plea that the neurological clinician interpret films, if followed, would as a rule be disastrous. The clinician is generally quite unable to interpret properly roentgenograms. The special ability in this field that can come only with constant practice belongs to the radiologist. The logical method of arriving at a final diagnosis is by a merging of the special information contributed by both radiologic and clinical experts.] EDWINM. DEERY

Roentgenographic Diagnosis of General Precocity with Brain Tumors, F. RUCK- ART. Zur Rbtgendiagnose des Krankheitsbildes der allgemeinen Frtihreife bei Hirngeschwiilsten, Rantgenpraxis 4: 718-720, 1932. A single short case report of a male child who showed evidence of precocious development followed by gradually increasing signs of intracranial pressure. Roentgenograms of the skull showed a tumor shadow in the region of the pineal gland. Further fdms revealed changes in the epiphyseal lines of the long bones of the body, which were more mature than was to be expected in a child. The writer believes that precocity with premature union of the epiphyseal lines may ultimately retard growth, so that the patient may finally be undersized and underdeveloped. Such was apparently the case with this child. A subsequent necropsy revealed a “ large mixed tumor of the third ventricle.” The pineal gland itself was enlarged and had undergone extensive cystic degeneration. There is a brief review of the literature, with references to similar cases of precocity. EDWINM. DEERY

Vestibular Disorders with Intracranial Tumors, P. RIGATJD. Les troubles vestibu- hires au cours des tumeurs endocraniennes, Toulouse m6d. 34: 37-50, 1933. Remarks which reflect the usually accepted facts in regard to alterations in the responses of tho vestibular mechanism in patients having brain tumors. Owing to as yet imperfectly understood factors, an abnormal vestibular response is frequently produced by intracranial tumors situated in many parts of the brain. The most striking and positive data are obtained in acoustic nerve tumor cases, which show a marked reduction or even total absence of the normal responses on the affected side. Other posterior fossa tumors cause vestibular changes that, when properly interpreted, may lead to a correct diagnosis. Vestibular symptoms not uncommonly accompany intracranial tumors. Such symptoms may be produced by the general increase in intracranial tension, or may be due to the direct effects of a tumor involving any portion of the vestibular pathway. EDWINM. DEERY

Necroses and Hemrrhnges in Brain Tumors, B. KARITZKY.Nekrosen und Blutungen in Hirngesihhwlilsten, Virchow’s Arch. f. path. Anat. 289: 83-95, 1933. This study of 133 intracranial tumors from the point of view of necrosis or hemorrhages within the growth was originally part of a discussion as to effects produced by electric accidents. The cases are from the Pathologic Institute of Dortmund. There were 115 gliomas of various types and 18 ganglioneuromas. THE NERVOUS SYSTEM 263

The commonest sites were the right temporal lobe 28, cerebellum 27, left temporal lobe 25, left frontal lobe 14, and right frontal lobe 14. Detailed histopathologic descriptions of representative tumors are given. The greatest amount of necrosis and hemorrhage was found in tumors that are classified as gliosarcomaa, although 80 per cent of all the gliomas showed both these features in some degree. Necrosis depends upon alterations in blood supply within the growth. Hemorrhages occur in brain tumors only when necrosis is present. In no case was hemorrhage or necrosis found to be the direct result of external violence. In general the more cellular .a gliomatous tumor, the more prone it is to develop necrotic and hemorrhagic areas. EDWINM. DEERY

Multiple Intracranial Tumors in Children ; Suprasellar Adamantinoma Associated with Cerebral Glioma, P. C. CARBONAND C. A. HELLWIG. Am. J. Dis. Child. 46: 119-131, 1933. A case is reported of a suprasellar adamantinoma and a cerebral glioma occurring in a boy of five years. He had complained for some months of failing vision, and rough tests were suggestive of a field defect. The neurological and general physical examinations were slightly suggestive of a left cerebral tumor. Ven- triculography gave evidence of a left-sided expanding lesion. At operation a large cyst was encountered in the depths and its fluid content aspirated. The yellow fluid did not coagulate nor did it contain crystals. Two months after an uneventful recovery the patient had a convulsive seisure and died. At necropsy a chiasmal region cyst was found which had greatly distorted the optic nerves. Upon subsequent sectioning of the brain a further cystic lesion was found in the left temporal lobe. The gross appearance of this second cyst and its location suggested an old abscess. Upon microscopic examination the chiasmal region cyst was found to be composed of a fibrous wall having a lining of stratified squamous epithelium. Other areas showed masses of epithelial cells in interlacing columns, A layer of ameloblastic cells was found and throughout the masses of cells were small cysts. A diagnosis of suprasellar adamantinoma was made. Examination of the cystic tumor in the left temporal lobe did not confirm the suspicion, held at necropsy, that the lesion was an abscess. There were no inflammatory changes in the cyst wall, which was composed of large cells of the astro- cyte type. The tumor elements blended gradually into the surrounding cerebral tissue. A diagnosis of cystic astrocytoma was made. From a study of the literature, multiple intracranial tumors in children would seem to be more rare than in adults. The author includes a resume of the reported cases of multiple brain tumors. In the present case calcium deposits within the adamantinoma were found microscopically, but they were not seen in the roentgenograms. EDWINM. DEEPY

Vdous Use6 of Electrosurgery in the Treatment of Brain Tumors, hNEf3T Sac~s. Southern M. J. 25: 1013-1019, 1932. Electromrgery when properly used is a most valuable aid in dealing with intracranial lesions. It should not be used to make the scalp incision, as the wound, if so made, would not heal by primary union. If blood vessels within the brain are grasped with a clamp or forceps, and " coagulated " with the electric current, they will usually stick to the instrument used, tear, and bleed. If the vessel is coagulated before being cut and simply stroked with the instrument conveying the electric current it will not bleed, With proper technic, vessels 3 to 4 mm. in diameter and even larger have been occluded. Besides the sealing 12 264 ABSTRAOTS off of blood vessels in and about a tumor, electrosurgery has other valuable applications. The most promising procedure for communicating hydrocephalus is the removal of the choroid plexus. By the use of the coagulating current the great number of vessels of the choroid plexus can readily be shriveled and destroyed. The coagulated plexus is left in situ. EDWINM. DEERY Tumors Affecting the Optic Chiaem and Optic Tracts, J. H. GLOBUR.Arch. Ophth. 9: 729-750, 1933. . There are several diseases of the central nervous system in which visual disturbances are frequent. Chief among them are epidemic encephalitis, multiple sclerosis, various forms of syphilis of the nervous system, and, above all, intracranial tumors. The ophthalmslogist is often the first to recogniae early papilledema. With tumors of the posterior fossa, or in the region of the quadrigeminate plate, or somewhat more forward in the interpeduncular space in the third ventricle, papilledema will appear early, advance rapidly, and reach a degree in excess of that which is usually encountered in lesions of a still more anterior location. Disturbances in acuity of vision and particularly in the fields of vision are more common with tumors of the brain than is commonly recognieed. The optic pathway forms a compact and well delineated system traversing the entire length of the brain. Because of its extent and passage through crowded parts of the brain it is frequently encroached upon by expanding intracranial lesions. Depending upon the part of the pathway involved, there will result characteristic visual field defects. These either alone or, more particularly, when correlated with signs arising from involvement of nearby parts of the brain, may take the form of a series of eymptom complexes. They may be designated in accordance with the relationship of the lesion to some critical point in the course of the optic pathway as follows: (1) prechiasmal, (2) chiasmal, including (a) suprasellar and (b) intrasellar, (3) the temporal lobe syndrome, (4) the occipital lobe syndrome, (5) the quadrigeminal plate syndrome. The chiasmal syndrome is produced by primary gliomos of the optic chiaam. These are very rare tumors, usually producing no changes in the outlines of the sella turcica and no suprasellar calcification. There may be other manifestations of von Recklinghausen’s disease present. Primary optic atrophy appears early, and there is sometimes a superimposed papilledema. There is a rapid loss of vision associated with a unilateral temporal field defect. There may be enlargement of an optic foramen demonstrable in the roentgenograms. Tumors of the croniophryngeal duct also produce the chiasmal syndrome. Like the primary glioma of the chiaim, these tumors are suprasellar in location. They are teratoid in character, having a bigeminal derivation. Their source of origin is in the embryonal rests along the craniopharyngeal duct. The symptoms appear most often in pre-adolescence. Because of the effect of the tumor on the hypothalamic region, they include manifestations of vegetative dysfunction, such as polydipsia, polyuria, sexual and skeletal infantilism, varying degrees of adi- posity, and hypersomnia. These, when added to bitemporal hemianopsia, involvement of the oculomotor nerves, and deposits of calcium salts in the suprasellar region without deformity of the sella turcica, point definitely to a tumor of the craniopharyngeal duct in the interpeduncular space. Supraaellar meningiomas, although not infrequently prechiasmaI lesions, may at times be clinically indistinguishable from the previously described forms. Cushing has characterized the tumor by a syndrome occurring in middle-aged patients free from endocrine disturbances and consisting of primary optic atrophy, bitemporal hemianopsia, and an unaffected sella turcica, with perhaps an oaca- sional alight degree of suprssellar calcification. THE NBRVOUS SYSTEM 265

The demand for a deformed sella turcica as essential for the diagnosis of an hypophyseal tumor must occasionally be abandoned, as there are pituitary adeno- mae which, because of their eupraeellar location, do not distort that structure. They are most likely to occur in middle-aged persons, who, being free from hypophyseal symptoms (as the gland is left unaffected), show no distortion of the sella and present bilateral optic atrophy and a bitemporal hemianopsia. It is very important to realize that pituitary tumors may be correctly diagnosed in the absence of the classic bitemporal hemianopsia, and that an homonymous defect is sometimes found. The initial visual disturbance may take the form of a small unilateral temporal defect. Occasionally high-voltage roentgen or radium therapy may give rise to apparent improvement and to the false hope that the pathologic process has been arrested. However, in the course of time an explosive reappear- ance of symptoms will shatter one’s belief that the disease process may be per- manently held in check. Leaione of the temporal lobe, when not accompanied by such localizing signs as uncinate seizures, visual hallucinations, or typical speech disturbances, often present difficult diagnostic problems. A knowledge of the course and distribution of the geniculocalcarine fibers is of great help in such cases. Their significance is apparent in the part they play in the causation of a partial or so-called quadrantic type of hemianopic field defect. This visual distortion may often be the only deciding diagnostic sign to pomt to a localization of the tumor in a temporal lobe. The most characteristic sign of a tumor of the occipital lobe is an homonymous hemianopsia. Preservation of macular vision in a quadrantic homonymous hemianopsia is of real value in eliminating the possibility of the tumor being in the temporal lobe. The character of visual hallucinations may be of some help in distinguishing between temporal and occipital tumors. It is generally held that the unformed type of hallucination is characteristic of tumors of the occipital lobe, while formed hallucinations suggest the temporal lobe. Tumore of the quadrigeminal plate may be included in a consideration of growths interfering with the optic pathways. The short association fibers connecting the lateral geniculate and the anterior quadrigeminate body are part of the optic system, and their interruption may cause some disturbance in the ocular mechanism. Thus paralysis of upward gaze, skew deviation, and Argyll Robertson pupils, which are characteristic of this syndrome, may be traced to some disorder in this link of the optic pathways. The appearance of symptoms pointing to the presence of an expanding intracranial lesion demands a thorough search for signs aiding in determining the site and probable character of the growth. All available diagnostic means must be employed for the accurate localization of the lesion. Among these study of the visual fields holds a most important place. Detection of what at first glance appears to be an insignificant distortion of the field of vision may serve as the only lead to the site of the tumor. Exploratory craniotomies may now be carried out with much greater safety than formerly. Such a step is fully warranted even in conditions in which the removal of the tumor is highly problematical, particularly when the patient is faced by the prospect of eventual blindness. The neurosurgeon is fully prepared to recognize situations in which the risk incident to tumor.remova1 is balanced by the chance of a cure. Such is the case with tumors which, provided they are recognized early enough in their evolution, are removable with excellent results. Among these are the meningiomas, pituitary adenomas, benign gliomas, and even a few of the craniopharyngeal duct tumors. Many pictures and case reports illustrate the conditions described. EDWINM. DEERY 266 ABSTRAOTS

Chiasmal Syndromes, A. J. MCLE-4N. Western J. Surg. 40: 355-370, 1932. Optic atrophy is a characteristic and early symptom of lesions in the region of the optic chiasm. It is often present when there is no other characteristic symptom except persistent dimness of vision even with proper glasses. A careful neurologic examination is necessary, as most of these lesions produce characteristic neurological syndromes, and many of them are operable in the earlier stages. Among the lesions in the chiasmal region that are operable, with favorable prognosis for cure or marked palliation, in the early stages, are: pituitary adenoma, of which the author reports 2 illustrative cases, chordoma, meningiomata of the tuberculum sellae, craniopharyngiomata, and arachnoiditis circumscripta cystica. Among the lesions about the optic chiasm that are surgically unfavorable are gliomas of the third ventricle, gliomas of the chiasm, occurring chiefly in children and adolescents, and parasellar aneurysms.

Tumors of the Gasserian Ganglion, M. J. COOPER.Am. J. Med. Sci. 185: 315- 324, 1933. The severe symptoms which accompany tumors of the gasserian ganglion have resulted in the recognition of the condition for many years. There are, however, but 76 reported cases in the literature. The author has found 4 such tumors in the records of some 5000 cases in the files of the Neuropathologic Laboratory of the Philadelphia General Hospital. Three of these are reported. (1) A male of forty-seven years had suffered for a year with pain in the face, beginning first in the distribution of the second division of the fifth nerve and gradually involving the entire left side of the face. In addition to almost constant pain, there were acute paroxysms of tic-like character. Neurological examination was essentially negative. The motor branch of the left fifth nerve, as well as the corneal reflex on that side, was found to be functioning normally. Exposure of the ganglion revealed a discrete tumor which probably involved the seventh cranial nerve as well. It was partly excised and proved upon microscopic examination to be composed of small round to oval cells together with a large amount of connective tissue. Remnants of the ganglion were present, with many altered ganglion cells. Scattered throughout the tissue were small islands of cells having large vesicular nuclei containing faint chromatin granules. The tumor was classified as a type of Schwannoma or sheath neuroma. At the time of the patient’s discharge there were some residual pain in the left cheek and mouth and a left seventh nerve palsy. Four weeks later, because of rapidly progressing cerebellar symptoms, a second operation [cerebellar] was performed. A tumor, which later proved to be of the same histologic nature as the first tumor, was removed from its attachment directly over the posterior lacerated foramen. (2) A man of thirty-four years complained for one year of headache, numbness of the left side of the face, and poor vision. Examination showed hyperalgesia of the left forehead and cheek and a decrease in the left corneal reflex. At times thero was diminution of pain and temperature sensation in the distribution of the first division of the left fifth nerve. There were definite weakness of the left masseter and temporal muscles and a peripheral left facial weakness, Tendon reflexes were exaggerated, more so on the right, and a Barany test was suggestive of a left cerebellopontine angle tumor. The left gasserian ganglion was exposed, however, and a tumor seeming to extend backward into the posterior foasa was found and partly removed. Upon microscopic examination the tumor was made up of numerous islands of primitive round cells closely resembling the cells of the cerebellar medulloblastoma. The tissue, also, most closely resembles the retino- blastoma or glioma of the retina. The final diagnosis was neurocytoma. The patient was lost sight of at the end of a year, and the final outcome is unknown. THE NERVOUS SYSTEM 267

(3) A male of thirty-three years had complained for about six months of pain in the right side of the face and blindness in the right eye. Prominence of the right eyeball had.been noticed for the past five months. Pain was limited to the distributions of the second and third divisions of the right fifth nerve. The patient was dull mentally and speech was almost unintelligible. The Romberg sign was positive and the gait unsteady. Tendon reflexes were normal, the limbs ataxic; there were blindness from primary optic atrophy on the right and a right exophthalmos. Hyperesthesia in the right trigeminal distribution was observed, but no loss of sensation could be demonstrated. Corneal and right motor fifth tests were normal. Death occurred one year after the onset of symptoms. At necropsy a firm tumor was found within the folds of and under'the dura, on the inferior and lateral surfaces of the right temporal lobe. The growth involved the gasserian ganglion, being continuous with the central trigeminal root. Microscopically the tumor was encapsulated, and scattered in its substance were small clusters of degenerated ganglion cells and irregular bundles of nerve fibers surrounded by Schwann cells. The pathological diagnosis was fibroblastoma. The symptomatology of gasserian ganglion tumors consists first in trigeminal pain hnving a dull and constant quality. Acute tic-like paroxysms in addition are common. Objective diminution or loss of the sensations of touch, pain, heat and cold in a part or all of the trigeminal distribution is considered common; the combination of spontaneous pain and impairment of sensation objectively being regarded by many as diagnostic. A loss of corneal, lacrimal, and gag reflexes, as well as impairment of function of the motor branch, may occur. Signs dependent upon disturbance of the nerves supplying the intrinsic and extrinsic muscles of the eye are not unusual. With the extension of the growth to invade or compress the brain or the structures of the posterior fossa, additional symptoms and signs occur, dependent upon the structures affected. A statistical study of the symptomatology of all the reported cases in the literature bears out the above remarks. The value of roentgenology in the diagnosis is questionable, as it appears not to be dependable. The degree of malignancy of the tumors in this region, whether they be primary or metastatic, obviously influences the prognosis. The pstho- logic diagnoses reported in 22 cases analyzed for this communication were as follows: endothelioma 10, neuroma 2, sheath neuroma 2, neurocytoma 1, neuro- fibrosarcoma I, sarcoma 1, fibroblastoma 1, chondroma 1, neurofibroma 1, undetermined 2. Before conclusions can be offered as to the effect of operation upon duration of life, larger groups of cases must be studied. The operative results obtained in early cases have been good. Exploratory operation in the region of the gasserian ganglion by competent operators is justified for patients who suffer suspicious constant trigeminal pain not satisfactorily explained, and for patients who show objective indications of interruption of the trigeminal motor sensory pathways without evidence of an etiology other than ganglion tumor. This paper includes a careful analysis of the available literature, two statistical tables, and four illustrations. EDWINM. DEERY

Venous and Arterio-Venous Angiomas of the Brain; Clinical and Roentgeno- graphic Study of Eight Cases, S. BROCKAND C. G. DYKE. Bull. Neurol. Inst., N. Y. 2: 247-293, 1932. A clinical and roentgenographic study of eight cases of blood-vessel malformations of the brain, in contrast to the hemangioblastomas. The first three cases were venous angiomas. 268 ABSTRACTS

(1) A left-handed man of thirty-three years complained of headaches and convulsive seiaures. The headaches, paroxysmal in type, had been present for eighteen years and were generally localised in the frontal or left temporal regions. They were always preceded by an aura consisting of numbness of the right leg, ditainess, nausea, and vomiting. For the past three years convulsive seiaures with loss of consciousness had occurred. The physical examination was essentially negative. Roentgenograms of the skull showed a large irregular calcified mass in the left occipital and parietal regions, made up of a series of parallel linear streaks. X-ray plates of the heart showed slight cardiac enlargement. Upon the basis of the above findings a diagnosis of venous angioma of the left occipital lobe was made. (2) A male child with a port-wine nevus of the right forehead, scalp, and upper lip (distribution of first and second branches of right trigeminal nerve) suffered a probable left cerebral hemorrhage at the age of nine months, following which amentia and right hemiplegia developed. Encephalograms revealed a poren- cephalic cyst on the left side, also a convoluted calcification characteristic of a venous angioma in the right occipital lobe. (3) A young man with a history of acute epidemic encephalitis some years before had exophthalmoa, blindness of the right eye, ocular palsies, a left facial weakness, cerebellar incoordination, and mental deterioration. Upon examination there were found a large nevus of the right cheek, ataxia, a marked pulsation of the right carotid artery synchronous with a loud intracranial bruit. There was bilateral exophthalmos and the right fundua showed an extensive venous angioma of the retina. Roentgenograms showed a heart shadow of normal site, and an enormously enlarged vascular channel in the right frontal bone but no abnormal calcification. Necropsy, following suicide, showed the right cavernous sinus to be the site of an angiomatous lesion confluent with a matted, flat angiomatous mass covering the right part of the optic chiasm. Further study of the brain revealed that the angiomatous lesion extended from the right retina, optic nerve, optic chiasm and tract, to the right mid-brain and, via the right superior cerebellar peduncle, to the right half of the cerebellum. Five cases of arterio-venous angiomas are reported. (1) A man of fifty-one years had recently complained of bilateral tinnitus, irritability, and mental changes. Examination disclosed an exostosis in the mid-occipital region below which were the occipital arteries which had undergone aneurysmal enlargement. The vessels of the neck were enlarged and actively pulsatile. The heart was enlarged, and there were bilateral ptosis, exophthalmos, and sluggish pupillary reactions. Eight years later a left homonymous hemianopsia was found. Roentgenograms of the skull showed an extensive thinning of the right occipital bone and irregular streaky deposits of calcification deep in the right occipital lobe. The heart shadow was definitely enlarged. (2) A boy of sixteen years with mental retardation, right homonymous hemianopsia, and an arteriovenous angioma in the frontal region of the scalp showed enlargement of the heart, an unusual cardiac murmer, tachycardia, and pulsating carotids. The slowly increasing swelling on the forehead had not been painful and the only complaint was difficulty in keeping up with his school studies. Auscultation of the frontal swelling gave a loud bruit. In the upright position the patient proved to have a continuous humming murmer, with systolic accentuation, over the upper part of the mid chest, transmitted upward along the vessels of the neck. Besides evidence of diffuse increase of vascularity, the skull roentgenogram showed many fine streaks of calcification in the left frontal lobe. (3) In a woman of twenty-five years there developed, in the course of a year, papilledema, defective vision, and a left homonymous hemianopsia. Examination showed an enlarged heart, tachycardia, a faint mitral systolic murmer, and a very THE NERVOUB BYSTEM 269 low diastolic blood pressure. Roentgenograms of the skull did not show abnormal calcification. An exploratory craniotomy for a suspected right frontal neoplasm was performed and an arteriovenous angioma was found. Considerable subjective relief followed the operation [which provided a decompression]. (4) A woman of fifty-three years suffered from headache, tinnitus, and failing vision over a period of three years. Upon examination there were found a right lower facial weakness, a right homonymous hemianopsia, optic atrophy, and evidence of mental changes. The blood pressure was low and the heart enlarged. The left temporal and carotid arteries were larger than normal and showed strong pulsations. An intracranial bruit was heard over the left temporal region. Ab- normal calcification was found in the left frontal lobe, as well as anomalous vascular channels in this region. (5) A man of thirty-four years had a history of acute epidemic encephalitis, followed nine years later by convulsive seizures. Examination revealed bilateral papilledema with optic atrophy, left homonymous hemianopsia, left internal rectus paralysis, nystagmus, right facial weakness, diminution of deep reflexes, and peculiar sensory and mental changes. Roentgenograms of the skull failed to aid in establishing a diagnosis. Ventriculography revealed an internal hydrocephalus. Subsequent necropsy showed an angioma filling the upper third or fourth of the midbrain. The venous angiomas occurred in males with an average age of twenty years. The arteriovenous angiomas were found in three males and two females with an average age of thirty-six years. In the six patients in whom definite data were obtained, two were left-handed, two ambidextrous, and two were right-handed. Two patients gave a history of “ acute epidemic encephalitis.” “ In the last few years it has become increasingly evident that the signs and symptoms so commonly attributed to acute epidemic encephalitis are often due to disease in the inter or mid-brain of entirely different causation.’’ Among the symptoms of these intracranial angiornas, the commonest were tinnitus or subjective noises in the head, headache, convulsive seizures, and mental changes. The estimated average duration of symptoms for the venous angiomas was ten years, and for the arteriovenous lesions fifteen years. The visual fields were most strikingly affected in the arteriovenoua group, all having shown an ho,monymous hemianopsia. As a result of the arteriovenous communication, important cardiovascular effects ensued in the caRes .of arteriovenous angiomas. The arteries of the dura and scalp became enlarged, and the carotid arteries and the heart became dilated. While the systolic blood pressure was rather low in all the cases, averaging 110, the diastolic pressure averaged 50 in the arteriovenous and 80 in the venous group. As a result there was a high pulse pressure in the former group with a water hammer quality of the pulse. It has been shown [by Sir Thomas Lewis and A. N. DruryJ that in arteriovenous communications considerable blood goes directly from the arteries to the veins, with a consequent fall of the mean arterial pressure. Electrocardiographic studies were made in six of the present group and were normal in five. The intracranial bruit heard over the skull was a typical arterial “ blow ” with a systolic accentuation. In four cases, extracranial angiomatous lesions of the scalp or face were found. Five cases showed fairly characteristic intracranial calcification. In regard to therapeutic measures: when there is a large arterial component in a progressively developing cerebral angioma, ligation of the carotid vessels on one side of the neck is indicated. Roentgen therapy seems worth while in some cases and appears to speed up the natural tendency to calcification. Surgical removal of the intracranial angioma, whether venous or arteriovenous, is usually impossible. Some sixteen very good illustrations and three charts illustrate this paper. EDWINM. DEERY 270 ABSTR A CT8

Anatomical Types of Brain Gliomaa, P. SCHWARTZ.Anatomische Typen der Hirngliome, Nervenarzt 5: 449-456, 1932. A review and study of some 400 intracranial tumors which have been collected during the past ten years at the Frankfurt Pathological Institute. A series of detailed anatomical studies is presented, with illustrations, of various tumors (gliomas), showing their location, extent, and apparent site of origin. Neoplasms are studied which have involved a frontal lobe, the corpus callosum, paracentral lobule, superior temporal gyrus, hippocampal gyrus and gyms supramarginalis. It is apparent from the study of brains containing gliomas that the area between the corpus callosum and the substance of the hemisphere is one of the most frequent sites of origin for these tumors. Many tumors with a small cortical presentation are found, when studied at necropsy, to be very extensive growths, not infrequently actually originating deep in towards the midline. EDWINM. DEERY

Familial Glioma, W. BENDERAND F. PANSE.Familiares Gliom, Monatschr. f. Psychiat. u. Neurol. 83: 253-285, 1932. A discussion of hereditary factors as applied to the gliomas, together with some 57 brief case abstracts. From investigations based upon this series it seems likely that hereditary factors may play some part in causing gliomas. Three histories are given in greater detail. A patient of sixty developed signs of an intracranial tumor; necropsy revealed multiple gliomatous nodules scattered throughout the brain. The second case did not come to necropsy, and the third had neither operation nor necropsy. The hereditary factors found in the investigation of these three patients were considered to have a relationship to the development of the intzacranial gliomas. EDWINM. DEERY

Ventriculography in Tumors of the Posterior Fossa. A New Radiographic Sign, J. ESTELLAAND L. ESTELLAY BERM~DEZDE CA~TRO.La ventriculograffa en 10s tumores de la fosa posterior. Nuevo signo radiogrhfico, Progresos de la clin. 40: 409-413, 1932. The authors believe that many diagnosticians are failing to obtain proper resdts in the diagnosis of posterior fossa tumors because they do not appreciate the advantages of placing the patient in different positions with respect to the radiographic plate. Thus, given a patient with a tumor of the right posterior fossa which is causing pressure and deformity of the occipital pole of the right ventricle: (a) if a straight lateral roentgenogram is taken with the patient lying down, with the right side of the head down and against the plate, the ventricular fluid will gravitate to the abnormal right ventricle while the air will distend the left side and give a normal appearing ventriculogram; (b) on the other hand, if the left side of the patient’s head is placed down and against the plate, the fluid will gravitate to the normal left ventricle, the air will partly distend the right ventricle, and the defect in the posterior horn of the ventricle will then be apparent; (c) if an antero-posterior film is taken with the occiput down and against the plate, the ventricular fluid will gravitate posteriorly in the ventricles, while the air will distend the normal appearing anterior portions of the ventricles and give a normal appearing ventriculogram; (d) if the patient is reversed so that the frontal region is down and against the plate while the occiput is up, the ventricular fluid will gravitate to the anterior portions of the ventricles leaving the posterior poles of the ventricles to be distended with air, showing up any defect in their contour. The article is well illustrated by drawings and reproductions of roentgenograms. JOHN E. WIRTH THE NEBVOUS SYSTEM 271

Multiple Tumor Implants in the Ventricles Revealed by Ventriculography, J. R. LEARMONTEAND J. D. CAMP.Am. J. Roentgenol. 29: 393-394, 1933. A male of twenty-nine years complained of headaches, fatigue, and vertigo, followed by unsteadiness of gait, for about six months. More recently there had developed a progressive failure of vision. Except for incoordination and stagger- ing gait, objective neurologic signs were absent. Roentgenograms of the skull revealed evidence of increased intracranial pressure, erosion of the anterior and posterior clinoid processes, and thinning of the orbital plate of the frontal bone. Vision was somewhat reduced and perimetry showed bilateral cecocentral sco- tomas. Since the ophthalmologic signs pointed to the presence of a prechiaRma1 lesion, whereas the clinical signs were cerebellar, ventriculography was performed for purposes of localization. The films revealed an internal hydrocephalus with a dilatation of the third ventricle. There was an obvious rounded filling defect in the floor of the t,hird ventricle and a lobulated defect in the inferior portion of the anterior horn of each lateral ventricle. In the effort to explain these findings upon the basis of a single lesion, a diagnosis was made of a basofrontal tumor extending to and involving the floor of the third ventricle. The patient died three days after exploration of the chiasmal region. Necropsy revealed a large tumor mass filling the fourth ventricle and extending forward and upward through the aqueduct of Sylvius, surrounding the pineal gland, and implanting itself at numerous Rites in the floor of the third ventricle and in the walls of the lateral ventricles, which had a papillomatous aspect. The tumor had grown through the floor of the third ventricle and had Rurrounded and infiltrated the optic nerves and the optic chiasm. There were also many implants on the surface of the brain. Microscopically the tumor proved to be a medulloblastoma. When the ventriculograms were reviewed in the light of the necropsy findings, it became apparent that the multiple tumor implants on the floor of the anterior horns and in the third ventricle had stood in relief against the air filled ventricles, producing the rounded and lobulated defects observed. The possibility of diagnosing tumor implants in the ventricles by means of ventriculography does not seem to have been considered in the literature. Inasmuch as this condition is not uncommon, the findings in this case will serve to emphasize the importance of considering multiple lesions when a ventriculogram reveals more than one filling defect. [The spinal cord findings in this case are not included. It is more than likely that this medulloblastoms of the fourth ventricle had seeded implants throughout the spinal subarachnoid space as well.] EDWINM. DEERY TemporoparietalTumor with Varied Symptomatology, DELMAS-MARRALET.Tu- meur temporo-paribtale visible s’accompagnant d’hbmianopsie, d’aphasie, de surditb corticale et de crises convulsive8 (radiographies), Bordeaux chir. 4: 211-212, 1932. Brief account of case in which a man presenting a visible swelling in the left temple, with hemianopia, aphasia, cortical deafness, and finally Jacksonian epi- leptic attacks, was found at autopsy to have a large, partly cystic tumor [not histologically described] occupying the temporal and parietal lobes. F. CAVERS Report of a Case of Retotheliosarcoma (Reticulosarcoma) of the Cerebral Hemi- sphere, N. C. FOOTAND S. COHEN. Am. J. Path. 9: 123-131, 1933. A tumor is reported which is “ of an almost unique character,” and which presents considerable difficulty in the way of diagnosis. A girl of nine years had 272 ABSTRACTS enjoyed good health up to eight months ago, at which time severe frontal headaches, projectile vomiting, nausea, and visual loss developed. Upon examination the right pupil was larger than the left, and there were papilledema, absence of knee jerks, and a right homonymous hemianopsia. A diagnosis of left frontal tumor was made and, following a preliminary simple decompression to relieve pressure, the tumor was partly removed at a second operation. A necropsy, limited to the head, revealed residual tumor tissue beneath the cortex of the left temporo-parietal region and extending deeply toward the central part of the brain. Superficially the growth seemed encapsulated, whereas more deeply it was obviously infiltrating. The sectional surface presented circumscribed, pearly white areas that alternated with streaks or localized spots of an orange-colored tissue that gave the tumor a xanthomatous appearance. The growth was rather nodular beneath its capsule, and the pearly areas suggested cellular alveoli, while the orange-colored material may have been necrotic tissue or a stroma with lipoid infiltration. With routine stains it was at once apparent that the greater part of the tissue was composed of nests of enormous and very bizarre giant cells and syncytia lying in a stroma of rather edematous connective tissue. The cells presented a most pleomorphic ‘appearance and showed sphenoidal, turnip-shaped, fusiform, unipolar, bipolar, or cylindroid outlines. The individual cells contained from one to as many as twenty nuclei of varying sire and shape. Some of the cells had a large number of minute vesicular nuclei. Mitotic figures were abundant. Cell cytoplasm was for the most part pale and vacuolated. The larger cells approximated 50 to 80 microns in their longest diameter. The stroma gave the general impression of trabeculae, between which occurred the sinusoids containing tumor cells. The more healthy areas of the tumor suggested a retothelial origin, but against this is the marked lack of blood vessels and the site of the growth. A variety of special staining methods were used to determine the nature of the growth. Methods for neuroglia cells and fibrils failed to demonstrate any neuroglial elements. The same methods failed to establish the presence of ependymal cells. Moreover, the tumor did not obviously involve the wall of a ventricle. A meningeal origin can be ruled out on the basis of the site of the tumor and of its architecture, which in no way suggeste that of a meningioma. With methods for nerve cells the tumor elements showed a close resemblance in general outline to ganglion cells. Definite processes appearing like dendrites of pyramidal cells were found. Absent, however, were nerve fibers and Nissl bodies. Further special methods demonstrated the presence of abundant collagenous fibers in the stroma, and many areas were reminiscent of splenic tissue. Froren sections stained with scarlet R and hematoxylin show a very rich lipoid content. With the above facts available, a neurogenic origin for the tumor cannot be seriously considered. In spite of the apparent similarity of its larger cells to ganglion cells, all the evidence points more clearly to a retothelial origin. In spite of the dictum that such tumors occur in the base, hind brain, or cord, rather than in the hemispheres, there seems to be no valid reason why they should not be found there as well. “ It would appear that our case represents a malignant metamorphosis of such a tumor-Gushing and Bailey’s hemangioblastoma or Roussy and Oberling’s angior6ticulome. It would under this hypothesis constitute a retotheliosarcoma, or reticulosarcoma under the old terminology.” In speaking of such a tumor the term “ endothelioma ” should be avoided to escape the confusion that might arise between it and the endothelioma of the dura. EDWINM. DEERY THE NERVOUS SYSTEM 273

Tumors of Rathke’s Pouch, M. VIDAUR. Sobre 10s tumores de la bolsa de Rathke, Arch. de oftal. hispano-am. 32: 1-43, 1932. This article gives a good general survey of the development, the symptomatology, the diagnosis, and the treatment of tumors of Rathke’s pouch, as well as clinical histories of 5 cases. In 3 of these the tumor was removed successfully by operation. The writer mentions also a case which he himself observed but which has not been verified. The article contains 27 pictures and diagrams. It is to be regretted that no bibliography is added, as this would have increased the value of the contribution. JOHANNBSP. M. VOGELAAR Operations by the Nasal Route on Pituitary Tumors, 0. HIRSCH. Die nasalen Operationen der Hypophysentumoren, Klin. Monatsbl. f. Augenh. 89: 782- 789, 1932. Since both the intracranial and nasal route operations for pituitary tumors have equally enthusiastic adherents, both methods are discussed in some detail. The nasal route we owe to Schloffer. It ha8 subsequently been modified by Kanavel, Kocher, Proust, Leche and others. v. Eiselsberg, using this method in 36 cases, had only 9 postoperative deaths, while Cavina lost but 3 of 29 patients operated upon by this method. Hirsch’s own “ endo-nasal ” method is mentioned. This operation was soon superseded by his “ septal ’’ method, which he has since used in some 233 cases. With this method his mortality in the past thirteen years has been 5 per cent. The chief indication for operation is a progressive decrease in visual acuity. Progressive endocrine symptoms or headaches rarely constitute reasons for operating. [For some earlier remarks on this type of operation by the writer see Klin. Monatsbl. f. Augenh. 85: 609, 1930.1 A statistical study, chiefly of a group of 175 cases, is included, and methods used by other neurological surgeons are discussed briefly and compared with the writer’s. It is believed that the septal route with decompression of the pituitary adenoma from below gives highly satisfactory results and preservation of vision, often for many yeare. [In America an intracranial approach is usually favored. In approaching the chiasmal region and the underlying tumor from above, the lesion is directly visible to the surgeon. Moreover, the optic nerves are in sight and can thus be protected during tumor removal. There is definitely less risk from meningitis. Approach- ing the tumor from below is favored by some. By this simpler method the residual tumor tissue, which always remains, has an opportunity to expand downward into the sphenoidal cells rather than upward into the cranium. Unfortu- nately the integrity of the dural diaphragm above the sella turcica cannot be known beforehand, and not a few of the adenomas have already penetrated into the cranial cavity.] EDWINM. DEERY

Cancer of the Rypophysis, E. DE ARAUJO. Cancer da hypophyse, Brasil-m6d. 45: 1119-1122, 1931. A woman thirty-five years of age was admitted to the hospital in a comatose condition in which she remained for about six hours, until death. No history could be secured, and all that could be learned was that her illness had been of sudden onset, with headache and fever of a few days’ duration. At autopsy a rounded tumor, of a dark color (chocolate brown), was seen protruding from the sella turcica, covered with a fine layer of smooth, .glistening tissue which formed a genuine capsule. On removal of the brain, this tumor was seen to be pear- shaped, tapering downwards. The portion of the tumor projecting into the cranial cavity measured 32 mm. in. the antero-posterior diameter and 34 mm. in 274 ABSTRACTS the transverse diameter. The mass which projected into the interior of the skull was connected by a sort of pedicle with the portion contained in the pituitary fossrr. The tumor mass had undoubtedly originated from the hypophysis. On removing the portion of the tumor contained in the pituitary fossa, the walls were found to be intact. Microscopic study of the parenchyma showed &rands of cells with a finely granular or more or less homogeneous cytoplasm, which took an intensive and uniform stain with acid dyes and was distinctly eosinophilic. Cells of this type were the only ones encountered in t.he neoplasm. The nucleus, of regular shape as well as outline and distribution of the chromatin network, showed affinities for basic dyes. The stroma consisted of thin and scanty fibers, nowhere arranged in lobules. Only traces of the original structure of the gland were seen. The microscopic diagnosis was cancer of the hypophysis, with eosinophilic cells. Presumable Case of Pituitary Region Tumor, TRAUMA". Uber einen Fall, der als Tumor der Hypophysengegend gedeutet wurde. Ztschr. f. Augenh. 80: 197, 1933. A man with gradually failing vision was found upon examination to have a central scotoma on the right side, with fairly normal vision on the left. Under obeervation he developed a bitemporal hemianopsia. Aside from his poor vision there were no neurological complaints, but sexual impotency was present. Sero- logical tests were negative for syphilis. Roentgenograms of the skull showed an enlargement of the sells turcica and some erosion of the posterior clinoid processes. Further roentgenograms of the long bones of the body were all within normal limits. Upon rhinological examination there wae found some evidence of an inflammation of the ethmoid bone on the left Ride. The patient was considered to have a pituitary adenoma, and two series of roentgen-ray treatments were given, with marked improvement in visual acuity and a shrinkage of the bitemporal field defect. EDWINM. DEERY Intraspinal Tumors in Spina Bifida Occulta, J. GONZ~LEZ-AQUILAR.Tumores intrarraqufdeos en la espina bffida oculta, Progresos d. 1. clin. 40: 311-314, 1932. In 32 laminectomies on patients with spina bifida occulta and cord symptoms the author found that in 27 the only tumor process was the fibrous band extending from the dura to the bony defect or to the subcutaneous tissues of the back. In two cases this fibrous band extended below the dura and was intimately associated with a venous angioma. In another two cases the band was loosely connected to a fibrolipoma of the dura. In one case a fibrolipomatous mass extended for a distance of 5 cm. and was intradural as well as extradural. Operation greatly improved or cured all of these patients, so that the author is very optimistic about operation in spina bifida occulta with associated tumors, as they are likely to have the same benign characteristics as the ones he encountered. JOHNE. WIRTH Medullary Meningoexothelioma, SANCHEZLUCAB. Meningoexotelioma medular, Arch. d. med. cir y especial. 35: 484, 1932. Because of the confusion in terminology of endotheliomas of meningeal origin the author has adopted the plan, which he says Rio-Hortega advocates, of calling (a) endotheliomas, those tumors which arise from the endothelium of vessels, (b) peritheliomas, those tumors whioh arise in the adventitia of vessels, and (c) exotheliomas, those tumors which arise from endothelial syncytial tissue such as the arachnoid (meningoexothelioma) and the perineurium (neuroexothelioma). He reports briefly a case of meningoexothelioma at the level of the fourth to the THE NERVOUS SYSTEM 275 sixth dorsal vertebra, which partially surrounded the cord, giving rise to pressure symptoms but not destroying the meninges or the bone and showing no microscopic signs of malignant infiltration. He believes the tumor arose from the lymphatic vessels of the dura or from the loose connective tissue between the dura and the spinal cord. JOHNE. WIRTH Further Developments in a Case of Intramedullary Andoma Operated Upon in 1912. Remarks on the Diamosis of Spinal Cord Tumors, F. SCHULTZE. Weiterer Verlauf bei einem im Jahre 1912 operierten Falle von intrame- dullarem Angiom nebst Bemerkungen uber die Diagnostik der Rlickenmarks- tumoren, Deutsche med. Wchnschr. 58: 1357-1358, 1932. A patient was operated upon in 1912 and a lesion believed to be an intramedullary angioma was found, involving the upper part of the thoracic spinal cord. The postoperative recovery was fair, and in the following years the patient received roentgen therapy, because of a persistent paralysis. In addition to the motor difficulty, the patient has had localized pains along the fifth rib on one side. A detailed account of the neurological findings in 1932 suggests that there has been some little further improvement. Brief general remarks upon the subject of spinal cord tumors and their diagnosis reflect the usually known facts. EDWINM. DEERY

Tumor of the Brachial Plexus, F. PAPIN.Tumeur du plexus brachial. Gar. hebd. d. sci. m6d. d. Bordeaux 54: 259-261, 1933. A girl of sixteen years had a neurinoma of the fifth cervical nerve near the brachial plexus, without any functional trouble. It was removed with only slight temporary difficulty in the abduction of the arm after operation. Tumors of this type are rarely located in the brachial plexus; they should always be removed, as some show a tendency to become malignant.

Clinical Aspects and Genesis of Neurofibromatosis, D. E. KNIASCHANSKY.Zur Klinik und Genese der Neurofibromatosis. Arch. f. Dermat. u. Syph. 166: 371-374, 1932. The cause of neurofibromatosis is not known. Trauma, hereditary factors, neurotic diathesis, and dysplasia have been prominent terms in the list of supposed causes. The importance of intoxications in such cases has been considered by Mosbachei. Kniaschansky gives a single case report. A woman of thirty years had a large lesion of neurofibromatous nature on the back, together with many other smaller macular and papillary lesions present since birth. Of recent years the large lesion on the back had slowly increased in sire. In addition a “ mantle ” of skin 45 cm. in circumference hung from the waist. This unusual lesion grew larger during pregnancy. There was a history of severe lead poisoning and of typhus fever some five years previously. The possible influence of the lead poisoning upon the course of the disease is discussed, but no definite conclusions are reached. Some of the patient’s children also showed evidence of neurofibromatosis. EDWINM. DEERY Changes in the Nerves, Skin, and Bones in Recklinghausen’s Neurofibromatosis and Their Genetic Connections, A. STALMANN.Nerven-, Haut- und Kno- chenveranderungen bei der Neurofibromatosis Recklinghausen und ihre ent- stehungsgeschichtlichen Zusammenhllnge, Virchow’s Arch. f. path. Anat. 289: 96-126, 1933. A review of the literature is followed by observations upon some 35 patients with neurofibromatosis. The clinical and laboratory findings, reflecting the 276 ABSTRACTS usually known facts about the disease, are given and discussed. All of the patients were investigated from the point of view of hereditary incidence of the disease, which many of them showed. There are detailed descriptions of the cases constituting the series, together with eleven clinical illustrations. EDWINM. DEERY Relation between Neurofibromatosis and Circumscribed Gigantism, H. J. SCHERER.Zur Frage des Zusammenhanges zwischen Neurofibromatose (Recklinghausen) und umschriebenem Riesenwuchs, Virchow’s Arch. f. path. Anat. 289: 127-150, 1933. This is a careful study of a case of von Recklinghausen’s disease in a man of fifty-three years. No history of the patient’s family was obtainable. When he was twenty years old he first noticed small nodules on the skin of both forearms. These had extended gradually over the whole body. A hairy mole had been excised nineteen years previously and had since recurred. The patient came to the hospital because of severe stomach symptoms due to an ulcer. Autopsy showed an extensive von Recklinghausen’s neurofibromatosis in the form of numerous small and large nodules in the skin, the vagi, and the nerves of the extremities and the organs. The intracranial nerves and the spinal roots were free from these changes. On the right side of the hip was a very large pedunculated growth of the skin, and there was a general pigmentation of almost all parts of the body. Both vagus nerves were diffusely thickened; likewise the sympathetic branches, but much less than the vagi. The esophagus was greatly thickened. The wall of the dilated stomach was about 1 cm. thick. The mucous membrane showed coarse folds. At the fundus was an ulcer of considerable size and two smaller ones lay on the lesser curvature. There were a few old scars at the pylorus. The whole intestinal tract was enormously distended but showed neither ulceration nor thickening of the wall. The appendix was large and long; the proximal portion was about the thickness of a lead pencil, the distal portion about 1 cm. in diameter; the wall was 2 to 3 mm. thick, and the lumen was patent. The wall of the appendix showed an extraordinary development of nerve fibers and ganglion cells, extending into the mucous membrane. There were extensive thickenings of the vessels. In the stomach and the esophagus much the same type of change was found and in both the muscularis contained large numbers of ganglion cells and nerve fibers. Small neurinoma nodules were present in the muscular layers. Careful detailed microscopic studies are given of the nerve fibers, which showed peculiar swellings along the axis cylinders. The writer thinks that the extraordinary hypertrophy of the muscle tissue of the stomach and esophagus may be due to influence of the vagus, as ligature of that nerve trunk in animals has been observed to cause a growth of the stomach wall. Possibly the chronic vagus irritation due to the changes in both vagi may have caused hypertrophy by irritation of the muscle fibers, The 14 illustrations are excellent and a bibliography of 50 references is ap- pcnded. EDWINM. DEERY Characteristics of Neurofibromatosis, H. BLOTEVOOEL.Das Charakterbild der Neurofibromatose (Recklinghausen), Dermat. Wchnschr. 96: 361-368, 1933. A preliminary paper introductory to a study of von Recklinghausen’s disease now in progress. The writer stresses the “ neurofibromatous constitution ” of patients with this disease and refers the reader to the clinical aspects of such cases as are described by Stalmann in Virchow’s Arch. f. path. Anat. 289: 96, 1933 (see above). There follows a statistical survey of the patients referred to in regard to blood groups, finger prints, and a variety of anthropologic measurements. EDWINM. DEERY THE NERVOUS SYSTEM 277

Simultaneous Appearance of Hereditary Multiple Neuro5bromata and Gliomata (Peripheral and Central Neuro5bromatosis) with Diffuse Involvement of the Brain, Spinal Cord, and Meninges, F. HARBITZ. Uber das gleichreitige Auf- treten multipler Neurofibrome und Gliome (Gliomatose) (periphere und sen- trale Neurofibromatose) auf erblicher Grundlage und mit diffuser Verbreitung in den Ruckenmarks- und Gehirnhauten, Acta path. et microbiol. scand. 9: 359405, 1932. . Also in Norsk. mag. f. laegevidensk. 93: 841-848, 1932. Five cases are reported in support of the argument that neurofibromatosis is a diffuse disease of the “ ectodermic ’’ elements. A boy of nine years had pains in the legs, scoliosis, motor weakness of the limbs, a facial paralysis, ataxia, and progressive mental deterioration. Upon examination multiple neurofibromata were found over the body surface. After a long illness, during which time there were several convulsive attacks, the child died. At necropsy, besides an internal hydrocephalus, there were found multiple areas of gliosis widespread in the brain and spinal cord, as well as many more neurofibromata. The patient’s mother had had multiple tumor nodules diagnosed as neurofibromata. Six of the woman’s 8 other children had either areas of pigmentation or definite tumor nodules. The case is reported as showing the hereditary tendency of neurofibromatosis and the close relationship between this disease and gliomatosis. A woman of forty-nine years with no family history of neurofibromatosis had rapidly advancing signs of an intracranial tumor and died two months after the onset of symptoms. The body showed extensive pigmentation of the skin and numerous subcutaneous tumor nodules, which upon microscopic examination proved to be typical neurofibromata. A woman of fifty-two years with subcutaneous neurofibromata suffered from a rapidly progressive paraplegia and sharp pains in both arms and legs. There was also marked loss of hearing on both sides. Necropsy revealed multiple tumor nodules of varying sire in the brain, about the basal ganglia. Similar lesions were found in the region of the fourth ventricle and Sylvian aqueduct. The greater part of the Rpinal cord was “ practically encapsulated ” by tumor tissue. Histologic examination of the tissues from the various sites showed similar characters and the tumors were classified as medulloblastoma. A boy of six years with no familial history of disease had several generaliaed convulsions and later complained of headaches and progressive loss of weight. Examination showed evidence of increased intracranial pressure and signs of ataxia and incoordination. An exploratory craniotomy revealed a medulloblastoma of the left half of the cerebellum. A subsequent necropsy showed that the tumor had spread extensively throughout the brain and spinal cord. A boy of sixteen years had for nearly a year had signs and symptoms of a brain tumor. A necropsy showed a large infiltrating medulloblastoma of the right cerebral hemisphere. The last two cases presumably showed some evidence of neurofibromatosis as well. EDWINM. DEERY Two Cases of von Recklinghausen’s Neuro5bromatosis, G. PETQES,A. PETQES, AND R. BARGUES. Deux cas de neurofibromatose de Recklinghausen, J. de m6d. de Bordeaux 110: 294-295, 1933. Two cases of von Recklinghausen’s disease, in young men aged twenty-two and twenty-five years, are reported. In the first case there were a number of areas of pigmentation and numerous cutaneous tumors of various sires, sub- epidermic; a biopsy of one of these tumors showed a benign glioma. This patient showed no neurological symptoms, but marked mental deficiency. In the second case there were similar areas of pigmentation and small cutaneous tumors, both of which had been present since infancy. This patient also showed marked mental 278 ABSTRACTS deficiency and inability to adapt himself to any occupation. The authors consider these cases of special interest because the mental deficiency was in each case the outstanding symptom; the pigmentation and the tumors were relatively unimportant. Neurofibromatosis (von Recklinghnusen’s Disease), PEDROPIULACHS. Sobre la neurofibromatosis (enfermedad de Recklinghausen), Progresos de la clin. 40:469-477, 1932. Piulachs presents a case of neurofibromatosis which involved the cutaneous and subcutaneous tissues of nearly the entire body. There were also nerve disturbances and slight bony changes. The symptomatology of the disease is discussed at length, but no new ideas or facts are expressed. There is a short bibliography . JOHNE. WIRTH Neurofibromatosis in a Child, with Skeletal Malformations, H. GRENET,P. ISAAC-GEORGESAND L. LOUVET. Maladie de Recklinghausen; forme pig- mentaire, sans tumeurs, Bull. SOC.de p6diat. de Paris 30: 536-537, 1932. A girl of ten years showed numerous pigmented patches in the skin, resembling in appearance and distribution those which are found associated with nodules in the fully developed form of neurofibromatosis. There were also skeletal deformities, probably congenital, such as commonly occur in that disease. The upper part of the sternum had an oblique anterior bony wing, producing increased depth of the left supraclavicular fossa; the left clavicle was subluxated; the cer- vicodorsal spine showed kyphoscoliosis, and there were slight bony deformities in the left arm about the elbow and wrist. F. CAVERS

BONES, JOINTS, AND MUSCLES

Bone Tumors, ERNESTODESPAIGNE. Tumores de 10s huesos, Bol. de la liga contra el c4ncer 7: 225-239, 1932. A popular paper on the classification of malignant bone tumors, A brief description of each type is given, together with symptomatology and treatment, but no bibliography. JOHNE. WIRTH

Treatment of Bone Tumors, M. FRIEDMAN.J. M. SOC.New Jersey 30: 214-222, 1933. This is a resume, with illustrative case reports, of multiple myeloma, endothelial myeloma, giant-cell tumor, chondroma, and osteogenic 8arcoma. Treat- ment for these conditions is discussed. W. s. MACCOMB Post-traumatic Sarcoma of the Internal Tuberosity of the Tibia, Josd A. CAEIRO. Sarcoma postraum4tico de la tuberosidad interns de la tibia. Bol. y. trab. de la SOC.de cir. de Buenos Aires 16: 1236-1243, 1932. An Italian sixty-two years of age fell from a height of 8 feet, striking his head, hip, and the internal surface of his right knee and leg. His scalp had to be sutured but he was not detained in the hospital. He did not return to work for two months after this and received massage for pain in the lumbo-iliac region. Three months after the injury progressive and continuous pain developed in the region of the inner surface of the right knee. Four months after the injury the knee began to swell, and a tumor appeared on the inner surface of the head of the tibia. Six months after the injury a thigh amputation was performed for a destructive giant-cell osteogenic sarcoma of the head of the tibia. BONES, JOINTS AND MUSCLES 279

The author believes that the six fundamental criteria are present in this case to place it in the group of traumatic sarcomas. [It may be noted that there is no mention of a traumatized area in the region of the knee at the time of the injury and no specific statement that it was apparently normal to physical examination at that time. There is only the patient’s history of trauma and of a normal knee until three months after the injury.] JOHNE. WIRTH

Irradiation in a Case of Osteogenic Sarcoma; Recovery, S. MOORE.Surg. Gynec. & Obst. 56: 681-686, 1933. Following a brief discussion on the frequency of occurrence and methods of treatment of osteogenic sarcomata, the author reports a case occurring in the head of the tibia of an eleven-year-old girl, following trauma one month before. The lesion was treated by the insertion of radium element in needles over a period of three days for a total dose of 1,166 milligram hours. This was followed with heavy doses of x-ray irradiation (factors not given). The patient remained free of disease for ten years. [The photomicrograph reproduced does not permit of a diagnosis of osteogenic sarcoma, nor are the roentgenograms characteristic. Lesions very closely resembling osteogenic sarcoma may follow bone injury in children.]

Metastasizing Chondrosarcoma of the Coronoid Process of the Mandible, J. G. PASTERNACK,R. D. LILLIEAND R. A. JONES. Arch. Path. 15: 649-654, 1933. Enchondroma of the skull is held to be a rarity. The tumor reported here developed in the coronoid process of the mandible, a membrane bone, and produced metastases of unusual size. The patient, a white male, twenty-six years old, presented a painful swelling in front of the left ear. Radiographs disclosed an irregularly calcified mass 2.5 inches in diameter in the left parotid region, that had eroded the condyle and ramus of the left mandible. At operation a hard, elastic, encapsulated tumor the size of a baseball was found. Microscopic study revealed spindle-cells grading through myxomatous tissue into areas of cartilage. Under local radium treatment the patient was apparently cured. A year and a half later he was admitted with a recurrence the size of an orange at the old site, marble-sized masses over the left occiput, right jaw, right shoulder, right scapula, and a mass the size of an orange below the right costal margin. In addition, a mass thought to be the spleen was palpable in the left hypochondrium. Under short courses of roentgen therapy these tumors diminished somewhat in size. Four months later the patient died. Necropsy revealed bulky metastatic deposits in both kidneys. Histologic study established the tumor as a chondrosarcoma. [Why not a complex-.parotid tumor?] WILLIAMJ. HOFFMAN

Osteochondromatosis in a Para-articular Bursa of the Inguinofemoral Region, 0. BARTOLI.Contributo clinico ed anatomo-patologico alla osteocondroma- tosi della sinoviale, Chir. d. org. di movimento 17: 260-266, 1932. A woman of fifty-eight had, twelve years before admission to hospital, noticed a small, firm, rounded lump in the right inguinocrural region, which had grown larger and was now causing pain and some difficulty in walking. The mass was ovoid, with its long axis parallel with that of the limb and its upper pole just below the inguinal ligament. It was covered by normal skin and when palpated showed crepitus. At operation it was found to be attached by a broad base to the fascia lata, part of which had to be resected with it. The removed sac contained about 50 C.C. of yellow fluid containing no formed elements; it gave negative results on inoculation into guinea-pigs. There were about twenty mulberry-like 280 ABSTRAOTS nodules, mostly free but some attached to the wall of the sac, from which they had been produced by a process of budding. These bodiea resembled in structure and development the loose osteochondromatous nodules found in joints, and the author gives a clear account of the development of the cartilage and its conversion into bone, illustrated by seven excellent photomicrographs. There is an extensive bibliography, though only one of the publications included in this is referred to in the paper itself. F. CAVERS

Multiple Myeloma, N. FLAX. Am. J. Roentgenol. 29: 479-486, 1933. An increase in reported occurrence of multiple myeloma haa accompanied the more general use of x-rays. Pathological fractures are more common in this disease than with any other form of bone pathology save osteogenesis imperfecta. The roentgenological lesions are widespread punched-out areas of rarefaotion seen most frequently in the ribs, lumbar spine, and skull. Differential diagnoses to be considered are osteomalacia, endothelioma, Paget’s disease, syphilis, lymphosarcoma of bone, and chloroma. Radiation therapy has not been known to check the progress of the disease, though it will relieve the pain. GRAYTWOMBLY

Hyperproteinemin Associated with Multiple Myeloma, M. M. WINTROBEAND M. V. BUELL. Bull. Johns Hopkins Hosp. 52: 156-185, 1933. A patient with coldness, blanching, and mottling of the extremities suggestive of Raynaud’s disease was found to have a large amount of a peculiar protein in her blood, which precipitated spontaneously immediately on withdrawal of the blood from the body. This substance, when washed and dried, was found to be soluble in dilute acids and alkalies and could be crystallixed. It wea not one of the nucleoproteins. In spite of great care in drawing the patient’s blood to prevent cooling or change in pH, the precipitated protein was always present, suggesting that it occurred in the blood stream as a precipitate. Quantitatively there was found to be a minimum of 7.25 grams of this protein per 100 O.C. of blood. The patient subsequently suffered a pathological fracture of the right humerus, and numerous areas of bone destruction occurred in the scapula, skull, and right ilium. Autopsy showed pleama-cell myeloma invading the humerus and lumbar vertebra. At no time during the patient’s hospital stay was there Bence Jones protein in the urine. The blood protein was not soluble on boiling, differing in this respect from Bence Jones protein. GRAYTWOMBLY

Hyperparathyroidism. Relations of the Parathyroid Gland with the Bones. Recklinghausen’s Disease of Bone (Generalized Osteitis Fibrora), PABLO BARLARO.El hiperparatiroidiamo, Prensa m6d. argent. 19: 780-783, 1932; Las relaciones de la glhndula paratiroidea con 10s huesos, 19: 822-825, 1932; La enfermedad 6sea de Recklinghausen (osteitis fibrosa generaliiada), 19: 878-882, 1932; Recorrida bibliogrhfica sobre casos relacionados con 10s puntos tratados; especialmente hiperparatiroidismo, enfermedad 6sea de Reckling- hausen y adenoma de la paratiroidea, 19: 934-939, 1012-1015, 1088-1090, 1142-1144, 1932. In this monographic paper appearing in seven issues of La prensa medica argentina Barlaro reviews the literature of hyperparathyroidism, its relation to bony changes, and especially to von Recklinghausen’s disease of bone, but adds no new material of his own. He reprints 3 series of case reports collected by other authors from the literature and draws conclusions from them. There is no bibliography other than the mentioning of names throughout the text. JOHNE. WIRTH BONES, JOINTS AND MUSOLES 28 1

Twenty Operations on the Parathyroids for Various Pathologic Conditions, R. LERICHEAND A. JUNG.Vingt op6rations parathyroldiennes dans diverse8 affections, Rev. de chir., Paris 52: 5-35, 1933. Only 2 of the authors’ 20 cases need be mentioned here. The patients were young men, aged twenty and twenty-five years, both medical students. In both, radiologic examination showed isolated foci of osteitis fibros’a, the diagnosis being verified by biopsy, and in both there was increased calcium in the blood and urine. In the first case only one parathyroid was found at operation, of nor,mal size, and this was removed; in the second, no parathyroids were found, and both inferior thyroid arteries were resected. Neither patient seemed to have derived appre- ciable benefit from the operation, at the time of reporting, though there was slight reduction in the blood and urine calcium. The authors admit that in these two cases there may have been a parathyroid adenoma which was missed at operation, but they point out that both were early cases with relatively small, localized bone lesions, and only slightly raised blood and urine calcium. They suggest the possibility that in the early stages of osteitis fibrosa there may be no adenomatosis of the parathyroids, and that the development of a parathyroid tumor may be a secondary result of the change in calcium metabolism. The case histories are illustrated by good roentgenograms. F. CAVERB Use of Beef Bones as Transplants After Operation for Osteitis Fibrosa, R. FALTIN. Heteroplastischer Defektersatz durch Rinderknochen nach Operation wegen Ostitis fibrosa, Acta chir. Scand. 71 : 227-244, 1932. The author advocates the use of heterogeneous bone grafts of young beef bones to fill the defects caused by buretting or partial resection of a bone for osteitis fibrosa. No special preparation besides sterilization by boiling for one half hour is necessary for the graft. The histories of two cases in which these heterogeneous grafts have been made are included. In one absorption of the graft with replacement by new bone was complete after three years, while in the other small portions of the graft were absorbed but the larger pieces remained unchanged and encapsulated in a thin bony shell three and a half years after the transplantation. The article is well illustrated by roentgenograms. BENJAMINR. SHORE Case Diagnosed as von Recklinghausen’s Disease; Diagnosiri Changed to Gen- eralized Itanthomatoeis, C. PARIBEL.A propos d’un cas de maladie de Recklinghausen. Rectification du diagnostic : xanthomatose g6n6ralis6e, Scal- pel 86: 285-290, 1933. In a girl ten years of age the diagnosis of osteitis fibrosa cystica (Reckling- hausen’s diseaae) was made on the basis of the clinical and x-ray findings. A parathyroid gland embedded in the thyroid was removed but proved to be of normal structure. The operation had no effect on the bones nor the general health. Subsequently a chemical analysis of the blood showed the calcium normal and cholesterol high (322 mg. per cent). Biopsy of one of the lesions showed no cyst, but very friable tissue, microscopic study of which, by Snapper, revealed a fibrous osteitis with numerous xanthomatous and lipoid cells. A diagnosis of generalized xanthomatosis or lipoid granulomatosis was made.

Juxta-articular and Articular Angiomas, J. SABRAZBS,R. DE GRAILLYAND G. GINEBTE. Lea angiomes juxta-articulaires et articulaires, Gaz. hebd. d. sc. m6d. de Bordeaux 54: 193-198; 225-230; 241-250, 1933. Twenty-five cases of angiomas situated in or near the joints have been collected and classified as follows: juxta-articular, 9 cases; juxta- and intra-articular, 282 ABSTRAOTS

6 cases; intra-articular, 10 cases. The last group is further subdivided as capsular, 5 cases; synovial, 2 cases; diffuse, involving the synovia, 3 cases. In most instances the knee is the joint involved. The first two types of angioma are found in older children and especially in adolescents, rarely is adults; they occur twice as often in males as in females. As they increase in she they interfere with joint function and in some cases cause pain; they can be decreased in size by pressure on the tumor mass or by raising the affected limb. Capsular angiomas are often circumscribed; in those intra- articular angiomas in which the synovial membrane is involved the growth of the tumor is more rapid and the symptoms more severe. The symptomatology is that of a joint tumor or of synovitis, or sometimes of simple hydrarthrosis. Pulsation in an articular angioma is rarely observed. The diagnosk is rarely made prior to operation; in cases where pain and marked limitation of movement are symptoms, tuberculosis of the joint is often diagnosed; in other cases cold abscess, lipoma, cyst, or foreign body. In cases where the symptoms are those of hydrarthrosis and puncture of the joint is done, the diagnosis of angioma can be made if the puncture yields only blood. As a rule, the radiographic findings are negative, except where there is calcification of the tumor or the formation of phleboliths. Absence of bone involvement eliminates the usual type of joint tuberculosis. Only in a few cases of diffuse intra-articular angioma are there any changes in the cartilage or in the bone that may confuse the diagno&. Articular angiomas show the same structure as angiomas elsewhere. Surgical removal is the treatment of choice. Incomplete removal is not usually followed by recurrence. If the tumor is radically removed, complete cure is the rule. Radiotherapy has been but little used in articular angiomas.

Lipomas of Muscles and Radiography, NICOL~STAQLIAVACCHE. Lipomas de 10s mdsculos y radiografia, Prensa m6d. argent. 19: 413417, 1932. In a previous publication (Prense m6d. argent. 14: 326, 1927) the author and L. Casanovas described the radiographic features of lipomas of muscles on the bases of 4 cases. Tagliavacche reports the following case in which the radiographic signs were an aid in the diagnosis. An Argentine male fifty-four years of age had a large tumor in the anterior deltoid region of the right shoulder. A roentgenogram showed a difference in the shadow of the tumor and that of the deltoid muscle. The humerus was clearly not involved and there was a clean line of demarcation between the bone and the tumor as well as between the deltoid muscle and the tumor. At operation a well encapsulated fibrolipoma was removed from the under surface of the deltoid muscle. The article contains a reproduction of the radiograph, photographs of the patient and of the excised tumor. There is no bibliography. JOHNE. WIRTH Case of Muscular Angioma, E. GAUDIER. A propos d’un cas d’angiome muscu- laire, Echo m6d. du nord 37: 141-143, 1833. A girl nine years of age waa found to have a tumor in the left thigh. She was free from symptoms, nor did the tumor interfere with muscular action. On removal it was found to be an intramuscular angioma. THE LYMPHATIC SYSTEM 283

THE LYMPHATIC SYSTEM:

HODGKIN’S DISEASE, LEUKEMIA, LYMPHOSARCOMA

Malignant Affections of the Lymph Nodes, N. PUENTEDUANY. Afecciones malignas de 10s ganglios linfaticos, Bol. de la liga contra el cheer 7: 210-221, 1932. A survey of malignant affections of the lymph nodes, including sarcomas, Hodgkin’s disease, local and generalized lymphosarcoma, endotheliomas, and lymphatic leukemia. There is a brief description of each disease with a few words on diagnosis and prognosis. No bibliography. JOHNE. WIRTH

Malignant Granuloma, 0. HERCELLES.Granuloma maligno, Cr6n. mbd., Lima 49: 143-149, 287-295, 1932. This is an excellently written survey of Hodgkin’s disease, for which the writer prefers the name malignant granuloma rather than lymphogranulomatosis, since the disease is not restricted to the lymphatic system. In referring to a possible relationship between malignant granuloma and the reticulo-endothelial system, he justly remarks that it is better to Rpeak of the reticulo-endothelial function as one of the many functions of connective tissue in general than of a reticula-endothelial system as a separate entity. No references to the literature are given. JOHANNESP. M. VOGELAAII Splenomegalic Forms of Malignant Lymphogranulomatosis, Especially in Chil- dren, P. NOB~COURT.Les formes spl6nom6galiques de la lymphogranulomatose maligne, en particulier ches l’enfant, Gas. m6d. de France, pp. 783- 787, Nov. 1, 1932. The author notesethat the spleen is usually involved to some extent in malignant lymphogranulomatosis, and he applies the term splenomegalic forms only to those cases in which marked splenomegaly is a prominent feature. Several such cases have been observed in children. The enlargement of the spleen may be associated with marked enlargement of the superficial nodes, especially the cervical groups; in other cases the Pplenomegaly may be the most marked symptom, and the enlargement of the superficial nodes relatively slight. In some instances the author has found the mediastinal nodes are involved, often with involvement of the pleura and symptoms of pleurisy. Where the superficial nodes are involved, a biopsy establishes the diagnosis. Where these nodes are not involved the indications that the splenomegaly is due to malignant lymphogranulomatosis are: involvement of the mediastinal nodes, as shown by roentgenograms; fever, especially of an undulant type; pruritus and other less frequent cutaneous lesions of lymphogranulomatosis. Splenectomy is not indicated in splenomegaly due to malignant lymphogranulomatosis. Radiotherapy produces a diminution in the size of the spleen 4nd a remiwion of symptoms, but there is always a return. The author is of the opinion that the spleen as well as the lymph nodes should be irradiated in all form8 of the disease. Malignant Granulomatosis and Associated Infections, L. RIMBAUD,M. JANBON, AND G. A. MARTIN. Granulomatose mltligne et infections associt!es, Mont- pellier m6d. 2: 363-375, 1932. When admitted to the hospital, the authors’ patient showed a cervical adenopathy, anemia, fever, and symptoms of endocarditis. These symptoms, except for the adenopathy, suggested a septicemia with cardiac involvement. The 284 ABBTRAUTB history showed that there had been an enlargement of the cervical nodes and also a mediastinal adenopathy sixteen months previously. The mediastinal symptoms had subsided under x-ray treatment, but the cervical node enlargement had persisted and for a time the patient had showed a marked anemia, which improved under treatment with liver diet and rest. The fever and cardiac symptoms developed after an acute infection diagnosed as influensa. Death occurred three months after admission, from cardiac failure. At autopsy the cervical and mediastinal glands showed changes typical of Hodgkin’s dieease; the heart and kidneys showed lesions indicating septicemia. The author reviews 6 other cases reported in the literature in which an infection was associated with Hodgkin’s disease. Various types of organisms have been found, but none could be proved to be the cause of the Hodgkin’s disease. In some cases the infection appeared to aggravate the Hodgkin’s disease and cause its generaliration; in some the infection appeared to have no effect on the course of the Hodgkin’s disease; in still others, while the infection did not appear to affect the course of the disease, it was the cause of severe symptoms and death. The authors’ case belonged to the last group, as there was no evidence of generali- zation of the lymphogranulomatosis, but the endocarditis caused the patient’s death.

Pelvic Lymphogranulomatosis, Y. BURGER. Lymphogranulomatose pelvienne Bull. SOC.d’obst. et de gynbc. 21 : 585-586, 1932. A woman forty-two years old who had been under treatment for six weeks for pulmonary tuberculosis mas found apon gynecologic examination to have a 12 cm. tumor of the right side of the pelvis, displacing the uterus. Operation diwlosed a tumor of the right broad ligament, which was surgically removed. The histologic diagnosis was malignant lymphogranulomatosis (Hodgkin’s disease) of characteristic structure. The patient received postoperative x-ray treatment and upon her discharge only a small mass was detectable. HOWARDC. TAYLOR,JR. Report of a Case of Early Hodgkin’s Disease Secondarily Infected with a Strain of Pathogenic Monilia, SAMUELR. HAYTHORN,GEORGE H. ROBINSONAND LLOYDJOHNSON. Ann. Int. Med. 6: 72-81, 1932. The case reported, in a man of seventy, presented an unusual combination of clinical and pathological symptoms. He was first seen four months before he died, complaining of arthritis. Later there was abdominal pain, with evidence of septicemia. Death was due to a terminal bronchopneumonia. Hodgkin’s disease was not suspected during life nor from the gross autopsy findings, there being no enlarged nodes, but rested on the microscopic findings, especially in the peribronchial nodes, and on the presence here and in other organs of numerous large cells of the Dorothy Reed type. From the heart blood, pericardial fluid, bile, spleen, lungs, and peribronchial nodes a strain of Monilia was isolated in pure culture, which proved fatal to rabbits. The final diagnosis was early Hodgkin’s disease secondarily infected with Monilia. The fact that the infected areas as well as the Hodgkin’s nodules contained the multinucleated cells suggests to the authors that these are wandering cells which may respond to inflammatory stimuli outside the Hodgkin’s nodules just as other wandering cells and blood elements are capable of doing. The illustrations include smears demonstrating the presence of Monilia, and photomicrographs showing the Hodgkin’s lesions in the peribronchial nodes and the presence of the giant cells in the lungs. THE LYMPHATIC3 SYSTEM 285

Case of Hodgkin’s Disease with Cutaneous Ulceration, ETIENNE,DROUET, LOUYOTAND DUMAS. Un cas de maladie de Hodgkin 8, forme cutanbe ulc6- reuse, Rev. m6d. d. l’est. 61: 312-314, 1933. A woman, thirty-five years old, with Hodgkin’s disease of three years’ duration, had received repeated radiation treatment to enlarged lymph nodes on both sides of the neck. The number, frequency, and dosage of these treatments are not stated. Two years after the beginning of treatment, ulceration of the skin of both sides of the neck appeared. Biopsy from the wound margins revealed the histological picture of Hodgkin’s disease. WILLIAMJ. HOFFMAN

Hodgkin’s Disease in Bone, H. C. GAGE. Brit. J. Radiol. 6: 297-299, 1933. A case is reported of an eleven-year-old boy suffering from generalized Hodg- kin’s disease. X-ray pictures of his right humerus showed a lesion in the upper end of the diaphysis with erosion of the cortex, destruction of the normal bone architecture, and new bone formation. The changes were very marked and suggested osteogenic sarcoma. A small area of erosion was found in the neck of the left femur. At autopsy sections from both areas showed rather fibrous Hodg- kin’s tissue. The case is unusual, also, in that right upper lobe pulmonary atelectasis developed from pressure on the bronchus by enlarged mediastinal nodea. GRAYTWOMBLY Unusual Case of Hodgkin’s Disease, A. F. HOCKER.Surg. Clin. North America 13: 457-459, 1933. Hocker reports a case of Hodgkin’s disease in a white male thirty years of age. The remarkable feature is that the patient is still living, ten years after the onset of symptoms and nine years after the beginning of radiation treatment. The diagnosis is histologically verified. WILLIAMJ. HOFFMAN Granuloma Malignum and Lymphosarcoma, G. ARPINO. Granuloma malign0 e linfosarcoma, Folia med. 18: 926-949, 1932. Three cases are briefly reported and illustrated with unsatisfactory photomicrographs : (1) A man, aged twenty-one, had enlarged nodes in the neck and a cough. Biopsy showed Hodgkin’s disease. No roentgen treatment was given and the patient died after two and a half years. No autopsy was obtained. (2) A woman, aged thirty-eight, had enlarged lymph nodes in the neck, which proved to be lymphosarcoma. No roentgen treatment was given, and the further course of the illness is not stated. (3) A few days after being struck in the neck in a fight, a man noticed enlarged cervical nodes. Biopsy showed Hodgkin’s disease. [There is no satisfactory evidence of the trauma having been an etiological factor.] No roentgen treatment was given, and the further course of the disease is not stated. C. D. HAAGENREN

Anaemia in Childhood. VII. Monocytic Reaction in Myelosis, R. GITTINSAND J. C. HAWKBLEY.Arch. Dis. Childh. 8: 241-250, 1933. The authors recently reported a case of monocytic leukemia in a child, in which autopsy and histologic examination showed generalized reticulo-endothe- liomatosis (see Abst. in Am. J. Cancer 18: 523, 1933). They now report a case in which the blood picture in a child one year old showed, during nearly six months of observation, a leukocytosis with marked increase in the number of circulating monocytes. This, with the clinical findings, made monocytic leukemia the most probable diagnosis. The child died four months after leaving the hospital. The 288 ABSTRACTS autopsy findings showed no evidence of the previous monocytosis, and demonstrated that the condition was in reality a chronic myelogenous leukemia; that is, the observed monocytosis was apparently incidental in the course of a chronic myelosis. The duration of the illness was nearly one year. The authors cite examples from the literature of four conditions showing monocytosis of leukemic or aleukemic type: (1) monocytic (histiocytic) leukemia; (2) leukemic reticulo-endotheliosis; (3) monocytic reactions in myelosis; (4) appearance of monocytoid cells, regarded as types of myeloblasts, in cases of myelosis. The present case falls under the third of these headings. There are Hix illustrations. F. CAVERS

Anemia in Childhood. VIII. Leukaemia (Leucosis) in Children. R. GITTINS. Arch. Dis. Childh. 8: 291-322, 1933. This report on leukemia in children is based on the study of 14 cases, but detailed case records have been omitted for reasons of space. There were 11 caseE of lymphatic, two of myeloid, and one of monocytic type. All were relatively acute. The ages of the children ranged from ten months to twelve years. The onset was in most cases insidious. In three cases of lymphadenosis no Rdenopathy was observed either during life or at autopsy. Splenomegaly was present in all cases, but was not marked, except in one patient with lymphade- iiosis; it was definitely greater in the two cases of myelosis. Gingivitis, stomatitis, and enlargement of the tonsils were not features in this series. No skin lesions were seen, apart from petechiae and purpura. " Considering the extensive changes in the bone marrow, it is surprising that bone changes are such a rare manifestation of leukaemia in children." Such bone changes were seen in only one of the author's cases. The duration of the disease was nineteen weeks in one case, twelve weeks in two cases, less than eight weeks in the remaining 11 cases. The author discusses various conditions which mimic leukosis; for instance, the blood picture may be leukemoid in various specific infections, anemias, sepsis, etc. His study of the two main types of leukemia in children leads him to conclude that macroscopic focal leukemic deposits in the viscera rarely occur in children, the infiltration being of a diffuse character. Certain features of myelosis can be imitated by severe myeloid reaction in inflammatory disease; but lymphadenosis is not imitated by any infective process occurring in man. " The impression left, after cytological and histological study, is uniformly that leucosis is a neoplastic process. Leucocytosis and leucosis appear to be respectively hyperplastic and neoplastic phenomena, and analogous to reparative processes and malignant focal new growths." F. CAVERE

Priapism in Leukemia, LLOYDF. CRAVER.Surg. Clin. North America 13: 472- 477, 1933.. Priapism as a complication of leukemia is mentioned so regularly in textbooks of medicine that the general impression of its frequency is undoubtedly exaggerated. As a matter of fact it is extremely rare. It has been observed in the lymphoid as well as in the myeloid form, and also in acute leukemia. In a few instances actual leukemic thrombi have been found in the corpora cavernosa, but in other instances in which the corpora cavernosa were explored no clot has been found. Craver's case is the only one of priapism in a series of more than 100 male patients with leukemia observed at the Memorial Hospital since 1918, in half of whom the disease was of the myeloid type. The patient, a twenty-four-year-old THE LYMPHATIC SYSTEM * 287

Italian, was admitted complaining of priapism of nineteen days’ duration. Dur- ing this time he had received x-ray treatment over the pubes without effect. The white cell count on admission was 179,000, with the typical blood picture of chronic myelogenous leukemia. Five daily low-voltage x-ray treatments of 1007 each were given over the spleen. The priapism and pain disappeared on the fifth day. Impotence followed, the usual sequel according to the literature. WILLIAMJ. HOFFMAN Case of Lymphatic Pseudoleukemia Treated by Continuous Irradiation of the Entire Body, W. S. MACCOMB.Surg. Clin. North America 13: 406-411, 1933. This report by MacComb illustrates the effects obtained in a case of pseudoleukemia by continuous high-voltage irradiation of the entire body at long distance and low intensity. The patient, a man fifty-three years of age, presented clinical and radiological evidence of enlargement of all the regional lymph nodes. A prominent feature was the marked enlargement of the temporal, parotid, and submaxillary regions. The blood findings and a node removed for biopsy sup- ported the diagnosis of lymphatic pseudoleukemia. The patient was given 25 per cent of a skin erythema dose (187 T units measured in air) at a distance of 5.5 meters over a period of 149 hours (about eight days). At the time of discharge there was improvement in the general condition and decrease in the size of all the lymph node masses. The blood count remained unchanged. A month later further decrease in the size of the nodes was observed. The abdominal nodes regressed to a diameter of 10 cm. It was thought best, however, to give further treatment, and the previous dose, 25 per cent of a skin erythema, was delivered at a distance of 7.4 meters, requiring 278 hours of treatment over a period of fourteen days. The abdominal mass actually increased from 10 cm. to 13 cm. in diameter. The superficial nodes had not recurred. The abdominal nodes were then treated by local irradiation, 500 r anteriorly and posteriorly at a distance of 150 cm. Regression followed and for five months the patient held his improvement. At that time the generalized adenopathy had recurred, while the white cell count had fallen to 2,000 per cubic millimeter. Injections of sodium nucleotide brought this up to 5100. A third dose, 25 per cent of a skin erythema, was given over a period of eight days, a$ the end of which time the white blood count was 8,300. This improvement was short-lived, and the patient died five months later. MacComb believes that this form of treatment is of value as a palliative measure in leukemias of this type. [The method is, however, time-consuming and expensive to administer owing to the cost and attendance charges, and many radiologists are convinced that just as good results are obtainable with the routine technic,] WILLIAMJ. HOFFMAN

Lymphosarcoma. E. C. CRACIUN,I. TETU,AND A. UREU. Sur le lymphosar- come, Bull. et m6m. SOC.m6d. d. HBp. de Bucarest 4: 593-b98, 1932. A young man nineteen years of age had severe dyspnea and was found to have a large mediastinal tumor. Radiotherapy reduced the size of the tumor and relieved the symptoms, but the patient became markedly asthenic, with severe pain in the region of the kidney, and edema. Hemorrhagic symptoms developed before death. A blood count previous to radiotherapy showed 15,000 white cells with 79 per cent neutrophiles. At autopsy the mediastinal tumor and nodules in the lungs and other tissues showed a remarkably homogeneous structure made up almost entirely of lymphocytes and reticular cells. In the liver and kidneys the lesions were those of lymphocytic infiltration rather than neoplasm. This 288 ABSTRACTS case is reported as a contribution to the puaaling and obscure group of neoplasms which seem to combine two morbid processes, lymphosarcoma and aleukemic leukemia. Lymphosarcoma with Unusual Metastaees in a Thirteen-Months-Old Infant, P. L. Davrs. Arch. Path. 14: 584-585, 1932. The cervical nodes in a child of nine months became swollen following enlargement of the abdomen and the child fell several times to the right side. X-ray examination four months later suggested a diagnosis of right subacute mastoiditis, but no pus was found on opening the mastoid process. Neurologic examination suggested subdural abscess; the findings included marked right exophthalmos and beginning right optic atrophy. Death occurred five months after admission to hospital. At autopsy there were found greatly enlarged retroperitoneal nodes, especially at the level of the head of the pancreas. This seemed to be the primary site of the tumor, and from it a chain of nodes extended to the hilus of the enlarged liver. There were metastatic nodules in the right lobe of the liver, right kidney, and right lung. The epidural space of the right middle fossa showed tumor infiltration of 2 cm. thickness; the inner plate of the bones over the middle ear and mastoid was eroded, and the right orbital fossa was invaded. The tumor cell in all these sitefi was .an adult lymphocyte. Sections of the invaded cranial bones showed tumor masses in the veins and blood sinuses of the marrow, indicating that the tumor cells had been carried by the blood stream. F. CAVER8

Case of Lymphosarcomatoeis, C. DE F. LUCAS. Burg. Clin. North America 13: 412414, 1933. The author reports a case of lymphosarcoma of the alveolar ridge with widespread visceral metastases to the thyroid gland, larynx, cervical nodes, and pancreas. The patient died with the symptoms of chronic incomplete intestinal obstruction. At autopsy a metastatic lymphosarcomatous mass was found in the ileum, incarcerated in an intussusception at a point about 45 cm. proximal to the ileocecal valve. WILLIAMJ. HOFFMAN

Leukosarcoais and Endotheliode, V. MATTEI. Leucosarcosi e reticolo endo- teliosi, Clin. med. itd. 63: 537-559, 1932. Two cases are reported in detail, including tables showing the changes in the blood picture during the course of the disease, photomicrographs of the blood smears, and histologic sections. (1) A man aged thirty-seven had fever and enlarged cervical and axillary nodes. His blood showed a leukemia, in which large, immature white cells of the type described by aternberg predominated. No roentgen treatment was given, and the patient died four and a half months after the onset of the disease. Au- topsy showed a large mediastinal leukosarcoma and leukosarcomatous infitration of many organs. (2) A man aged twenty-eight had a fever and generalized enlargement of lymph nodes. His blood showed an aplastic anemia without any leukemia. No roentgen treatment was given, and the patient died two and a half months after his illness began. Autopsy showed diffuse infiltration of the lymph nodes, liver, kidneys, and spleen with reticulum cells. The author classifies the case as ' ' subleukemic reticulo-endotheliosis. C. D. HAAGENSEN THE LYMPHATI(31 SYBTEM 289

Malignant Hyperplaeia of the Entire Reticulo-endothelid System (So-called Reticulo-endothelioma), J. M. LASOWSKY.uber eine systembesogene blastom- artige Hyperplasie des Reticuloendotheliums (sog. Reticuloendotheliom), Virchows Arch. f. path. Anat. 288: 631-640, 1933. The clinical history and autopsy findings in a case of diffuse hyperplasia involving the entire reticulo-endothelial system are reported in detail. Besides t.he primary tumors in the lymph nodes, tonsils, spleen, liver, and bone marrow, metastases to the epicardium and pericardium, lungs, pleura, meninges, esophagus, trachea, laryngeal mucosa, and perirenal connective tissue were observed. Histologic study of the tumors showed complete replacement of the normal lymphoid structures by rapidly growing cells resembling in part those of the reticulum and in part those of the endothclial system. Photomicrographs of various portions of the tumors are included. BENJAMINR. SHORE

Lipoid Reticuloma and Perithelid Reticulosarcoma, E. FIORINI.Reticoloma lipoidifero e reticolo-sarcoma periteliale, Tumori 6: 335-350, 1932. Two cases are described and illustrated with photomicrographs. (1) A ma88 of lymph nodes which had grown slowly over a period of three years was removed from the groin of a woman of thirty-eight. The author classified the growth as a “ lipoid reticuloma.” No recurrence was observed one year after operation. (2) A rapidly growing group of lymph nodes appeared in the groin of a woman aged fifty-six. They were removed and a histologic diagnosis of “ perithelial reticuloma ” was made. No follow-up of this case is included. C. D. HAAGENSEN

A Form of Malignant Adenopathy, SEGRERICCARDO. Sopra una forma non comune di adenopatia maligns, Boll. d. 1. ital. p. 1. lotta contro il cancro 6: 63-64, 1932. A case is reported of a woman of thirty-seven who complained of epistaxis and enlargement of the nodes of the neck. The Wassermann reaction was positive but antisyphilitic treatment was without effect. There was gradual general lymph node enlargement. Biopsy showed a primary malignant tumor of the lymphoid system with general metastases. It appeared to be a lymphendothe- lioma. JEANNETTEMUNRO

Case of Subacute Aleukemic Lymphadenosis, L. VELASCOBLANCO AND A. PUGLISI. Consideraciones sobre un case de linfadenosis aleucemica sub-aguda, Arch. amer. de med. 8: 26-36, 1932. A boy of twelve first showed a swelling of the glands in the right submaxillary region, which was followed by an increase in size of the corresponding glands on the left side, accompanied by fever. The white blood cells were never more than 9,600 per cubic millimeter, but the neutrophilic granulocytes fell from 39 per cent to 6 per cent, and death took place in about four months. The liver, spleen, and lymph nodes were greatly enlarged. Microscopically the nodes and infiltrated organs showed pure lymphocytic cell forms. The text contains three figures. JOHANNESP. M. VOGELAAR 290 ABSTRACTS

STATISTICS

Mortality of Tuberculosis and of Cancer in Relation to the Social Structure of the Berlin Population, G. WOLFFAND A. JAHN.Die Sterblichkeit an Tuber- kulose und an Krebs in Beaiehung zur soaialen Struktur der Berliner Be- volkerung, Arch. f. soz. Hyg. u. Demog. 7: 461-477, 1932. In a study of the mortality rates of tuberculosis and of cancer in Berlin in 1826-1931, in relation to the social condition of the population, it was found that there was a close correlation between the tuberculonis mortality rate and the percentage of working class population in the various districts. No such correlation was found between the death rate from cancer and the social structure of the population. The incidence and mortality of cancer do not appear to have any relation to environmental conditions. This would indicate that cancer cannot be considered a contagious disease in the usual sense of the word.

Remarks on Cancer Mortality in Egypt and its Prevention, A. W. WAKIL. J. Egyptian M. A. 15: 238-262, 1932. The author states that mortality statistics are not available for all Egypt, but only for urban areas where there are health officers. He presents an analysis of cancer mortality in these areas, based on the official statistics, with consideration of the age distribution of the population. Statistics Rhow that there is a higher percentage of children up to ten years of age nnd also a higher percentage at the ages ten to twenty years in the Egyptian population than in the population of England, France, Switzerland, and the United States. The percentage of persons forty years of age and over is definitely less in Egypt. The age distribution of the Egyptian population is, therefore, not as favorable for cancer as in the other countries mentioned. The death rate for cancer averaged 21.5 per 100,000 for Egypt in the year8 1919 to 1928 inclusive. It has shown no evidence of increase in this period. The average general mortality rate for these years in Egypt was 3310 per 100,000, so that cancer deaths represented but a small percentage of total deaths. A study of 4,846 cancer deaths in 1920 to 1928 shows that the rate was much higher in persons over forty than under forty; it was higher for women than for men, especially in the age periods forty to sixty years, where the ratio was 14 females to 10 males, this being due to the frequency of cancer of the breasts and of the uterus in this age period. The cancer death rate for Syrians, Palestinians, Turks, and others from the Near East was not higher than for native Egyptians. Moslems show a lower cancer death rate than either Christians or Jews. The only available public health statistics for the location of cancer are for 750 deaths in the year 1928. These show 26.7 per cent of all cancer deaths to be due to cancer of the stomach and liver, and 13 per cent to be due to cancer of the female genital organs. The incidence of buccal and skin cancers is much lower in Egypt than in the United States and European countries; the incidence of cancer of the breast is also lower. In the Egyptian statistics 42.8 per cent of cancer deaths are recorded as due to cancer in (( other sites 'I; this percentage is high because it includes cancer of the bladder, which is more prevalent in Egypt than elsewhere because of bilharaial infection and the consequent bladder irritation. [As the author is perfectly aware, all these figures possess only a relative value in the absence of accurate population data, frequent autopsies, and careful cer- tffication of deaths.] EDUCATION AND PUBLIC HEALTH 291

Critical Note on the Rarity of Cancer at her-el-Aini Hospital, A. K. HENRY. J. Egyptian M. A. 15: 331-336, 1932. In seven years at the Kasr-el-Aini Hospital, the author performed only 2 operations for gastric carcinoma and 2 for rectal cancer, and had 3 other inoperable cancers of the gastro-intestinal tract under his care. Thus there were only 7 cases of gastro-intestinal cancer in approximately 13,000 admissions, an incidence of 0.05 per cent. The incidence of gastro-intestinal carcinoma in the entire in- patient admissions was 0.07 per cent; the incidence of all malignant disease 0.9 per cent. The author wisely points out that these figures cannot be taken as necessarily indicating a low incidence of gastro-intestinal cancer, or of malignant disease in general, in Egypt. The hospital “ is and must be at the present time largely an accident hospital.” Also the supply of beds is inadequate, and cancer patients coming in too late a stage for operation must be refused admission in favor of non-malignant disease that can be cured. [There are other records showing that cancer is not infrequent in Egypt, as those of Ashour and Afifi (see absts. in Am. J. Cancer 19: 125, 515, 1933).]

Cancer Mortality Statistics in Cuba from the Year 1902 to the Year 1926, GUSTAVO ODIODE GRANDA.Estadfsticas de la mortalidad por chncer en Cuba desde el ano 1902 hasta el an0 1926, Bol. d. 1. Liga contra el cancer 7: 357-392, 1932. The author gives in tabular and graphic form the Cuban mortality statistics of cancer from 1902 to 1926. The information is given for white and negro groups and according to sex. In a separate graph, giving the total death rate per 100,000 of population from 1900 to 1929, it is shown that the rate rose slowly from 26 in 1900 to 48 in 1913, where it remained fairly constant until 1925 and 1926, when it rose to 52, declining rapidly thereafter until it reached 41 in 1929. JOHNE. WIRTH

Report of Patients Examined and Treated in the Radium Institute “ Juan Bruno Zayas ” (Mercedes Hospital) During the Year 1931-1932, N. PUENTEDUANY. Relaci6n de enfermos examinados y tratados en el Instituto del Radium “ Juan Bruno Zayas ” (Hospital Mercedes) en el presente afIo 1931-1932, Bol. d. 1. Liga contra el chncer 7: 257-265, 1932. A report on 669 patients, 540 of whom had neoplasms. The author believes that the patients were seen earlier in the course of the disease than in the previous year and attributes this to the publicity on cancer from all sources. The cases are analyzed according to nationality, sex, age, marital status, race, profession and anatomical site of tumor. In the latter tabulations skin, female genital organs, and buccal cavity lead the list. JOHNE. WIRTH

EDUCATION AND PUBLIC HEALTH Responsibility of the Medical Profession in the Cancer Situation, J. M. HOFF- MAN. J. Florida M. A. 19: 421-422, 1933. The author emphasizes the importance of securing correct diagnosis in every lesion that may be cancerous or precancerous, no matter how trivial it may seem when first observed by the physician. The general practitioner must acquaint himself with the early signs and symptoms of cancer if the cancer campaign is to be effective. 292 ABSTRACTS

Responsibility of the Medical Men in the Control of Cancer, B. T. SIMPSON. New England J. M. 208: 11-18, 1933. This is a rather popular presentation of the place of the general practitioner in the diagnosis of cancer, illustrated (1) by cases seen early by the family doctor but disregarded, with disastrous results, and (2) by others seen more recently, in which early treatment has been given and the prospect for cure is good. The New York State organiration for meeting the cancer problem is described.

Relations of the Pathologist to the Cancer Problem, BURTONT. SIMPSON.South. M. J. 26: 48-54, 1933. Statistics show that in cancer a clinical diagnosis cannot be made in more than 70 per cent of the patients, and that the macroscopic appearance alone can be expected to afford a correct diagnosis in a little more than 80 per cent of these. The increasing need of biopsies is thus obvious. A biopsy may be diagnostic only, or therapeutic when there is a need of determining the type and amount of treatment. At the State Institute at Buffalo, where biopsies are done as a routine and have been made on more than 7000 patients, no deleterious effects from the procedure have ever been observed. It has been conclusively proved that cutting into tumors does not increase the incidence of metastases. Many lesions which have been diagnosed clinically as malignant have proved upon microscopic examination to be benign, and operations are frequently performed which could well have been avoided had a biopsy been taken. Biopsies are frequently made of lesions of the skin to determine their radiosensitivity. Lesions of the mouth, tongue, and mucosa of the cheek should always be fiubmitted to biopsy for the differential diagnosis. Simpson has urged biopsies on all cervical lesions and. the removal of all breast tumors. The question of biopsies on bone tumors is still debated. It has been emphasized that one of the serious obstacles to the successful treatment of cancer is inadequate pathological diagnosis. As to the effect of radiation upon tissues, nothing definite has been produced permitting one to kisualise the essential processes initiated by radiation. In the early days of radiation therapy it was thought that the action wah a specific one and that its effect was confined to the cell. As knowledge of radiation therapy has increased, it has been found that there is, besides the effect on the cells, also an effect on extracellular tissues. An initial hyperemia is accompanied by exudate of serum and leukocytes and occasionally by red blood cells. Reparative processes follow, and granulation with fibrosis is the end-result. It has been accepted as a general rule that the more mature a cell the more resistant it is to the effects of radiation. On the other hand, embryonic and immature cells are considered radiosensitive. Rapidly growing cells which have a high growth metabolism are especially sensitive; they are probably in a state of delicate equilibrium, and therefore are easily thrown out of balance, The location of the tumor is of importance when radiosensitivity is being considered. This may be due to the response of the surrounding tissue to irradiation. As a rule radiosensitivity runs parallel to anaplasia, but this is not always the case. W. S. MACCOMB Obligation of the General Hospital in Providing Better Service for the Cancer Patient, BURTONJ. LEE. Bull. Amer. Coll. Surg. 17: 13-15, 1933. Special cancer institutes and cancer hospitals can care for only a small proportion of the cancer patients in the United States. The great majority of cancer patients must seek aid from the general hospitals; and these general hospitals, to EDUCATION AND PUBLIO HEALTH 293 deal with the problem effectively, must organize special clinics for the care of cancer patients. Such clinics have been organized in a number of general hospitals; and the American College of Surgeons is undertaking their standardization. What the Layman Should Know about Cancer, HUGHSHANE. New Orleans M. & S. J. 85: 604-606, 1933. The author has briefly outlined for the laity the well known important facts concerning cancer, urging frequent examinations by family physicians and early inquiry into any unusual symptoms. W. S. MACCOMB A Present Day Approach to the Problem of Cancer, GEORGEA. STEWART.Hahne- mannian Monthly 67: 81-89, 1932. A general presentation of the cancer problem followed by an account of some of the work in the Johns Hopkins clinic and surgical pathological laboratory. Newer Problems in Cancer and How to Meet Them, JOSEPHCOLT BLOODGOOD. Clin. Med. & Surg. 39: 178-162, 1932. In this address the author emphasizes the increasing cancer mortality, the need of education, the importance of the problem of diagnosis, especially in borderline cases, and the need for a differential stain for the cancer cell. Cancer, CHANNINGC. SIMMONS.New England J. M. 208: 337-338, 1933. A popular radio talk presented under the auspices of the Committee on Public Education of the Massachusetts Medical Society for the Department of Public Health. Relation of the Cancer Problem to Public Health, G. R. HOLDEN.J. Florida M. A. 19: 330-333, 544-546, 1933. General remarks on the increase of cancer in the United States. W. S. MACCOMB Necesaity of Special Hospitals for the Care of Incurable Cancer, T. MARIE. Sur la necessite de la creation d’6tablissements hospitaliers speciaux pour les cancereux dits incurables, Lutte contre le cancer 10: 83-86, 1932. When patients with advanced cancer reach a stage where frequent dressings are needed they should be cared for in Special Houses of Calvary. Here they are nursed by lay sisters. There are eight such hospitals in France which perform most valuable services. In addition to these Houses of Calvary, special cancer wards for incurable patients have been organized occasionally in general hos- pitala. The hospital facilities, however, for patients with advanced cancer are far from adequate. An appeal is made to the general public to contribute to this work of the French Anti-Cancer League. C. D. HAAGENBEN Anti-Cancer Campaign in the United States, JOSEPHCOLT BLOODGOOD. La lutte contre le cancer aux fitats-Unis, Lutte contre le cancer 10: 74-80, 1932. Bloodgood presents his general ideas regarding cancer to the French. C. D. HAAGENSEN Cancer Service at the U. S. Naval Hospital, Brooklyn, N. Y., C. W. STELLE. U. S. Naval Med. Bull. 31: 157-160, 1933. A short resume of the cancer service at the U. S. Naval Hospital at Brooklyn, New York, which was inaugurated nearly four years ago. W.8. MACCOMB 294 ABSTRACTS

Economics of the MtU3MchU8ett8 Cancer Program, G. H. BIQELOWAND H. L. LOMBARD.New England J. M. 207: 972-974, 1932. Basing their calculations on the net annual value of the average wage earner (as computed by Dublin), the additional expectation of life assured the individual with cancer by adequate treatment, and the possibility of complete cure in a certain percentage of cases, the authors estimate that a yearly saving of life valued at over $1,500,000 is possible through the efforts of the Massachusetts cancer service. At least a fourth of this saving per year may reasonably be credited to the state program at the present time. On this basis a table has been compiled comparing expenditures and profits with other lines of business. The figures indicate a very favorable position for the Massachusetts cancer program. While the amount spent for education (7%) is larger than for most of the adver- tising budgets, the item for administration (10%) is smaller and the percentage of money spent for service (83%) is second only to that of a large New York newspaper. The profits, on the other hand (25%), far exceed these, and from an economic standpoint the program would ‘appear extremely sound.

Uterine Cancer in Uruguay, CARLOBM. DoMfNQuEz. La lucha contra el c&ncer uterino en el Uruguay, Dia med. 5: 239-240, 1932. In Uruguay a systematic method of controlling cancer was begun in 1918 by forming a league of doctors. This league obtained better hospital facilities and instituted modern methods of treatment. It carried on propaganda about cancer by means of conferences, circulars, and various aommunications to physicians, dentists, pharmacists, nurses, magazines, newspapers, and theatres. In 1926 this league established a medical journal. It is now opening a new gynecological pavilion with a capacity of 50 beds and with modern equipment for roentgen and radium therapy. In the period of seven years from 1923 to 1930 the league treated 220 cases of cancer with 43 cases cured for five years or over. These figures, they believe, are quite promising, since most of their patients are in an advanced stage when first seen. JOHN E. WIRTH