Abstracts Experimental Studies; Tumors in Animals

ABSTRACTS EXPERIMENTAL STUDIES; TUMORS IN ANIMALS

Production of Cancer in Rabbits by Painting with Tobacco Tar. 11. The Appearance of Isolated Tumors in an Irritated Area, LO-FU-HUA. Uber die Erzeugung von Krebs durch Tabakteerpinselung bei Kaninchen. 11. Uber das Solitarauftreten einzelner Tumoren auf einer diffus gereizten Korperstelle, Frankfurt. Ztschr. f. Path. 47: 52-62,1934. It is well known that the malignant change sets in here and there at isolated points in a tar-painted area, never involving the entire irritated field. In the author’s experiments with tobacco tar the same scattered development of tumors was observed, and he asks what may be the reason therefor. This apparently random localization cannot be explained by the distribution of the hair follicles, for all tar carcinomas do not arise from these structures, and not every hair follicle suffers the malignant change. It seems more probable that tumors develop in minute wounds (scratches, etc.), as has been suggested by several investigators, though here again it is to be noted that the carcinoma develops, not throughout the whole length of the wound, but only at one point. The author adopts the view of Ribbert and of Borst, that new growths can arise only from specially predisposed cells, and that unless an irritant comes into contact with these sensitized elements no neoplasm will appear. Cells which possess this pathological attribute without definite morphological indication of its presence may be described as tumor anlagen of the second order, while those with appreciable evidence of its existence may be assigned to the first order. The former group, which constitutes the foundation for all experimental carcinogenesis, must be widely distributed, as tumors can be elicited at so many different sites, and it is probabIe that these anlagen of the second order are responsible for neoplasms which arise at a distance from the tarred area. In addition to this local predisposition, there exists, no doubt, a general susceptibility, for every irritated regenerative lesion does not end in cancer. Yet this explanation does not cover the entire case, for it still does not tell why a neoplasm does not involve an entire regenerating wound; the presence of general susceptibility must be assumed, since a neoplasm has arisen, but why should it appear at only one small point in the wound? No matter how important a factor regeneration may be, it would not be possible to elicit a tumor at any particular selected site in the body, even in the presence of constitu- tional predisposition. For the primary cause of neoplasia is not regeneration, but some characteristic idiosyncrasy of the chromosomes. WM. H. WOGLOM

Experimental Production of Bone Sarcoma in the Rabbit with Radium, 0. SCHURCHAND E. UEHLINQER.Experimentelle Erzeugung von Knochensarkom durch Radium beim Kaninchen, Schweiz. med. Wchnschr. 15: 664-667, 1934. The authors give a preliminary account of an osteogenic sarcoma in the femur of a rabbit, first discovered nineteen months after 3 micrograms of mesothorium (in vaseline) had been deposited in the marrow cavity. Death occurred two months later, as a con- sequence of generalized metastasis. The experiment shows, first, that a purely exogenous stimulus can initiate osteogenic sarcoma and secondly, that such a neoplasm can be evoked by a very small dose of radiation acting over a long period of time. Further discussion is postponed until observations on all the animals treated have been finished. [The authors refer to Martland’s observations (Am. J. Cancer 15: 2435, 1931) on hone sarcoma in the human subject following the accidental ingestion of radio-active materials, but have missed the description by Sabin, Doan, and Forkner (J. Exper. 677 ABSTRACTS

Med. 56: 267, 1932) of similar neoplasms produced in the rabbit by intravenous injection of these agents.] WM. H. WOOLOM Malignant Tumors Produced in the Rabbit by Irradiation of Infiammatory Foci, A. LACASSAQNE.Tumeurs malignes provoquhes, chez le lapin, par l’irradiation de foyers inflammatoires, Compt. rend. Acad. d. sc. 196: 09-71, 1933. To five sarcomas that ocourred about x-rayed abscesses in rabbits (Compt. rend. Sow de biol. 112: 562, 1933. Abst. in Am. J. Cancer 18: 628, 1933), the author now adds a carcinoma and a sarcoma, which developed after irradiation of the site where sterile diatomaceous earth had been injected into two rabbits. Thus irradiation of an inflammatory focus, whether this be infected or sterile, appears to initiate malignancy. [The development of epithelioma at the mouth of a fistulous tract in the gum of H young man, after five to six years’ daily exposure to x-rays, is of interest in this connection (Gricouroff: Bull. Assoc. frang. p. 1’Btude du cancer 23: 97, 1934. Abst. in Am. J. Cancer 21: 681, 1934).] WM. H. WOOLOM Attempts to Produce Neoplasms of the Renal Pelvis by the Use of Foreign Bodies and Tar, P. BRUNI. Tentativi di produzione di neoplasie della pelvi renale con corpi estranei e con catrame, Ann. ital. di chir. 12: 366-376, 1933. This is the report of an experiment carried out on only ten animals. Stones of cement and of cement mixed with tar were introduced into the renal pelves of four guinea- pigs and six rats. In no case were neoplastic growths of the pelvis found on autopsy three months later. Inflammatory lesions of the connective tissue and hyperplastic epithelial changes were observed. [No tumors should be expected at the end of three months’ irritation in either guinea- pigs or rats. Taenia crassicollis requires at least eight months to produce sarcoma of t,he liver in rats, and 1 : 2 : 5 : 6-dibenaanthracene takes the same period to induce sarcoma of the subcutaneous tissues in rats.] JEANNETTEMUNRO

Parasites and Tumor Growth, R. HOEPPLI.Chinese M. J. 47: 1075-1111, 1933. This is a review of caaes of natural infestation with parasites in which these organisme appeared to play an etiological r61e in the development of malignant new growths, and of cases of experimental tumor production by parasites. The conclusion is drawn that various ecto- and endo- parasites, as well as certain bacteria, are capable of initiating malignant disease in man and other vertebrates. The response of the host’s tissues is essentially the same in all cases, leading through chronic inflammation to cell proliferation and ultimately to neoplasia. The tumor, which is only an indirect result of the infestation, is probably caused by glandular secretions orthe end products of metabolism, mere mechanical irritation appearing to be a less important factor, Susceptibility on the part of the host is a necessary antecedent, for wide variations are found between different species, different strains of the same species, different individuals of the same strain, and different organs and tissues of the same individual. There is no fundamental difference in the development of a tumor due to a parasitic agent, and of one caused by a chemical such as tar. No true malignant neoplasm has yet been discovered in an invertebrate, and within the group of vertebrates tumors are much more common in birds and mammals than in the reptiles and amphibia, an observation indicating that predisposition to new growths in vertebrates is in inverse .proportion to the power of regeneration. A thirteen-page bibliography brings the article to a close. WM. H. WO~LOM

Decrease in the Resistance to Tumors Produced by Tumor Filtrates. Experimental Investigation, LUIOISPADAFINA. La chute des rhsistances antinboplasiques avec le filtrat tumoral: recherches exp6rimentales1 Cancer 11 : 1-24, 1934. One of the most interesting of recent discoveries is the demonstration of substances in or between tumor cells, which exert a stimulating action upon the neoplasm. These have been found not only in carcinomas and sarcomas of mammals (rats, mice) but in chicken sarcoma as well, and they appear to be operative both in vivo and in vitro. EXPERIMENTAL STUDIES ; TUMORS IN ANIMALS 679

They are characteristic, moreover, of the malignant cell, for all attempts to disclose their presence in normal tissues have failed; the latter, indeed, appear to contain an inhibiting substance. In a series of 4 experiments, totalling 73 mice in all, the author showed that preliminary injection of filtrates of the Ehrlich mouse carcinoma enhanced the growth rate and metastasis of this neoplasm, and that the resistance conferred by normal tissues could be decreased by similar treatment. WM. H. WOGLOM

Hormonal Regulation of Tumor Growth and Metabolism, MAX REISS, HERMANN DRUCKREYAND ADOLF HOCHWALD.Beitriige zur hormonalen Steuerung des Tumorwachstums und Reines Stoffwechsels, Ztschr. f. d. ges. exper. Med. 90: 408-420, 1933. For years the Jensen sarcoma has grown vigorously and at all seasons in 100 per cent of 60 to 100 gm. rats of the author's strain, whereas in older ones the percentage of SUC- cess has been smaller and subject to seasonal fluctuations. This can hardly be explained otherwise than by reference to some endocrine influence, and attention was first directed to the hypophysis because of the relation which it bears to body growth. Some 300 rats of 60 to 120 gm. were hypophysectomized and inoculated, some before, some after the extirpation, with the Jensen rat sarcoma. It may be said at once that the tumor took in all cases, though its subsequent growth was profoundly influenced. The most distinct effect occurred when grafts were introduced about two to three weeks after operation; here the sarcoma grew until it had attained the size of a pea, or of a cherry at the most, and then regressed entirely. The longer the interval since extirpation, the shorter was the life of the tumor. Where excision was practised in rats already bearing a tumor the growth of the sarcoma was inhibited from then on, but complete regression did not take place if a nodule was larger than a cherry three weeks after operation. Tumors removed from hypophysectomized animals showed a decreased oxygen consumption. Attempts were made to gain some insight into the disturbance of reciprocal hormone activities brought about by removal of the hypophysis. First, growth hormone was injected into hypophysectornized rats, a procedure which nullified completely the retarding effect of the operation upon tumor growth, and tended to restore the type of respiration normal for the neoplasm. The thyrotropic factor of the anterior hypophyseal lobe, thyroxin, and the thyroid hormone were all without influence on tumor growth and tumor metabolism either in normal or in hypophysectornized animals, nor did the sex hormone of the anterior lobe destroy the etTect of hypophysectomy; on the contrary, this may have been somewhat reinforced. The rBle of the gonads was investigated by injecting sex hormone from the anterior lobe into castrated animals; tumor growth and metabolism both suffered, as they did in normal ones. The gonads themselves seemed to have some regulatory action on tumor growth, for this was definitely stimulated in castrated rats and inhibited, again, when oestrus hormone was administered, but their cooperation evidently is not essential to the anterior lobe sex hormone. Finally, removal of the anterior or middle lobe of the pituitary, or the administration of pituitrin, affected neither tumor growth nor metabolism. As augmented tumor growth in these experiments was always associated with relatively high oxygen consumption, and regressive changes with a diminution in the amount consumed, it is evident that attempts to control neoplasms by increasing their respiration lack any theoretical foundation. Furthermore, the experiments suggest that entirely autonomous growth, in the nlder and commonly accepted sense of the term, does not exist. WM. H. WOGLOM 680 ABSTRACTS

Effects of Methylene Blue and other Oxidation-Reduction Indicators on Experimental Tumors, MATILDAMOLDBNHAUER BROOKS. University of California Publications in Zoology 39: 293-302, 1934. It was discovered by Warburg that tumors possess an abnormal carbohydrate metabolism, obtaining most of their energy from glycolysis rather than from .respiration. If, therefore, it were possible to establish respiration at the expense of glycolysis, neoplastic growth might return to the normal type. Methylene blue, which increases the rate of oxygen consumption, and theref ore that of metabolism, was injected into various transplanted rat and mouse tumors, its action being controlled by the use of a number of other dyes or of the solvent alone. All dyes were employed in aqueous solution (Ringer-Tyrode solution without glucose). Methylene blue caused tumors to ulcerate and disappear, inhibition being ascribed to " poising " of their tissues at a redox potential compatible with normal growth. Through the catalytic action of the dye oxygen consumption is increased, glycolysis discouraged, and normal growth promoted. [As the material was injected directly into the tumors, it is clear that these experi- menta have no bearing upon the treatment of malignant disease in the human subject.] WM. H. WOQLOM

Effect of 2 : 6-Dichlorophenol-Indophenol on Tumour and Kidney Respiration, K. A. C. ELLIOTT. Nature 134: 254, 1934. Lipmann (Biochem. Ztschr. 265: 133, 1933) has shown that 2 : 6-dichlorophenol- indophenol reversibly inhibits glycolysis in muscle extract. Elliott, using this substance on tumor tissue, found that there was no inhibition of glycolysis but that the respiration of rat sarcoma No. 1 was practically completely inhibited in the absence of glucose; in the presence of glucose there was no marked effect. In the kidney cortical tissue the inhibition was complete whether glucose was present or not. It would appear that cancer tissue is able to produce from glucose a substance which counteracts the activity of indophenol.

Thyroidectomy and Tumor Growth, M. REISS AND J. BALINT. Thyreoidektomie und Tumorwachstum, Med. Klin. 30: 706-707, 1934. The Jensen rat sarcoma grew very poorly, or not at all, in thyroidectomized animals, and excision of the thyroid even delayed the growth of established tumors. The inhibition of body growth and tumor growth after this operation appeared to be due to some influence exerted by the anterior hypophyseal lobe. [Rohdenburg, Bullock, and Johnston (Arch. Int. Med. 7: 491, 1911) reported that the removal of certain glands, the thyroid among them, lowered susceptibility somewhat, vhile Bischoff and Maxwell (J. Pharmacol. & Exp. Therap. 46: 51, 1932. Abst. in Am. J. Cancer 20: 647, 1934) found no significant effect therefrom.] WM. H. WOQLOM

Effect of Deuterium Oxide on Rat Sarcoma R-39, CHARLESE. REAAND SAMUELYUSTER. Proc. SOC.Exper. Biol. & Med. 31: 1068-1060, 1934. Water containing 0.11 per cent of deuterium oxide (" heavy water "), when injected into and around rat sarcoma 39 in amounts of 1 C.C. every other day until 10 doses had been given, exerted no demonstrable effect in most cases. Thus in 44 of 50 rats the size and course of the tumors were practically the same as in controls that were given sterile water in the same way. In the remaining six rats, however, the tumors seemed to grow more rapidly and were slightly larger than any in the control animals. The authors are inclined to attribute some significance to this apparent stimulation, though confessing that interpretation of the event is in no way clear. [The negative findings in the majority of the authors' rats agree with those of Sugiurs and Chesley (see following abstract) with mouse sarcoma 180 and the Flexner-Jobling rat carcinoma, and of Woglom and Weber (J. A. M. A. 102: 1289, 1934. Abst. in Am. J. Cancer 21 : 863, 1934) with sarcoma 180 and mouse carcinoma 63.1 WM.H. WOQLOM EXPERIMENTAL STUDIES ; TUMORS IN ANIMALS 681

Effect of Heavy Water (Deuterium Oxide) on Viability of Mouse Sarcoma and Rat Carcinoma, KANEMATSUSUGIURA AND L. C. CHESLEY. Proc. SOC. Exper. Biol. & Med. 31: 1108-1111, 1934. The authors have previously shown that the growth of mouse sarcoma 180 and the Passey mouse melanoma was unaffected by soaking grafts in heavy water " containing 14.8 per cent or 40 per cent of deuterium oxide and made isotonic by addition of the salts of Locke-Ringer solution (Proc. SOC. Exper. Biol. & Med. 31: 659, 1934. Abst. in Am. J. Cancer 22: 415, 1934). In the present communication they state that 94 per cent heavy water, made isotonic in the same way, was equally without effect on mouse sarcoma 180 and the Flexner- Jobling rat carcinoma, when grafts were Roaked in it for twenty-four hours at 4-5" C. WM. H. WOGLOM

Studies in Tissue Metabolism. 111. The Effect of Oxidised 1 : 2 : 5 : 6-Dibenzanthra- cene, ERICBOYLAND AND MARGARETE. BOYLAND.Biochem. J. 28: 244-256, 1934. Oxidized 1 : 2 : 5 : 6-dibenzanthracene inhibited oxidation and glycolysis in all tissues studied (rat muscle, liver, kidney, and brain; Jensen rat sarcoma, rat sarcoma 10, mouse sarcoma M 154, mouse sarcoma M 4, and mouse carcinoma 63). There was no great difference between the effects on normal and on malignant tissues, except that the latter (with the exception of carcinoma 63) were more slowly inhibited. As all known reactions involving enzymes take place in aqueous solution, it seems probable that carcinogenic hydrocarbons are altered in the body to form water-soluble compounds before they can produce biological effects. The oxidation products of these hydrocarbons produced by oxygen in ultraviolet light are water-soluble and have a large inhibitory effect on oxidation processes. The present work shows that the action of the oxidized 1 : 2 : 5 : 6-dibenzanthracene on malignant cells is very similar to that on normal tissues. It is possible that the production of tumors by these carcinogenic compounds involves an oxidation of the compound, either to a product identical with that isolated and used in the experiments here under discussion, or to a less stable intermediate oxidation product. Subcutaneous injections of 0.4 per cent solutions of the oxidation products used in the present work have not yet, after fourteen weeks, produced any tumors in rats or mice. WM. H. WOGLOM

Determination of the pH of Normal and Malignant Tissues with the Glass Electrode and Vacuum Tube Null Indicator, H. M. PARTRIDGE,J. A. C. BOWLES,AND ANNA GOLDFEDER.J. Lab. & Clin. Med. 19: 1100-1105, 1934. In a previous communication (Ztschr. f. Krebsforsch. 40: 186, 1933. Abst. in Am. J. Cancer 21: 115, 1934) the authors have discussed the results of measurements with the glass electrode on certain normal and malignant tissues, and it is the purpose of the present paper to describe the method employed. The conventional Poggendorf circuit was used, with the exception of a vacuum tube null instrument. Mechanically the apparatus was stable, and electrically the drift wa8 very small-often less than the equivalent of one millivolt per hour. [For complete details and a diagram of the apparatus, the reader is referred to the original.] The average value for 4 Flexner-Jobling rat carcinomas was pH 7.36; for 3 mouse carcinomas 63, pH 7.39; for leg muscle from 5 normal rats, pH 6.84; for normal leg muscle from 3 rats bearing the Flexner-Jobling tumor, pH 6.87, and from the 3 mice with carcinoma 63, pH 6.85; for 5 livers from normal rats, pH 6.86; for 4 livers from those bearing the Flexner-Jobling carcinoma, pH 6.95. WM. H. WOQLOM

Lipoids and Tumors, E. MORELLI. I lipidi e i tumori, Boll. d. lega ital. p. 1. lotta contro il cancro 7: 88-92, 1933. This is a short resume and discussion of the experimental work reported on the subject of lipoid metabolism in its relation to cancerous changes in the organism. No original work is given. JEANNETTEMUNRO 682 ABSTRACTS

Contribution to the Study of Cancer Immunity, L. SIM~ESRAPOSO. ContribuiqBo piira o estudo da imunidade anti-cancerosa, Arq. de pat. 5: 5-204, 1933. This is a magnificently illustrated article of over 200 pages, with a very complete bibliography. One hundred and sixty-nine spontaneous breast cancers in mice were studied with regard to their morphology. In 57 of the mice two or more tumors were present. The author believes that these were not, however, multiple tumors but metastases from a single primary tumor. [Support for this view is not furnished by Woglom’s dcmonstration of the fact that the growth rates of multiple tumors (2 to 6) in a mouse were very different one from the other (J. Cancer Research 4: 1, 1919).] The author also studied certain grafted tumors, mouse carcinoma 63, sarcoma 37 of the Imperial Research Fund, and the Jensen rat sarcoma. He tried to graft these tumors into the brains of rats, guinea-pigs, rabbits, fowls, and pigeons, but did not succeed in obtaining any takes. He observed the proportion of regressions in transplanted growths over a long period; noted the fluctuations in the vitality of the tumors, which had already been observed by Bashford; studied the histology of the growths; and also investigated the influence on the growth of tumors of the filling of the cells of the reticulo-endothelial system with inert material, but obtained no immunity or stimulation of growth by this procedure. Administration of autolysates and extracts of tumors in the three types of transplantable neoplasms mentioned produced no immunity. The author was unable to confirm the conclusions of Lumsden with regard to the humoral aspect of anti-tissue immunity Thus, while the work is largely a repetition of what has been done by others, it is an extraordinarily useful summary of what has accrued to our knowledge of the biology of animal tumors by the study of grafted neoplasms. A striking feature is that the spelling of the foreign names in the bibliography and the interpretation of the work of the authors quoted are astonishingly accurate, far more so than in the average continentd monograph.

A Further Contribution to the Study of the Nature and Specificity of Neoplastic Antigens, E. MORELLI. Ulteriore contributo 8110 studio della natura e della specificit$ degli antigeni neoplastici, Boll. d. lega ital. per la lotta contro il cancro 7: 203-214, 1933. The author studied the antigenic properties of two tumors of thyroid origin, a primary cancer and a metastasis to the abdomen from a thyroid cancer. Seven animals were injected with suspensions of the tumors, and in four cases sera reacting with the alcoholic extract of the homologous tumor were secured. In one case the serum also reacted with extract from a mammary carcinoma. [From such a limited experiment no conclusions of value can be drawn.] JEANNETTEMUNBO

Stimulating Action of Aqueous Extracts of Ehrlich Adenocarcinoma on the Growth in Weight of the Albino Rat, F. LANFRANCHI.L’azione stimolante sullo accrescimento ponderale del top0 albino degli estratti acquosi dell’ adeno-carcinoma di Ehrlich, e comparativamente di alcuni organi, Bull. di sc. med., Bologna 105: 226-235, 1933. Lanfranchi used an extract of a well developed non-ulcerated tumor, triturated with alcohol and dried so that one gram of dried material corresponded to five of the fresh tumor. The dried material was then diluted with Ringer’s solution and centrifuged, and the supernatant liquid used in full strength, 1 C.C. corresponding to 20 mg. of fresh tumor, or diluted to one-tenth of the full strength. Extracts of liver and kidney similarly prepared were also tried. Fifty-four rats and mice were used. Injections of full- strength or dilute solution were given every week or three times weekly for three months. All animals given injections of tumor, liver, or kidney grew and developed more rapidly than the controls. Since the rate of growth was about the same where diluted and infrequent injections were given, the effectis not to be attributed to the extra nutri- tive material given but rather, the author believes, to hormonal action. The injections did not affect the fertility of the animals, nor their behavior in regard to subsequent tumor grafts. No control animals were injected with Ringer’s solution alone. [Experiments on growth rate of transplanted tumors are of little value unless pure EXPERIMENTAL STUDIES ; TUMORS IN ANIMALS 683 strains of animals are used, and in large numbers to eliminate the fluctuations in growth rate which may occur even in untreated tumors.] JEANNETTEMUNRO

Proliferative Reaction of Guinea-Pig Skin to Sulphydryl and Its Relation to Neoplasia, STANLEYP. REIMANNAND ETHELR. HANKELE.Arch. Path. 17: 764-768, 1934. The guinea-pig is added to the list of organisms which have proved responsive, in their rates of cell division, to the application of members of the sulphydryl group. As in rats and mice, cell division is increaAed in the irritated area of skin, and there then follows a secondary augmentation in the degree of cell differentiation and organization. WM. H. WOQLOM Megakaryocytosis in White Mice with Spontaneous Mammary Carcinomas, W. C. HUEPER. Am. J. M. Sc. 188: 41-49, 1934. This report is based on histologic examination of the organs of 210 white mice, 172 of which had spontaneous mammary carcinoma while the remaining 38 were normal members of the same strain. Of the cancer mice 91 and of the normal animals 19 had been subjected to roentgen-ray treatments of varying intensity, the total dosage ranging from 40 to 6000 r delivered over a period of from one to six weeks. Twenty-one cancer animals had received no treatment of any kind and died a natural death, while the remainder had had at some time during their lives injections of organic and inorganic chemotherapeutic agents of various kinds. Mice with spontaneous mammary cancer are known to have a high incidence of extramedullary megakaryocytes in various organs; and as they rather often show extramedullary lymphoid and myeloid foci sometimes reaching leukemoid proportions and therefore comparable to those pathologic conditions of the human hematopoietic system which are not infrequently associated with heterotopic megakaryocytosis, the carcinomatous mowe appears to be a suitable source for collecting additional information on the origin and histogenesis of heterotopic megakaryocytes. The author concludes that, in addition to extramedullary megakaryocytes of embolic origin (lung, kidney), autochthonous megakaryocytes also occur in various organs (epleen, liver, lymph-nodes) of white mice with spontaneous mammary carcinoma. WM. H. WOQLOM

Transmission of Myeloid Leukemia in Mice, J. FURTH.Proc. SOC.Exper. Biol. & Med. 31: 923-925, 1934. Myeloid leukemia, the most common type of leukemia in man, is so rare in animals that there is some doubt whether it has ever been observed in those under domestica- tion. The disease has been described in mice, it is true, but neither bone-marrow nor blood smears were available to the reporter. It was rarely found among the author’s strain of mice until a large number of them had been exposed to a single dose of x-rays (about 400 T) or to repeated smaller doses at approximately monthly intervals. The disorder could be transmitted to other mice by intravenous or subcutaneous injection of emulsions of affected spleens, the former procedure eliciting systemic disease, the latter giving rise to tumors (myelomata). The experiments indicate that leukemic myeloid cells, like leukemic lymphocytes, have the characteristic8 of neoplastic cells. WM. H. WOQLOM

Leukemias of Dogs, D. WIRTHAND R. BAUMANN.Die Leukiimien des Hundes, Folia haemat. 50: 242.259, 1933. Wirth and Baumann report 3 cases of lymphatic leukemia associated with a lymphadenosis and 11 casey of myelogenous leukemia in dogs. The article is illustrated by photomicrographs of the blood, lymph nodes, and spleens of Nome of the animals. BENJAMINR. SHORE 684 ABSTRACTS

Heterotopic Collections of Bone Marrow Resembling Tumors in Fowl, CH.OBERLINQ AND M. GU~RIN.Formations de moelle osseuse hhtbrotopique d’aspect tumoral cliez la poule, Bull. Assoc. franp. p. 1’6tude du cancer 23: 341-349, 1934. The nodules described in this paper are not uncommon, 8 having been found among some 800 fowls. They appear as small masses, about the size of a nut, situated behind the kidney, sometimes bilateral, usually separated with ease from the surrounding structures, though occasionally adherent to the underlying bone, soft, and dark red or yellowish red in color. Microscopic examination showed them to be composed of red and yellow bone marrow. In four instances where they occurred in birds with leukemia their structure reproduced exactly that of leukemic marrow, and in one fowl that died of tuberculosis this heterotopic medullary tissue was thickly strewn with tubercles. Thus these masses possess not only the morphological features of bone marrow but its functional characteristics as well, and participate in the changes which it undergoes in the presence of pathological conditions. Attempts at inoculation were unsuccessful, as was to have been expected, for these nodules are not tumors. One rather surprising feature is the fact that they did not transinit leukemia nearly so effectively tw the bone marrow itself. Similar deposits of heterotopic bone marrow have been described in man, usually in the adrenal, much more rarely at the hilus of the kidney, between the kidney and the adrenal, in the abdominal wall, or along the thoracic vertebrae. Diverse suggestion8 have been offered from the point of view of histogenesis and pathogenesis, but this discovery of similar nodules in fowls has contributed nothing toward an explanation. The paper was discussed by Cailliau, who asked why the nodules in question could not equally well be regarded &s foci of revived hematopoietic activity. WM. H. WOQLOM Sensitivity of Dividing and Non-Dividing Cells to Radiation, WM.H. LOVE,J. C. MOTTRAM. Nature 134: 252-253, 1934. In an earlier publication (Brit. J. Radiol. 6: 615, 1933. Abst. in Am. J. Cancer 20: 058, 1934) Mottrani stated that he had confirmed the conclusion arrived at by him in 1913 that the dividing cell is more sensitive than the non-dividing cell. Bean root tip8 were used as material. Wm. H. Love, in a letter to Nature, criticizes Mottram’s statement as not differentiating between the mitotic and premitotic states. Love’s own investigations (Arch. f. exper. Zellforsch. 11 : 463, 1931) showed that the premitotic cell is more radiosensitive than the mitotic cell. Love also states that all that Mottram has described was advanced as early as 1906. Mottram replies that his 1913 paper determined only the ratio of the dividing to non-dividing cells. He agrees with Love and with Spear (Proc. Roy. SOC.,ser. €3, London 108: 190,1931;110: 224,1932) that they have shown that, of the various stages between one mitosis and the subsequent one, the premitotic stage is the most sensitive, but he knows of no experiment of theirs to prove that the cell in the premitotic stage is more sensitive to radiation than the cell during mitosis.

Experiments on the Chorio-Allantoic Membrane of the Chick Egg with regard to the Action of Homogeneous X-ray Irradiation. E. S. DUTHIE.Brit. J. Radiol. 7: 238- 245, 1934. Duthie has repeated the experiments of Moppett, radiating the chorio-allantoic membrane of the chick with x-rays scattered by a crystal. The effect of the crystal is to render the radiation over a small area approximately homogeneous. Moppett claimed that certain wavelengths, notably 0.1 1, 0.53,and 0.79 Angstrdm units, had more potency than the intermediate values, and that an antagonism existed between radiation of different wavelengths, a small dose of radiation of one wavelength being capable of inhibiting an otherwise potent dose of a homogeneous radiation of another wavelength. In view of the experimental work of Packard with Drosophila eggs and a great variety of wavelengths, Moppett’s conclusions have always seemed questionable, and Duthie was unable to find that the radiation as given by him had any effect on thechorio-allantoic CLINICAL OBSERVATIONS ; BLOOD STUDIES 685 membrane of the chick, while in the eggs used as controls the tissues showed a great deal of damage, which the author believes was the result of cooling. [See in this connection the review of Moppett’s book, Homogeneous X-radiation and Living Tissues, in Am. J. Cancer 19: 397, 1933; also abstracts of papers by Scott (ibid. 18: 408, 1933) and Goulston (ibid. 21: 872, 1934).]

Experimental Cancer Research, CARLSTERNBERQ. Uber experimentelle .Geschwulst- forschung, Wien. med. Wchnschr. 84: 509-513, 1934. This lecture reviews experimental cancer research but adds no new material. WM. H. WOGLOM

THE CANCER CELL

An Attempt to Explain Cancer, L. MARCOTTE.Essai d’interprbtation du cancer, Gal;. m6d. de France, pp. 444-445, June 15, 1933. Marcotte maintains that normally there is equilibrium in the activity of the nucleus and the protoplasm of the cell. Certain irritants, however, tend to overstimulate the activity of the nucleus in relation to that of the protoplasm, with the production of abnormal karyokinesis and the development of the cancer cell.

Intracellular Structures in Monocytes in Cases of Malignant Disease, 0. C. GRUNER. J. Lab. & Clin. Med. 19: 917-923, 1934. A description is given of certain bodies found in the monocytes (especially) in a high percentage of cases of malignant disease, and in a very few cases which were clinically non-malignant. They are demonstrable only with Giemsa’s or Leishman’s stain. Their possible nature is discussed, but no definite conclusion is reached. WM. H. WOQLOM

Determinants of Cell Division in the Adult, A. P. DUSTIN. Nos coiiiiaissances actuelles sur le d6terniinisme de la division cellulaire chez l’adulte, Cancer 11 : 25-42, 1934. The author reviews his investigations on the thymus, a gland which he believes to play an important rGle in the storage and release of nucleo-proteins and thus, ultimately, in the cell division of adult mammals. WM. H. WOQLOM

CLINICAL OBSERVATIONS; BLOOD STUDIES

Precancerous Lesions, G. SOTTI. Lesioni precancerose, Boll. d. lega ital. p. 1. lotta contro il cancro 7: 63-71, 1933. The author discusses the difficulties in determining what constitutes a precancerous condition and stresses the value of morphological and histological studies in demonstrating changes leading toward anaplasia. JEANNETTEMUNRO

Metastatic Localization of Neoplasms at Points of Fracture, F. P. TINOZZI.Sulla localizzazione metastatica di neoplasmi in focolai di frattura, Ann. ital. di chir. 12: 933-938, 1933. A woman of sixty-seven sustained a traumatic fracture of the humerus in its middle third. Four weeks later the plaster cast became very tight and a large tumor was found to have formed surrounding the area of fracture. Further examination disclosed cancer of the breast with axillary metastases on the side of the injured arm. X-ray showed carcinomatous metastasis at the site of the fracture. The author believes that the metastasis developed subsequent to and as a result of the injury. He attempted to Be- cure metastases at points of experimental fracture in cancer-bearing rats but in no case was there delayed union or metastasis about the fracture in his small series of animals. [There is no experimental evidence that a fracture determines the location of a tumor, and though such determination is frequently assumed in human beings, there is also 686 ABSTRAOTS

no proof here. In the example cited above the tumor in all probability was present in the bone long before the fracture occurred and was the cause of the fracture rather than the reverse, as assumed Iiy Tinozzi.] JEANNETTEMUNRO

Epithelioma Developing in the Scar Following a Bum, B. It. SHORE.Surg. Cliii. North America 14: 331-333, April 1934. A raised,. actively growing epithelioma developed in the center of a marred area on the left thigh of a thirty-nine-year-old patient, thirty years after the burn which caused the scarring. When the patient was first seen, the tumor was protruding, fungating, infected, and measured 6 cm. in diameter. The growth was excised with a fusiforni piece of scarred skin and underlying fascia 34 cm. long and 11 cm. in its widest portion. Healing of this large denuded area was secured with Thiersch and Reverdin grafts. A block dissection of the left inguinal lymph nodes was done later. Histologic study of the tumor showed it to be a squamous-cell epithelioma. The inguinal lymph nodes showed no metastatic growth. The patient has remained well, without evidence of recurrence, for two years. Two photographs are included. BENJAMINR. SHORE

Multiple Tumors (Primary Laryngeal and Bronchial Carcinoma), L. LAUBAND E. VON ZALKA. Beitrag zur Multiplizitat der Geschwtilste, Monatschr. f. Ohrenh. 67: 1089-1095, 1933. In a man of fifty-one pulmonary symptoms developing after operation for cancer of the larynx were found to be due to bronchial carcinoma. The laryngeal tumor was a typical squamous-cell epithelioma with areas of cornification; the bronchial carcinoma was alveolar carcinoma with oval cells (oat-cell cancer) and metastases in the left adrenal, the liver, and the gallbladder. The author could find in the literature only 3 cases of multiple primary malignant tumors in which the larynx was one of the organs involved and no other case in which both the larynx and the bronchi were the site of tumors. The report is accompanied by four illustrations, including two photomicrographs, and a brief bibliography.

Primary Malignant Tumors of the Foot, Report of 37 Cases, B. F. SCHREINERAND W. H. WEHR. Radiology 21: 513-521, 1933. Among 10,459 malignant tumors seen at the New York Institute for the Study of Malignant Disease, the authors found 37 which were located in the foot. The most common type was melanotic sarcoma or nevus-cell carcinoma, of which there were 17 examples. The remaining cases consisted of 8 squamous-cell carcinomas, 6 sarcomas of the soft tissues, 4 sarcomas of bone, one adenocarcinoma, and one basal-cell carcinoma. The treatment of the melanotic tumors was highly unsatisfactory, and it is felt that earlier diagnosis is essential so that radical measures may be taken before the spread of the growth. Squamous-cell epitheliomas in their early stages can be healed by irradiation, but advanced ca8es may call for amputation of the limb. In two cases melanotic sarcomas developed at the sites of previous calluses which had been irradiated several years before, but the causal relationship is not definitely ascertained. The literature is briefly reviewed and there are nine excellent illustrations of gross lesions. THEODORES. RAIFORD

Glomus Tumor: A Clinical Study with a Report of 10 Cases, F. E. ADAIR. Am. J. Surg. 25: 1-6, 1934. Ten cases of glomus tumor are reported by Adair. In 4 of these cases the lesions were situated beneath the finger nail, while in the other 6 they occurred on various aspectfi of the arms and legs. Pain was the striking characteristic of all these tumors. In 8 cases the lesion was surgically removed and studied histologically; in the other 2 casen the diagnosis was made from the clinical characteristics. In the 8 operative cases the patients have remained well from three months to eleven years. There have been no recurrences. The article is illustrated by photographs and a drawing. BENJAMINR. SHORE CLINICAL OBSERVATIONS ; BLOOD STUDIES 687

Tumor of a Subcutaneous Glomus, M. L. MASONAND ARTHURWEIL. Surg. Gynec. Obet. 58: 807-816, 1934. A fifty-six-year-old man had a glomus tumor situated in the subcutaneous tissues of the left leg just lateral to the patella. The clinical and histologic characteristics were typical of these tumors, and complete relief was obtained by surgical excision. The historical and histologic aspects of glomus tumors are reviewed from a study of 34 cases reported in the literature. The article is well illustrated by a photograph, photomicrographs, and a drawing. BENJAMINR. SHORE

Heterotopic Epithelial Tumors of the Salivary Glands, A. SNELLMAN.uber hetero- typische epitheliale Geschwulste der grossen Speicheldrusen, Arb. a. d. path. Inst. d. Univ. Helsingfors 7: 419-452, 1933. Snellman has studied in detail the histologic characteristics of 8 epithelial tumors of the salivary glands. Be concludes that the grade of anaplasia of the cells, as evidenced by the arrangement and amount of the nuclear and nucleolar material, has a direct relation to the malignancy of the tumor. The article is illustrated by excellent photomicrographs and drawings. BENJAMINR. SHORE

Skeletal Muscle Sarcoma, E. M. BICK. Ann. Surg. 99: 949-956, 1934. Bick reports 20 cases of skeletal muscle sarcoma included in a series of 35 skeletal muscle tumors collected from the Hospital for Joint Diseases and Mount Sinai Hospital, New York City. The sites of predilection for intramuscular sarcomas are the thigh, abdominal wall, and forearm. Sixteen of the 20 tumors occurred in these regions, with about equal frequency. There were 13 fibrosarcomas, 4 neurofibrosarcomas, and one case each of myxosarcoina, myosarcoma, and chondrosarcoma. The treatment of primary intramuscular fibrosarcomas or myxosarcomas is radical surgical excision of the tumors. Following this there should be given a prolonged course of deep roentgen radiation, even though it is well known that tumors of connective tissue origin are relatively radioresistant. The success of therapy in skeletal muscle sarcomas depends upon the grade of malignancy of the tumor at the time of treatment, early diagnosis, and the completeness of excision. The end-results in this series of cases are not given. BENJAMINR. SHORE

Angioma Cavernosa of Striated Muscles, D. SOLI. Sull’ angioma cavernoso dei muscoli striati, Bull. d. sc. med., Bologna 105: 77-94, 1933. The author reports a case of an angioma which nearly replaced the splenius capitis muscle. He reviews the literature and discusses the etiology and pathology of angiomas of striated muscle. The article contains photomicrographs and a bibliography. JEANNETTEMUNRO

Xanthoma Tuberosum Multiplex, M. F. STEIN. Med. Bull. Vet. Admin. 10: 345- 348, 1934. The lesions of xanthoma tuberosum multiplex are widely disseminated, being found most frequently on the elbows, knees, and hips, although they may occur in any part of the body. They are of various types-papular, tubercular, nodular, etc.- and as a rule are soft or semi-solid. Pollitzer and Wile (J. Cutan. Dis. 30: 235, 1912) believe that the condition represents an irritative connective-tissue hyperplasia, and that the extrav- asation of cholesterol and fatty acids in the blood serves as a stimulus. The disease progresses to a certain stage and then remains stationary. It seldom produces systemic symptoms and is never fatal. Spontaneous involution has been observed. The author’s patient was treated, after recurrence following surgical procedures, by a modification of the method suggested by Wile et a1 (Arch. Dermat. & Syph. 19: 35, 1929). He was placed on a diet of 100 gm. protein, 50 gm. fat, and 400 or more gm. carbohydrate, the total calories being over 2500. Insulin was given to produce rapid carbohydrate combustion and at the same time to effect a more rapid disintegration of the fatty acids. 688 ABSTRAUTS

On admission the patient had a blood cholesterol of 340 mg. and weighed 205 pounds. The blood Wassermann and Kahn reactions were positive. At the end of six months of treatment the weight was 181 pounds, the blood cholesterol was reduced to 185 mg., and the Wassermann and Kahn reactions were negative, though no anti-syphilitic treatment had been given. While no involution of the xanthomatous masses was obtained, it was thought that the progress of the disease had been arrested. W. S. MACCOMB

Large Cholesteatoma with a Small Perforation, of the Attic, E. RUTTIN. RiesigeR Cholesteatom bei kleiner Attikperforation, Monatschr. f. Ohrenheilk. 67: 756-758, 1933. A forty-two-year-old man complained primarily of vertigo, headaches, and purulent discharge from the right ear. Examination showed a perforation of Shrapnell’s membrane, with destruction of a part of the lateral attic wall. Operation exposed a large cholesteatoma filling the mastoid antrum, destroying a part of,the cranial fossa, and involving the bony labyrinth. Removal necessitated an extensive resection, during which the malleus and the tympanic membrane were excised and the facid nerve divided. Five months after the operation the patient was perfectly well and symptom-free except for facial paralysis. There are no illustrations. THEODORES. RAIFORD

Rare Tumor of the Lobule of the Ear in a Child, G. CLAUS. Seltene Geschwulstbildung des Ohrliippchens beim Kinde, Ztschr. f. Hals-, Nasen-. u. Ohrenh. 35: 212-218, 1934. Also in Internat. Zentralbl. f. Ohrenh. 36: 311-313, 1933. A child between two and three years old had a bluish red tumor involving the lobule of the left ear. The blood picture was normal, and biopsy led to a diagnosis of aleukemic lymphadenosis cutis. In the discussion of this case Herzfeld reported a tumor of the lobule of the ear in a woman of forty-six. The appearance suggested an angiomatous tumor, but pressure had no effect on either the size or the color of the growth. The tumor was removed and was found histologically to be a round-cell sarcoma. Beyer adds a report of a lymphangioma of the lobule of the ear in a child.of six.

SpecMc Gravity of the Blood in Human Cancer: Four Hundred Observations, with a Note on its Clinical Significance, DAVIDPOLOWE. J. Lab. & Clin. Med. 19: 983- 993, 1934. The specific gravity of the whole blood was determined by the falling drop technic of Barbour and Hamilton (J. Biol. Chem. 69: 625, 1926) in 400 cases of proved cancer. A relatively low incidence of anemia (specific gravity below 1.050, the normal figure being about 1.055 for males and 1.053 for females) was found-22 per cent for the series a8 a whole; in only 5.2 per cent did it reach a severe or moderately severe grade. Ae most of the patients had received some form of radiotherapy, it would appear that radiation is not so potent a cause of anemia as it is often said to be. WM. H. WOGLOM Spectrometric Studies on the Blood Serum of Carcinomatous Patients, L. BRAUER,F. Goos, AND C. HELLER. Spektrometrische Untersuchungen am Blutserum Karzino- matoser, Strahlentherapie 50: 527-528, 1934. The authors again maintain that precise analysis reveals no difference between the blood sera of carcinomatous and of healthy individuals. CHARLESPACKARD

Amid Nitrogen Content of the Plasma Proteins with Special Reference to Cancer, PETERF. MERZBACH.Untersuchung uber den Amidstickstoffgehalt der Plasma- proteine, mit besonderer Berricksichtigung Tumorkranker, Frankfurt. Ztschr. f. Path. 47: 116-122, 1934. No characteristic changes were found in the amid nitrogen content of plasma from cancer patients. WILLIAMH. WOQLOht DIAGNOSIS AND TREATMENT 689

DIAGNOSIS AND TREATMENT

Biopsy, J. C. BLOODGOOD.Am. J. Surg. 24: 331-344, 1934. Bloodgood believes that biopsy properly carried out is attended by but little if any risk. It is his belief that the greatest danger is that a diagnosis of malignancy, errone- ously made on border-line tumors, will lead to an unnecessary radical operation. He suggests that two pathologists be called upon for their opinions when biopsy is done. [It would save time to have one good one and stick to him, for truth cannot be obtained by averaging one correct and one incorrect diagnosis, and pathologists have been known to disagree.] In a discussion of bone tumors Bloodgood refers to two five-year cures reported by him in 1920. In one of these cases, an osteogenic sarcoma, biopsy was performed two weeks before the amputation. In the series of Geschickter and Copeland, biopsy was done in one half of the seventy or more cured cases. The use of the cautery and of a 50 per cent solution of zinc chloride is recommended for biopsies in bone tumors. As to breast tumors, Bloodgood believes that in most doubtful cases the tumor will prove to be benign, The opinion of a competent pathologist should be obtained before a radical procedure is done. W. S. MACCOMB

Biopsy as an Aid to Diagnosis, S. POLLITZER.New York State J. Med. 34: 462-463, 1934. . The author stresses the importance of care in taking biopsies of dermatological material and the importance of obtaining a section from an early stage of the lesion, together with some normal skin if possible. A synopsis of the clinical data should be furnished the pathoIogist. W. S. MACCOMB

Biologic Tests in Cancer Diagnosis, R. BRANCATI.Le prove biologiche nella diagnosi del cancro, Boll. d. lega ital. p. 1. lotta contro il cancro 7: 84-87, 1933. This is a brief r6sum6 of a speech in which the author discusses the general basis of humeral changes due to the presence of cancer on which the various biologic tests proposed for diagnosis are founded. He concludes that in view of the many different tests suggested in the literature, we may assume that no one is specific, but he believes that many give suggestive results, while some may eventually prove of clinical value in cancer diagnosis. JEANNETTEMUNRO

Reaction in the Serum of Cancer Patients, P. NEUDA. Ueber ein eigentiimliches Serumverhalten Krebskranker, Wien. klin. Wchnschr. 47: 189-190, 1934. The reaction described by Neuda is not diagnostic for cancer, as it occurs also in certain infectious diseases, and it is offered, therefore, only in the hope that some common factor may be discovered which will help to illumine the cancer problem. The reaction depends upon the presence in the serum of certain substances which cause agglutination of its own erythrocytes, and represents a .true antigen-antibody union. For technical details the reader is referred to the original. WM. H. WOGLOM

Recent Problems in Carcinoma, E. FREUND.Neuere Karzinomprobleme, Wien. med. Wchnschr. 84: 313-317, 1934. Cytolytic Reaction in the Diagnosis of Cancer, E. FREUND.Uber den Stand der derzeitigen Karzinomdiagnose auf dern Boden der zytolytischen Reaktion, Wien. klin. Wchnschr. 47: 440-441, 1934. Pathological Metabolism and New Growth, E. FREUND.Uber die Grundlagen einer Stoffwechselpathologie der Tumoren, ibid. 47: 471, 1934. Therapeutic Suggestions for a Metabolic Treatment of Carcinoma, E. FREUND.Uber therapeutische Vorschllige fur eine Stoffwechselbehandlung des Karzinoms, ibid. 47: 564-565, 1934. The author discusses in general terms his cytolytic diagnostic reaction and an attempt to control mouse carcinoma by dietary methods. 690 ABSTRAOTS

[Abstracts of articles describing this work will be found in preceding numbers of the American Journal of Cancer. See for example 21: 682, 683, 1934.1 WM.H. WOQLOM

Principles of X-Ray Therapy of Malignant Disease, HENRICOUTARD. Lancet 2: 1-8, 1934. Coutard discusses the principles of x-ray therapy of malignant neoplasms under four headings: (a) Results of sufficiently long standing to show that the cure of cancer by x-ray therapy is possible. (b) The physical and clinical technic by means of which these results have been obtained. (c) The general biological principles. (d) Present knowledge of x-ray therapy of cancer. Some of the results obtained at the Curie Foundation are presented in tabular form. Table 1, for example, shows for lymphosarcoma of the mouth, tongue, and nasopharynx, 17 per cent of seven-year survivals out of 45 cases. Table 11, on epithelioma of the tonsillar region, shows 17 per cent of seven-year survivals out of 46 cases treated; and Table 111, for epithelioma of the larynx, 27 per cent of 77 patients treated surviving at the end of seven years. Attention is called to the fact that these results may vary in a curious fashion from year to year, without any variation in the technic. In 1925, of 13 patients with epitheliomata of the tonsils and soft palate only one survived (7 per cent). In 1922, of 11 patients treated for carcinomata of the larynx not one was alive after three years, whereas in 1921 out of 8 patients treated 4 survived twelve years. [The mme curious fluctuations in results of treatment of carcinoma of the cervix have been reported from the Radiumhemmet by Heyman.] Coutard considers carcinoma of the larynx in the early stages very easily handled. The average dose required is only about 6000 T on the skin, given during fifteen to twenty- five days, with fields of 50 square centimeters. On the other hand, carcinomata of the larynx which have become extrinsic are very difficult, and in spite of heavy doses of 7000 to 8000 T on the skin, failure is not infrequent. The technic employed at the Radium Institute of the University of Paris calls for 190 to 200 kv., 2 mm. zinc and 3 mm. aluminum filters, with 3 cm. of wood next to the patient. Focal distances are from 50 to 60 cm. for lesions of the head and neck. For deeply seated carcinomata, such as those of the uterus, the focal distances have becn 80 to 100 cm. The dose delivered is measured on the skin and calculated in international r units. The fields or portals of entry, their shape and size, obvioudy vary with the different lesions. About the head and neck the area has been from 50 to 100 sq cni. and with alternating fields it is possible to reach a maximum in some cases of 700 to 800 r per day for one, two, or three days, while occasionally a dose of only 200 or 300 r per day is used, and sometimes less. In the lower abdomen the fields have been on the average 250 to 350 sq. cm., the dose not exceeding 500 T per day. Among the epithelial neoplasms treated at the Curie Institute those which have been cured received depth doses ranging from 3000 to 4000 T for the radiosensitive non-infiltrating forms and doses a little higher for the radioresistant forms. These figures represent the amounts received by the most deeply seated part of the neoplastic lesion. In treatment Coutard prefers to rely on daily examinations of the patient rather than upon physical measurements. This examination involves observation of changes in the appearance of the neoplasm, and also of the vasculo-connective tissues and the mucous membranes near the tumor, the glandular secretions, and the general condition of the patient. For while the dose is an element of x-ray therapy, the biological conditions under which this dose must be distributed are sometimes more important than the total quantity. The various reactions of the vasculo-connective and epithelial tissues are described in comiderable detail, and there are a number of excellent photographs illustrating the appearance of radio-epidermitis and the repair of the same. The practical point in connection with the healing of radio-epidermitis is that the area must not exceed a certain maximum or healing will be greatly delayed. In discussing the general biological principles underlying radiation, the point is made that the nutrition of the cells of the epithelioma during irradiation is dependent upon the conservation of the medium in which it lies, in other words, of the vasculo-connective DIAGNOSIS AND TREATMENT 69 1 tissues. If the total dose, or the daily dose, or the intensity per minute has been too high, if the field has been too large in relation to the dosage, or the filtration or voltage too low, the connective tissue may be modified. The nutrition of the epithelial cells thus becomes deficient, and the radiosensitivity, which seems to be linked with the activity of the metabolic interchange with the vasculo-coiinectivc tissue, is diminished, and the cancer cells behave as if they had become insensitive to the radiations. This is what Regaud described in 1913 under the name of radiovaccination. In tumors made up of undifferentiated tissue and in certain sensitive types, like lymphosarcoma, radiation modification of the connective tissues has very slight effect upon the cancer cells. The effect of x-ray on such cells is always rapid, sometimes within a few hours, and the cells of the tumors of this group die in the course of the first two weeks, a fact which is not true of the epidermoid or adeno-carcinomata. Hence the care of the vasculo-connective tissue is not important in the highly sensitive types of tumors, but of exceedingly great importance in those tumors whose resistance approxi- mates that of the normal structures about them. Initially, large doses were given at the beginning of a treatment, say 4500 r in six days, and smaller amounts later, but 'it was shortly found that the patients did not do so well as when the initial dose of 4500 r was given in ten to twelve days instead of six. It was found possible to obtain a cure on condition that the total duration of treatment did not exceed three weeks. Subsequently it became evident that the time limit of treatment beyond which a cancer seems to become insensitive is not fixed and the duration of treatment was increased up to thirty and forty days. In the latter case it is possible to obtain a cure when the daily dose during the first ten days does not exceed 300 T. Clinical study of the author's material shows that the changes in the vasculo- connective tissue are due much more to excessive daily doses and excessive intensity per tninute than to the excess of the total dose administered. Consequently the shorter the duration of the treatment and the higher the daily dose, the quicker the vasculo-connective tissue is damaged and also the quicker the tumor seems to become radio-insensitive. When the daily doses are weaker, provided that they reach the amount necessary for the destruction of the neoplastic cells, radiosensitivity of the tumor is longer preserved. The intensity per minute given at present varies from 3 to 5 r. Increasing the dose above 10,000, or even to 15,000 r, never gave a single cure, but always aggravated the general condition of the patient. Recently the duration of treatment in the highly radioresistant cancers has been increased from thirty to ninety days in some instances and the daily dose diminished to 200 or even 175 r per day, given in two sittings. In summarizing, Coutard points out that the two principal factors in x-ray therapy are the energy and the time. These must be considered in their relation to the cancer cells on the one hand and to the vasculo-connective supporting tissues on the other. Cancers of small size and embryonic type can be rayed rapidly, say for twenty daye, and the reactions may be very intense, but the results will be good if the duration of repair does not exceed fifteen days. Neoplasms of more normal type require longer treatment and the skin reaction should be less. In raying extensive neoplasms through large fields, the minimum period of treatment ought to be forty days, the cutaneous radio-epidermitis should not be exudative, and the radio-epithelitis of the vaginal, intestinal and vesical mucosa ought to be very slight. Even temporary symptoms of cystitis, proctitis, or enteritis should be avoided. The question of energy, i.e. of the cancericidal dose, is essential in the treatment of radiosensitive cancer and is more important than the time. The energy seems to be directly destructive. In the more highly differentiated radioresistant tumors the question of time is more important; the energy ought not to produce any destructive changes and the treatment should be prolonged and given in small daily doses. Despite all the experience which has been gained in this study of some fifteen years, Coutard states definitely that the cure of cancer by x-rays is still difficult as well as dangerous, and a very small margin may exist between the dose which will cure and the dose which will provoke a serious or even a fatal injury. Daily examination of the patient is necessary, for the changes in the normal tissues and in the genera1 condition 692 ABSTRAOTS

are sometimes so rapid that it is necessary to diminish the daily dose or the siae of the fields in the course of treatment. There is no fixed method for treatment; each patient and each tumor must be studied for themselves. F. CAVERN

Present Status of Radiation in the Treatment of Cancer, ARTHURC. CHRISTIE.J. A. M. A. 103: 985-989, 1934. This paper contains a very general discussion of radiotherapy in cancer, rather optimistic in tone, without the addition of any new facts to our knowledge. There are a considerable number of statements with which there will be no general agreement. For example, in discussing biopsy the author states that “ nothing has been more thoroughly established than the fact that trauma by cutting through or otherwise injuring cancer- bearing tissue greatly increases the danger of dissemination of the cancer cells both locally and to distant parts.” One of the criticisms of the statements made by many radiologists as to their accomplishments has been based upon the lack of definite histological knowledge of the nature of the growth treated, a knowledge which the surgeon considers essential before he publishes his records. , Nor will general acceptance be given to the statement that “ the initial treatment in all cases of breast carcinoma should be a thorough course of high-voltage roentgen irradiation over the breast and lymphatic drainage areas.” There is certainly no statistical foundation for such a statement. Quantitative X-ray Dosage. Units of Measurement. Evaluation of Biological Units, WANGERMEZ.Le dosage quantitatif des rayons X. Unites de mesure. Evalua- tion des unites biologiques, Arch. d’electric. m6d. 41 : 51-79, 1933. The author reviews the various methgds, chemical, physical and biological, which have been ueed to measure x-ray doses. With the adoption of the roentgen (r), thera- pists hoped to express biological reactions in terms of this unit, but that is not possible. Chief among the factors which make precise measurement difficult is scattered radiation, which plays a large part in producing biological effects. Because scattered rays are much softer than the primary beam they cannot always be correctly measured by thim- ble chambers. The amount of scatter varies with the skin distance, area of field, quality of the primary radiation, and nature of the organs irradiated. Only when small fields are used do the physical and biological measurements agree. Therefore, in describing a dose these factors should be mentioned, as well as the distribution of the dose in time, the type of apparatus used, and the method of measurement. CHARLEB PACKARD

Roentgen Irradiation of Malignant Tumors at Short Distances, H. CHAOULAND A. ADAM. Die RSntgen-Nahbestrahlung maligner Tumoren, Strahle’ntherapie 48: 31-50, 1933. The authors have developed a technic for irradiating superficial tumors at very small focal distances. Since all wavelengths are equally effective, the clinician need consider only the distribution of the radiant energy in time, that is the time factor, and in space. The fractionated method is best. At focal distances of 5 to 11 cm. 50 per cent of the x-ray energy is absorbed in the first few centimeters of tissue. The effect, therefore, is sharply localized. The tumors to be treated must be fully exposed to direct radiation. The authors have used 60, 100, and 180 kv., giving 215 to 500 T per day. Short exposures of high intensity are preferred. The total dose varies from 8000 to 16,000 r, the amount depending on the behavior of the tumor. If this disappears during treatment, further irradiation is stopped. After doses of 8000 r the skin reaction is intenee, sub- siding after three or four weeks. If further treatment is needed, it is given in a series of fractionated doses, each amounting to 2000 or 3000 r. Full reports of 28 cases are given. The longest period of observation is twenty- eight months, Skin tumors and superficial lymph node metastases have been treated, and one case of inoperable tongue cancer. In every instance the tumors have disappeared, with no recurrence. The authors believe that tumors of the oral cavity may be successfully treated by this method, but special tubes will be needed. The article is fully illustrated. [See following abstract.I CHARLESPACKARD DIAGNOSIS AND TREATMENT 693

Additional Report on the Method of Irradiating Carcinomas at Short Distances, H. CHAOUL. Weiterer Beitrag zur Rontgennahbestrahlung des Karzinoms, Strahlen- therapie 50: 446-452, 1934. Specially designed tubes for irradiation at 5 to 10 cm. are now available. At these short distances the author believes that the biological responses to the rays are different from those produced at greater distances. The skin tolerance is greater, probably because of the rapid falling off of the intensity in the first few centimeters of tissue. The author now irradiates very small areas, from 10 to 15 square centimeters and, rarely, 25 square centimeters. For a definite dose the skin reaction is the same whether the dose is given in one sitting of five hours at low intensity, or in several short exposures at high intensity; 6000 to 8000 T can safely be given. For tumors of the tongue and tonsils 9000 to 10,000 r is not too much. After an interval of three or four weeks these large doses can be repeated. The skin tolerance may be even greater than before. A table showing the reaction of 103 patients suffering from carcinoma of the skin, lip, tongue, etc., indicates that 90 per cent were symptom-free. Seven had been under observation for three years. In one case of rectal carcinoma sections taken after treatment showed no trace of tumor cells. Since practically all of these cases were inoperable, these results are significant, even though the time of observation is not long. CHARLESPACKARD

So-called Specific Effect of Short Waves in the Treatment of Malignant Tumors, M. HAARAND LOB: Die sogenannten spezifischen Effekte der Kurzwellen bei der Behandlung bosartiger Geschwulste, Strahlentherapie 50: 345-347, 1934. Short electric waves (2.8-20 meters) have been advocated in cancer therapy because they are supposed to have a specific effect on tumors. The authors, however, find no evidence of this. These waves produce their effect chiefly by raising the temperature of the tissues which they penetrate, the result being a hyperemia and final coagulation. This is not specific. Experiments with Jensen mouse sarcoma show that the tumor is injured by short waves only when the surrounding tissue also is injured. There is no evidence that a particular wavelength is more effective than any other. The method is not applicable to human tumors because they cannot be treated to the exclusion of healthy tissue. [That the effect is due to temperature has been denied by other workers. See Reiter: Deutsche med. Wchnschr. 59: 160, 1497, 1933 (Abst. in Am. J. Cancer 20: 445; 21: 871, 1934).1 CHARLESPACKARD

Radiation Treatment of Neoplasm, N. S. FINZI. Brit. J. Radiol. 7: 156-157, 1934. Finzi still believes that short wavelength radiation in amounts larger than most radiologists consider to be adequate is more effective than long. Both sarcoma and carcinoma respond better to such treatment than they do to soft radiation. [This is one of several papers presented at the Annual Congress of the British Institute of Radiology, Dec. 8, 1933. For abstracts of the others see Am. J. Cancer 22: 425-426, 1934).] CHARLERPACKARD

Preparation of Wax Molds for Radium Treatment of the Region of the Neck, R. SARASIN. Zur Technik der Herstellung externer Radiummoulagen der Halsregion, Strahlen- therapie 50: 520-526, 1934. A description of the method of preparing wax molds as a support for radium con- tainers during the prolonged treatment of superficial cancer. [The method was originally devised and employed in the Radium Institute of Paris (see Esguerra, Monod, and Richard: J. de radiol. et d’6lectrol. 6: 331, 1922; 7: 49, 1923).] CHARLESPACKARD

Telangiectasia and Radiotherapy, L. FREUNDAND J. G. KNOFLACHTeleangiektasien und Strahlenbehandlung, Strahlentherapie 50: 326-332, 1934. The authors report a case in which the symptoms strongly suggested chronic x-ray injury, but which proved to be erysipelas carcinomatosum. The right breast of the patient had been removed, and healing was normal. Subsequently 10 exposures of 800 r 694 ABSTRACTS each were given. Some months later telangiectases appeared but, in spite of this, more radiation was given. Thereafter pale red flecks filled with delicate veins were found near the radiated area. Since the dosage had not been excessive, these could not indicate chronic x-ray injury. A study of the previous history of the patient revealed that a similar condition had been present before operation. Sections showed the skin to be infiltrated with carcinoma. CHARLES PACKaRD

Endothemy in Tumor Treatment, G. G. PALMIERIAND G. PALTRINIERI.La diatermia nella cura dei tumori con particolare riguardo alle recidive ed ai ieliquati post- radioterapici, Bull. d. sc. med., Bologna 105: 145-154, 1933. The authors consider that the use of endothermic coagulation increases the possibilities of cure in the following types of cases: (1) radioresistant tumors either primary or secondary; (2) tumors which involve the facial bones deeply; (3) infected ulcerated cancers, in’which endothermy may be used as a preliminary to irradiation; (4) cauliflower growths, preliminary to irradiation; (5) relatively small benign growths of the skin, small primary skin cancers, and small recurrences. They believe that the endothermic cutting spark is particularly suited for securing biopsy material. Brief reports of 36 cases and illustrative photographs and drawings are included. JEANNETTEMUNRO

Cancer and Organotherapy, H. VILLIkRE. Cancer et opothhapie, Clinique, Paris 28: 342-343, 1933. From a review of recent literature and his own observations the author concludes that the extracts of various organs-especially the endocrine glands-cannot be regarded as having a specific action in retarding tumor growth.

TUMORS OF THE SKIN

Melanoma Studies. 111. A Theory of Pigmented Moles. Their Relation to the Evolution of Hair Follicles, GEORQEF. LAIDLAWAND MARQARETR. MURRAY. Am. J. Path. 9: 827-838, 1933. The authors claim that the pigmented mole shows distinct traces of having at one time been a tactile organ with a full complement of sensory nerves and tactile terminals. Numerous photomicrographs are presented to show that these moles are rich in nerve fibers and tactile cells, and that end bulbs of nerve fibers make contact with nevus cells exactly as they do with the tactile cells of the epidermis and of the hair follicles. Mas- son’s observation of a profusion of structures resembling meissnerian tactile corpuscles in certain pigmented moles was also confirmed. While most tumors have some prototype in normal adult or embryonic tissues, of which they are a more or less faithful reproduction, it is characteristic of pigmented moles that they bear no resemblance to anything known in normal mammalian skin. In the reptiles and amphibia, however, which are just below the mammals in the phylo- genetic scale, it is found that pigmented tactile spots are numerous and that these cor- respond closely in structure with the pigmented mole of man. Photomicrographs of tactile spots in alligators illustrate this point. The authors’ theory is that in the course of evolution the reptilian tactile spots were replaced by mammalian hair follicles. The pigmented, hairy mole appears to he a link or transition hetweeri the two. A bibliography is appended. [This is the third of a series of studies on melanomas the first two of which have been abstracted in an earlier number of this journal (18: 657, 658, 1933).]

Tumors of the Skin, M. L. H. FREEMAN.Delaware State M. J. 6: 15, 1934. Two cases are reported. In the first a basal-cell epithelioma, proved by biopsy, arose on the bridge of the nose at the point at which contact was made by gold-framed spectacles. There was also an area of dermatitis behind the right ear, where the spectacles came in contact with the skin. Six weeks after abandoning the spectacles both THE THYROID GLAND . 695

areas were completely healed without any further treatment. [The biopsy diagnosis is therefore doubtful.] A second incomplete case record is given of an epithelioma of the subauricular region. W. S. MACCOMB

Treatment of Early Rodent Ulcer, H. G. ADAMSON.Brit. M. J. 2: 994-995, 1933. This is a letter describing briefly a method for treating rodent ulcer at an early stage. It follows the usual technic used by dermatologists.

Dermatofibroma Lenticulare (Schreus), K. GULDEN. Dermatofibroma Lenticulare, Dermat. Ztschr. 68: 118-127, 1933. The author presents 13 cases of dermatdfibrorna lenticulare, an entity first described by Schreus (Arch. f. Dermat. 161: 456, 1930). These tumors occur most frequently on the upper trunk and extremities and differ from keloids in the more typical arrangement of fibrous connective tissue. Excision is not usually followed by keloid formation. In order to present a satisfactory classification of such lesions, many further studies are needed. There is one illustration. THEODORES. RAIFORD

THE THYROID GLAND

Normal and Pathological Histophysiology of the Human Thyroid Epithelium, J. WAHL- BERG. Sur Kenntnis der normalen und pathologischen Histophysiologie des menschlichen Schilddriisenepithels, Arb. a. d. path. Inst. d. Univ. Helsingfors 7: 197-330, 1933. This is an excellent detailed article concerning the histopathology and physiology of the normal and abnormal thyroid gland. Aside from adenomas, tumors are not discussed. The article is illustrated by excellent photomicrographs. BENJAMINR. SHORE

Diagnosis and Treatment of Malignant Tumors of the Thyroid Gland, M. NORDLAND AND L. M. LARSON. Minnesota Med. 17: 99-102, 1934. Also in Journal-Lancet 54: 70-74, 1934. This is a general review of the diagnosis and treatment of malignant tumors of the thyroid gland. In the authors’ series of 11 cases there were 10 carcinomas and 1 sarcoma. Four patients had apparently remained cured for twenty months, three years, four and a half years, and eight years respectively. One of these patients had severe myxedema, but the other 3 patients did not. Deaths of 6 patients took place up to nineteen months after operation. The individual with sarcoma was living with extensive metastases four months after thyroidectomy. In the treatment of carcinoma of the thyroid, surgery alone is usually not justified even if the entire tumor is thought to have been removed. Radiotherapy should be given as an added protection against extension of the disease. BENJAMINR. SHORE

Metastases From Malignant Tumors of the Thyroid, R. S. DINSMOREAND N. F. HINKEN. Am. J. Surg. 24: 202-224, 1934. The concept of a “ benign metastasizing goiter ” is erroneous. Careful clinical studies reveal that these apparently benign lesions will recur if incompletely removed; that the metastatic tumor can also act as a focus and disseminate the tumor tissue; and that the growth will ultimately kill the patient. Painstaking histologic examination of the primary thyroid tumor usually shows that the innocent appearing cells have definite invasive properties. It would seem that mch characteristics would brand these simple goiters ” with malignancy. In a series of 264 cases of thyroid malignancy there were 124 in which metastases were demonstrated. Pulmonary metastases were the most frequent, occurring in 36 cases. Both lungs were involved in 27, or 75 per cent of the cases, and in 6 of the 7 cases with unilateral involvement there were multiple lesions. There are three distinct 696 * ABSTRACTS types of thyrogenic pulmonary metastases; (1) the solitary, well defined, rather slow- growing metastatic nodule which is usually situated near the hilum or in one of the lower lobes; (2) multiple discrete nodules about 0.5 to 1 om. in diameter usually scattered throughout both lower lobes though any part of the lung may be involved; (3) a variety which is associated with a highly malignant thyroid tumor which invades the blood vessels and liberates showers of cancer cells into the circulatidn, forming multiple shot- like lesions throughout the lungs. Sometimes there are so many of these small emboli to one area of the lung that it gives a radiographic impression of an exudative process. Metastases to the skeletal system were observed in 18 cases. The morphologic characteristics of these secondary bone tumors vary. In some instances the metastatic cancer cells reproduce adenomatous thyroid tissue, the acini contain colloid, the vessels are dilated, and the tumor is very vascular. On the other hand, the embolic cells may develop into a bizarre, rapidly-growing, frankly carcinomatous mass that bears no resemblance to the parent thyroid tumor. All gradations between these two extremes have been reported. In 94, or 35 per cent of the 264 cases, there was definite enlargement of the cervical lymph nodes. However it is recognized that it is impossible to differentiate clinically between an infectious and metastatic enlargement of the lymph nodes. Other sites more rarely involved by secondary thyroid tumors were the liver, kidneys, brain, heart, eyes, and soft tissues. Active treatment such as thyroidectomy, lobectomy, biopsies, decompressions, and tracheotomies, supplemented by radiation therapy, particularly in radiofiensitive tumors, not only make the patient more comfortable but may increase the span of life in certain cases. The article is illustrated by photographs and photomicrographs. BENJAMINR. SHORE

Acute Capsulitis of Cystic Degenerated or Partially Degenerated Adenoma of the Thyroid Gland, WILLIAMA. PLUMMERAND ALBERTc. BRODERS.Am. J. Surg. 23: 63-69, 1934. The authors. have studied 16 cases of acute, painful enlargement of adenoma of the thyroid gland, in an attempt to distinguish clinically between acute capsulitis of a cystic degenerated adenoma and gross intra-adenomatous hemorrhage. On the basis of the symptoms, the cases were divided into two groups. The first group was composed of 14 cases in which the painful enlargement of an adenoma gradually developed. In eight of these, extensive hemorrhage into the substance of the adenoma was found at operation. The second group consisted of two cases in which extensive hemorrhage was found in the adenomas at operation, and in which the enlargement of the adenoma in each instance was so precipitate, reaching a maximum size in a few minutes, that hemorrhage was considered responsible for its enlargement. The authors conclude that acute, non-suppurative inflammation in the capsule of a cystic, degenerated, or partially degenerated adenoma, will cause painful enlargement of the adenoma, but that these acute symptoms are more or less transitory. Clinically, if enlargement of cystic degenerated or partially degenerated adenoma of the thyroid gland has occurred gradually over a period of several hours or days, and such enlargement has been accompanied by pain, one must assume that the enlargement is the result of acute inflammation. If operation is performed in the period of the acute manifestations, this diagnosis will be confirmed by evidence of acute inflammation in the capsule. If enlargement of a cystic degenerated or partially degenerated adenoma has reached its niaxirnum in a few minutes, accompanied by severe pressure or pain, it must be assumed that the enlargement is the result of hemorrhage, and at operation recent blood clots will usually be found in the substance of the adenoma. However, since the two conditions frequently are associated, microscopic evidences of acute inflammation are likely to be found in the capsule of the adenoma, and in these cases symptoms which must be attributed to the inflammation also will be present, namely, pain of longer duration, tenderness, local heat and possibly fever. The article includes summaries of two case histories and a short bibliography. There are no illustrations. WILLIAMJ. HOFFMAN THE BREAST 697

THE BREAST

Carcinoma of the Breast, A GENTILE,D. R. MURPHEYJR. AND E. P. LEHMAN. Am. J. Surg. 25: 91-96, 1934. The authors have reviewed the clinical and pathologic characteristics of the cases of breast cancer seen at the University of Virginia Hospital from 1905 through 1928. In 173 cases there were only 63 in which adequate clinical records and satisfactory pathological material for study existed and in which it was possible to follow the patient for at least five years after treatment. Eight or 12.5 per cent of these 63 cases, originally diagnosed as cancer, are now considered on the basis of a new unbiased histologic study to be benign. All of these patients, except one who died as the result of the operation, are living after five or more years. The five-year survival rate for the 63 cases originally diagnosed as carcinoma is 44.4 per cent, but if the 8 cases now considered benign are subtracted the survival rate is reduced to 38.1 per cent. The authors stress the fact that no statistical study of breast cancer and its treatment is of value without a pathological diagnosis based on modern knowledge of breast pathology. Neither the clinical index of malignancy nor the histologic grading of tumors appeared of any prognostic significance in this small series of cases. Seventeen of 152 cases available for histologic study which were originally called malignant have been diagnosed as benign. The new diagnosis in these cases was (1) lactation hypertrophy with and without acute and chronic mastitis in 3 cases; (2) benign papilloma in 3 cases; (3) acute and chronic mastitis unassociated with lactation hypertrophy in one case; (4) duct adenoma in one case; (5) chronic cystic mastitis in 8 cases. There are no illustrations. BENJAMINR. SHORE

Prognosis in Mammary Carcinoma; Its Relation to Clinical and Histological Grading and Treatment, E. K. DAWSONAND M. C. TOD. Edinburgh M. J. 40: 157-165, September 1933. Prognosis in Mammliry Carcinoma in Relation to Grading and Treatment, E. K. DAWSONAND M. C. TOD. Ibid. 41: 61-98, 1934. The first of these papers is a condensed version of the second. The major portion of the material studied consists of about one thousand mammary tumors, many of them cut in whole breast sections. The records of the follow-up departments of two Edin- burgh hospitals have been used to supplement this material, and in their discussion the authors have taken into account the current literature on breast cancer. First, it is emphasized that if this disease is treated while it is still early and confined to the breast, at least 70 per cent of patients should be alive and well ten years later, while of those showing spread beyond the mammary confines only 5 per cent will remain. That is, the dividing line beyond which a bad prognosis must be given lies between the cases in which the axillary nodes are free from invasion and those in which these nodes are already invaded at the time of treatment. Moreover, the histologic findings in whole breast sections confirm the conclusion that the clinical distinction between grades 2 and 3 of Lane-Claypon’s classification (Ministry of Health Report No. 51, 1928) is of no significance; for by the time the axillary nodes alone are palpable many cases have advanced further than this. The end-results of treatment ought to be as favorable in group 2 cases as in group 1 if the only difference were invasion of the axillary nodes and these nodes were removed. As a matter of fact, the end-results are very little better in grade 2 than in grade 3 cases. In the strict sense grade 2 is probably, non-existent. There is now considerable agreement among those who have studied carefully fairly large series, that if the malignant cells have once passed beyond the actual mammary area, the axillary nodes are not the only site of invasion, and the disease is already beyond effective attack by methods at present in use. Eggers (Trans. Am. Surg. Assoc. SO: 427, 1932), for instance, found that with the radical operation and meticulous care in dealing with the axilla, recurrence in the mammary area was very rare, yet his survival rates were no higher than those obtained in other clinics; the patients died not from local recurrence but from more distant metastases. TJnfortunatelv the really early 098 ABSTRACTS

cases (Steinthal group l),in which 85 per cent five-year cure is obtainable, form a small proportion of the total, as compared with group 2, with 19 per cent of cures and group 3, with 13.5 per cent in the Leeds surgical series (Ministry of Health Report 34, 1926). MacCarty (Am. J. Cancer 17: 25, 1933) states that in 62 per cent of the operable cases at the Mayo Clinic there is involvement of the axillary nodes, while 30 to 50 per cent of cases are inoperable and hopeless when first seen. Early cases raise the most difficult diagnostic problems. Biopsy cannot always be relied upon when a decisive report is required on a small piece of tissue, which may not be pathognomonic and may not even include part of the suspected area. The writers cite Greenwood’s remark that, after all, an early cancer will gain little further deadliness during the two or three days needed to establish a sure diagnosis and the possibility of spread of malignant cells can be averted by disinfection or electrocoagulation of the wound after removal of the tumor (two-stage operation if in the interval malignancy is histologically proved). This is preferable to risking radical operation for a benign tumor, and more certain than interoperative biopsy. The authors point out that Schmitz and Hueper, in presenting their histologic malignogram,” recognized that prognosis depends mainly on the type and efficacy of treatment, and believe that some of the histologic factors assessed in various prognoRtic schemes have been completely misunderstood. Their studies lead them to deny the bearing of tumor cell differentiation on prognosis, to oppose the contention that fibrosis is necessarily a favorable factor, and to agree with those writers who deny any specific function to the lymphocyte$. Microscopic examination can indicate whether the cancer cells are still, in the main, confined to the ducts, or have ruptured the duct walls, wit>h infiltration of the stroma; whether the lymph vessels are invaded, with the probability that the nodes are already involved; and whether the malignant cells have gained access to the blood stream. In discussing the methods of treatment, the authors urge the advisability of removing the small as well as the large pectoral muscIe; of including a large area of skin; and of the routine use of electrocoagulation. At present there are not enough statistics to indicate inore than that x-rays, and probably radium also, are capable of improving the chance of prolonged survival, and that treatment by gamma radiation alone has given in a few cases results only similar to those of surgery. In assessing the result of treatment, it should be remembered that the average duration of life in untreated cases, from the time when a lump is first noticed, has been estimated at about three years. A good bibliography is appended, and there are thirty-four excellent photomicrographs. [It may be of interest to readers of this journal to review in a little further detail the different schemes for classification of carcinoma of the breast. The first to discuss the value of such grouping in order to render statistics of cancer therapy more accurate was Steinthal (Beitr. z. klin. Chir. 47: 226, 1905). In clnssi- fying his operative material he uses three groups: (1) patients in whom the growth has been slow and the tumor is no larger than a plum, or about 3 cm. in diameter, is still confined to the breast tissue and not fixed to the skin wall, and, while a few nodes may be found in the axilla, with none that are palpable at the time of examination; (2) those patients with nodules which have recently begun to grow rapidly, in which the skin is adherent to the tumor and enlarged nodes are definitely palpable in the sxilla; (3) those patients in whom the whole breast is involved, the tumor has invaded the skin and deeper tissues, and the axillary nodes are always, and the supraclavicular nodes often, involved. Lane-Claypon (Ministry of Health Report 51, 1928) recognizes three main groups: (1) axillary nodes not invaded; (2) axillary nodes invaded but nothing to indicate further npread of the disease; (3) extension of the disease to some tissues outside the breast itself other than the axillary nodes. Groups 1 and 2 are divided into those in which histological examination has been made of the nodes, l-P and 2-P; and those in which clinical findings only are to be relied upon, l-C and 2-C. Schmitz and Hueper (Radiology 14: 223, 1930) divide primary breast cancers into 4 groups. They include in Group P-1 clearly localized, freely movable growths not adherent to skin or pectoral fascia and not involving the regional lymph nodes, as shown by histological examination. P-2 includes single, freely movable tumors without ex- THE BREAST 699 tension in the breast or metastases in the lower axillary lymph nodes, but also includes primary multiple carcinomata as observed after chronic cystic mastitis. P-3 includes tumors which have become adherent to the skin or fascia or both. There may be multiple tumors in the breast and metastases in both upper and lower axillary lymph nodes. The primary and the metastatic nodules are movable to a limited extent. Group P-4 includes those cases in which the tumor has permeated the skin, with ulceration, or has become fixed to the chest wall, or has produced such extensive metastases of the upper axillary and lymph nodes that these are movable, or, on the other hand, has invaded the supraclavicular nodes. The other breast may also be involved, and metastases may have been produced in distant organs. Schmitz and Hueper also add a classification for recurrences. Grade R-1 is a local, freely movable recurrence; in R-2 the metastases are movable but more extensive; R-3 includes both local and regional but Atill non-adherent recurrences; in R-4 the local or regional recurrenaes are fixed to the surrounding tissues with secondary invasion of distant organs. While with surgery grade P-4 is almost inevitably fatal, with the use of x-ray in addition to surgery some 3 per cent of these patients may live five years. Schmits and Hueper use a series of characteristics based upon the structure of the tumor, cytoplasm, nuclei, and stroma. Obviously such classification is possibIe only after an operation and histological study.] F. CAVERY

Resume of Ten Years of Surgery for Cancer of the Breast, W. A. COVENTRYAND R. J. MOE. West. .J. Surg. 42: 163-169, 1934. Coventry and Koe report 186 cases of cancer of the breast treated from Jan. 1, 1919, to Sept. 1, 1933. These patients were operated on by 26 different surgeons, 63 per cent of whom could be classified as experienced, and 27 per cent as occasional surgeons. Twenty-two per cent of the patients were forty years of age or younger. There were 2 males, an incidence of 1.07 per cent. The average duration of the symptoms before operation in the entire group was 11.2 months. In 121 of the 186 cases metastases to the axillary or supraclavicular lymph nodes were found after histologic study of the specimens. In only 70 of these cases were enlarged nodes felt before operation. The average length of life in those patients who had palpable nodes before operation was two and a half years, while those who had no palpable nodes preoperatively lived on an average of five and a half years. Radical operations were done in 146 cases; semi-radical operations, leaving the pectoralis minor muscle in place, were done in 12 cases, amputation only in 21, and excision of the tumor only in 7 cases. Of the 92 patients having x-ray therapy either before or after operation, 17, or 18.5 per cent, have lived five or more years, while 16, or 23.7 per cent, of 67 patients not treated with x-ray have lived five or more years. For a variety of reasons, however, pre- and postoperative roentgen irradiation for cancer of the breast cannot be judged accurately from this series. Of 91 patients operated on from 1919 to 1928, 24, or 26.3 per cent, are living five or more years after operation. Twenty-one of these had radical operations and 3 semi-radical. Mere amputation of the breast or local excision of the tumor produced no five-year cures. X-ray therapy was given in 11 of the 24 patients surviving five years. BENJAMINR. SHORE

Carcinoma of the Breast; Surgical Treatment and Results Three, Five, Ten, Fifteen, and Twenty Years after Radical Amputation, S. W. HARRINGTON.Journal-Lancet 54: 542-548, 1934. The educational program of the medical profession has been of aid in bringing to examination a greater number of patients with lesions of the breast, but it has increased the responsibility of the physician for establishing the diagnosis in early cases of malignant disease. The subjective symptoms and physical findings are usually inadequate in the determination of early cancer. In all doubtful cases the tumor should be removed for histologic study and this should be followed immediately by radical amputation if the lesion proves to be malignant. Marked progress has not been made in the institution of surgical treatment early in the course of malignant, disease of the breast, as is indicated by the percentage of cases 700 ABCITUUTS in which the lymph nodes have been involved at the time of operation. This percentage has remained approximately the same for the past ten years, averaging 67 per cent, The best surgical results are obtained from primary radical amputation in cases of unilateral carcinoma of the breast in which metastasis to the lymph nodes has not taken place. In a series of 3740 cases studied, 82 per cent of the patients were living three years, 73 per cent five years, 50 per cent ten years, 36 per cent fifteen years, and 21 per cent twenty years after operation. In cases with lymphatic involvement the results are not as satisfactory but probably are more favorable than in cases in which metastatic cancer has occurred elsewhere in the body. In a group of 2526 cases with axillary lymph node involvement, 41 per cent of the patients were living three years, 27 per cent five years, 13 per cent ten years, 9 per cent fifteen years, and 7 per cent twenty years after operation. The poorest surgical results were obtained in cases in which secondary radical amputations were done following primary, partial operations. The important indications for prognosis following the radical surgical treatment of breaRt cancer are the extent of the disease at the time of operation, particularly as to the absence or presence of axillary lymph node metastases, the thoroughness with which the radical operation is performed, the grade of malignancy of the primary lesion, and the age of the patient. BENJAMINR. SHORE

Irradiation in Carcinoma of the Breast, I. I. KAPLANAND R. ROSH. Ann. Surg. 97: 62-67, 1933. The authors review the results of treatment in 270 patients irradiated at the Bellevue Hospital between 1924 and 1930. Of these, 215 were referred for postoperative irradiation; 12 for radiotherapy both before and after operation; 40 for irradiation alone, and 3 for irradiation and operation. There were 252 carcinomas of the adeno- or duct-cell type, 14 scirrhous carcinomas, 3 cases of Paget’s disease, and one giant-cell sarcoma. Sixty-two patients are alive and well at the present time for periods of one to sevon years after treatment; 85 are known to be dead, and in the remainder the result is not known. A combination of external irradiation over the involved region and the lymphatic drainage area and the use of interstitial radium needles or tubes has been found most satisfactory. From this study it is concluded that, while postoperative irradiation is of some value, preoperative treatment is of distinct advantage in prolonging life and preventing recurrences. Radiotherapy alone has proved of value in inoperable cases and in certain operable ones. Judgment in the choice of cases and proper technic are essential for successful results. A table is included showing the period of survival after treatment. Of 38 patients treated in 1924, 4 were known to be alive seven years, 1 six years, and 3 five years. Of 22 treated in 1925, 1 was alive six and 1 five years. THEODORES. RAIFORD

Carcinoma of the Breast. Its Roentgen Treatment, J. M. REHFISCHAND L. H. GAR- LAND. California & West. Med. 39: 401-406, 1933. Because of the obvious inadequacy of statistics of treatment obtained by grouping together all types of breast cancer, the authors limit themselves to the presentation of their clinical impressions as to the results obtainable with radiation, chiefly external high-voltage therapy. They advocate roentgen radiation followed by surgery in nearly all cases, for even in elderly women the advisability of relying upon radiation alone is questionable. Postoperative radiation is advisable as a routine procedure. Inoperable cases should be treated by radiation alone, either by x-rays or by a combination of x-rays and interstitial radium radiation. Details of the authors’ own practice in both operable and inoperable cases are included.

Confrol of Metastases in Breast Cancer, S. GILBERTSCOTT. Brit. M. J. 1: 33, 1934. In a letter propos of radiotherapy for mammary cancer the author advises that removal of the primary growth by surgical diathermy, radium, or short-wave x-rays be followed by generalized radiation of the whole trunk with medium-wave x-rays. THE BREAST 701

Carcinoma of the Male Breast, with Special Reference to Etiology, J. B. GILBERT. Surg. Gynec. & Obst. 57: 451-466, 1933. The author reports the study of 47 cases of male breast cancer seen at the Memorial Hospital, New York. Forty-one cases are reported for the first time; 6 have already been reported by other authors (Wainwright and Coley). The incidence of cancer of the breast in males was found to be 1.24 per cent of mammary cancer and 0.41 per cent of all cancers in males. [In the summary the latter figure is changed to 0.14 per cent.] The average age of the patients was fifty-four years, and the left breast was involved more often than the right. Occupational mastitis due to chronic irritation is not infrequently a precancerous lesion; a previously existing benign tumor was noted in only 3 patients. No proved instance of a single trauma causing cancer was observed in this series. Any small localized swelling of the male breast with or without classical signs of cancer should be considered malignant until proved otherwise by histologic study. Discs or button-like indurations beneath the nipple should be surgically removed without delay. In all the cases reported the patient observed the presence of a tumor mass. Other symptoms were pain, bleeding, nipple retraction, and ulceration. Histologic study of 42 tumors showed 25 to be of the carcinoma simplex type, 9 adenocarcinomas, 2 scirrhous carcinomas, 1 epithelioma, and 5 carcinomas, the latter being diagnosed from punch biopsy specimene. All of the patients known to be dead or lost to follow-up showed clinical or radiologic evidence of metastases. The skin was involved in 8 cases, the axilla in 30, the supraclavicular fossa in 17, the lungs in 21, and the bones in 5 cases. Axillary lymph node involvement was found in 10 of 23 patients at the time of radical operation. Radical mastectomy was performed 24 times, local mastectomy 8 times, and local removal of the tumor 6 times. The majority of the patients received some form of irradiation therapy. Five of 26 patients observed prior to January 1928 survived five years. Three, or 11.5 per cent, of the 26 were alive without evidence of disease at the time of the report. A table presents the chief features of each of the 47 cases constituting the author’s series. BENJAMINR. SHORE

Carcinoma and Other Tumors of the Male Breast, J. T. MOORE. Am. J. Surg. 24: 305-326, 1934. This is a general discussion of benign and malignant tumors of the male breast, based upon a study of 11 cases, abstracted histories of which are appended. BENJAMINR. SHORE

Lymphosarcoma of the Neck and Carcinoma of the Breast in the Same Patient, B. R. SHORE. Surg. Clinics North. America 14: 327-329, 1934. A sixty-one-year-old woman was seen with a tumor in the right breast and a mass in the right side of the neck. The breast tumor was a typical carcinoma and the cervical mass was considered to be a metastasis. Preliminary to radical mastectomy, the cervical tumor was excised under local anesthesia and found to be a lymphosarcoma. Radical mastectomy was performed three months later. The patient has had repeated x-ray treatments over the neck and mastectomy wound, and is now well two years after operation. There are no illustrations. BENJAMINR. SHORE

Haemorrhage from the Nipple due to a Benign Intraductal Polyp, HELENINOLEBY. Lancet 2: 1206, 1933. Brief case report.

Ovarian Hormones in Relation to Chronic Cystic Mastitis, DEANLEWIS AND C. F. GESCHICKTER.Am. J. Surg. 24: 280-304, 1934. The clinical and pathological findings in 600 cases of chronic cystic mastitis have been analyzed. There are two types of this disease, one in which cyst formation pre- 702 ABSTRAOTS dominates and the other in which epithelial hyperplasia predominates. Both types are restricted to the active sex life of the patient, and the evidence indicates that the changes are duo to alterations in the action of ovarian hormones. The study of breast tissue of women at various known periods of the menstrual cycle and of pregnancy, and of animals which have been injected with theelin or theelin and progeRtin combined, reveals that the changes are fundamentally the same. The age period at which chronic cystic mastitis is most common corresponds with the age period at which these two hormones are most active. The article is illustrated by photographs and photomicrographs. BENJAMINR. SHORE

THE ORAL CAVITY AND UPPER RESPIRATORY TRACT

Malignant Tumors of the Oral Cavity, A. ZUPPINQER. Die malignen Tumoren der Mundhtihle, Ergebn. d. med. Strahlenforsch. 6: 661-626, 1933. The first half of Zuppinger’s paper is a general discussion of the diagnosis, histology, and treatment of tumors of the oral cavity. In the second half are reported 122 cases observed in the surgical and radiologic clinics of the University of Zurich from 1919 to 1931. Only 46 of the 122 patients had operable tumors when first seen, and in only 37 instances were complete radical procedures possible. Included in this series are tumors of the anterior portion of the tongue, floor of the mouth, faucial pillars, base of the tongue, mucous membrane of the cheeks, alveolar processes, and hard palate. Regional lymph node metastases were present in 95, or 78 per cent of the cases. Seventeen patients of the entire group have remained symptom-free for from one to eleven years. The percentage of absolute five-year cures is 9. After a rather lengthy discussion of the relative values of radiation and surgery in tumors of the oral cavity, the author concludes that implantation of radium is to be preferred for tumors of the anterior portion of the tongue, surgery for all cases in which bone is invaded by the tumor, and prolonged fractional radiotherapy for radiosensitive tumors of the oral cavity and for all those of the base of the tongue. The article is well illustrated with drawings, roentgenograms, and photomicrographs. BENJAMINR. SHORE

Carcinoma of the Lip and Mouth, CHARLESL. MARTIN. Radiology 22: 136-146, 1834. Martin cites the following principles for radiation treatment of carcinoma of the lip, mouth, and pharynx. (1) Six to twelve erythema doses of irradiation are needed for the actual cure of squamous-cell carcinoma. (2) Recovery is more rapid and surrounding normal tissues show an earlier return to normal when the treatment is administered over a prolonged period, usually from seven to fourteen days. (3) Short wavelengths produced by heavy filtration lessen the injury to surrounding normal tissues, but are not essential in the treatment of superfiaial lesions on thelip. (4) An attempt should always be made to produce a cure with the first series of treatments since a second attempt is never so successful and may be followed by serious and persistent lesions. (6) Infection and irritation, the latter due to tobacco, bad teeth, etc., interfere with healing and must be eliminated during treatment. Martin admits the excellent results which follow excision of the primary lesion of carcinoma of the lip, but maintains that radiation methods may produce an equally good outcome. The fact that such a result is often not obtained is .ascribed to the timidity of the average radiologist, who is guided by the recommendations of the dermatological literature. Martin treats early carcinomas of the lip by the daily application of an erythema dose of roentgen rays until six to twelve such doses have been given. Larger lesions are treated by implantation of radium element needles. Intraoral carcinoma is similarly treated by interstitial radium element needles. For carcinomas of the pharynx roentgen radiation is employed, a modified Coutard technic being adopted. The management of the lymph nodes is the most difficult problem in intraoral cancer. The author follows a conservative course. If no nodes are palpable, both sides of the neck receive heavy irradiation by roentgen rays and radium packe. If nodes become THE ORAL CAVITT AND UPPER RESPIRATORY TRAOT 703 palpable, a block dissection is advised. Inoperable nodes are treated by a combination of external and interstitial radiation, by which means a definite but brief period of palliation id sometimes achieved. The paper is well illustrated by clinical photographs of typical lesions before and after treatment, and by radiographs which show the location and distribution of the radium needles in cancer in various sites. WILLIAMJ. HOFFMAN

Management of Cancer of the Mouth and the Cervical Lymphatics, DOUQLASQUICK. Am. J. Roentgenol. 31: 366-377, 1934. Treatment of intraoral cancer embraces two distinct factors: the primary growth and the usual paths of dissemination. External irradiation occupies the leading position therapeutically and represents the first step in every case of intraoral cancer that is acceptable for treatment. A few growths which happen to be particularly radiosensitive may yield completely to this procedure. Roentgen radiation is the most practical form of external radiotherapy. Interstitial irradiation, when indicated, is best supplied by permanent gold radon seeds. Their advantages include ease of accurate placement and retention, minimum trauma, and wide technical adaptability and flexibility. When they are used in proper dosage, necrosis is rare except in the presence of syphilis or marked oral sepsis. An infected anaplastic tumor may be more radioresistant than a surgically clean Grade I growth; hence the necessity for rigid oral hygiene prior to and during treatment. It may be necessary to hospitalize the patient so that the mouth can receive proper care. Hourly irrigations of hot bicarbonate of soda solution or of hypertonic saline are valuable. Free application of liquid petrolatum following the irrigations will guard the mucosa from irritation. Cocaine should be avoided and butyn used to carry the patient through any extremely painful period. Adequate nutrition and fluid intake must be main- tained, and a post-nasal feeding tube may be necessary. Antiluetic treatment is not contraindicated during irradiation, but should be limited to mercury and the iodides. After the growth has been brought under control, the treatment may be pushed more vigorously. It is not Quick’s gractice to utilize surgery within the mouth for the direct treatment of the primary lesion, since he depends upon radiation to control the growth. Surgery is, however, empjoyed to facilitate access to the growth, and to provide drainage of the maxillary antrum, to remove a large segment of condemned irradiated tissue, to excise bone which has been invaded by tumor, and to remove heavily irradiated syphilitic areas of the tongue which are likely to undergo secondary necrosis. Quick believes that complete unilateral neck dissection should be limited to cases of fully differentiated epidermoid carcinoma, in patients in good general condition, whose primary growths are controlled, and in which the metastatic nodes are unilateral and palpable and present evidence of an intact capsule. Bilateral involvement and infiltration beyond the node capsule are distinct contraindications to radical dissection. Dissection, when performed, should be the most radical possible. The single exception is lip cancer, in which dissection limited to both submental areas and the submaxillary and upper deep cervical group on the involved side gave results equal to those where the dissection was strictly complete. Histology influences the selection of treatment. Completely differentiated growths are treated by neck dissection following external irradiation. Wholly anaplastic tumors receive external irradiation only. An intermediate histological picture contraindicates surgery, but, in the author’s judgment, calls for radium implantation following external therapy. WILLIAMJ. HOFFMAN

Cancer of the Lip. Results of the Treatment by Electrocoagulation and Irradiation, G. E. PFAHLERAND J. H. VABTINE. Pennsylvania M. J. 37: 385-389, 1934. Pfahler and Vastine report the late results obtained in the treatment of 275 cancers of the lip. The technic usually employed was destruction of the primary tumor by electrocoagulation, followed by administration of high-voltage x-rays directed through the lip and the submaxillary and submental regions. Repeated doses are given until a 704 ABSTRACTS total of 1400 T has been delivered through each portal. Extensive lesions in which destruction by electrocoagulation is not practical are treated by radium element employed both interstitially and externally. If the nodes are obviously diseased, both surface and interstitial irradiation are employed. Biopsies are taken in all cases. The authors’ material confirms the usual opinion that the cure of the local lesion in cancer of the lip is relatively easy, and that death is usually attributable to the regional metastases. WILLIAMJ. HOFFMAN

Surgery and Radium Therapy in Cancer of the Tongue, R. ALE~SANDRIAND G.PACETTO. La cura chirurgica e la radiumterapia del cancro della lingua, Boll. d. legs ital. p. 1. lotta contro il cancro 7: 72-80, 1933. Also in Ann. ital. d. chir. 12: 1062-1066, 1933. The author discusses briefly the types of cancer of the tongue and the indications for surgery, radium therapy, and mixed therapy. He reports statistics on 85 cases observed originally prior to 1927 and followed since. Twenty-eight of the cases were considered inoperable. The rest were treated by surgery, with or without accompanying radium treatment. There were 14 operative deaths. Of the remaining 43 patients operated upon, 16 lived for three or more years and 14 (26 per cent) lived five years after the operation. There were 56 per cent recurrences. The technic of radium therapy is discuesed. . JEANNETTEMUNRO

Carcinoma of the Lower Jaw Simulating Actinomycosis, J. NICOLAS,CH. P~TOURAUD AND CURVEILHER.fipith6lioma du maxillaire inferieure B forme actinomycosique, Bull. SOC.frang. d. dermat. et syph. 41: 154-155, 1934. A seventy-eight-year-old man had a firm, ulcerated tumor 2 cm. in diameter, involving the skin of the left lower jaw. Within the mouth another ulcerated tumor was located in the gingivo-labial fold. The regional cervical nodes were enlarged, hard, imd tender. The lesion resembled somewhat an infection by actinomycosis, but a biopsy showed it to be a squamous carcinoma. WILLIAMJ. HOFFMAN Paradental Cysts. General Considerations, CH. RUPPE. Kystes paradentaires. G6n6ralit6s1 Ann. d’oto-laryng., pp. 222-224, 1934. Macroscopic Pathologic Anatomy of Granulomas and Radiculo-Dental Cysts, G. ARDOIN. Anatomie pathologique macroscopique des granulomes et des kystes radiculo- dentaires, pp. 225-237. Macroscopic Pathologic Anatomy of Radiculo-Dental Cysts, F. LEMAITRE.Anstomie pathologique macroscopique des kystes radiculo-dentaires, pp. 238-242. Signs and Symptoms of Radiculo-Dental Cysts, CH. RUPPE. Signes et diagnostic des kystes radiculo-dentaires, pp. 243-251. Paradental Cysts and Radiography, MORELKAHN. Kystes paradentaires et radiographie, pp. 252-259. Treatment of Paradental Cysts, F. LEMAITRE,CH. RUPPEAND ZHA. Traitement des kystes paradentaires, pp. 260-263. These six short articles constitute a symposium on the subject of paradental cysts. They form an excellent summary of this subject but contain little that is new. WILLIAMJ. HOFFMAN

Sarcomatous Granuloma (Pseudosarcoma) of the Jaws, G. AXHAUSEN.Das sarko- martige Granuloma (Pseudosarkom) der Kiefer, Deutsch. Kieferchir. 1 : 79-1 14, 1934. The author reports seven cases of a non-specific granulation tumor of the jaws. These tumors comprise an entity distinctly apart from the so-called giant-cell granuloma and consist of two types of structure, first granulation tissue, and second a tissue transitional between this and a mixture of spindle-cell and round-cell mesenchymal elements. In some areas where mitoses are especially numerous, the tissue resembles a spindle-cell or round-cell sarcoma except for the lack of spontaneous necrosis and clear staining properties exhibited by the transitional stage between pure granulation tissue and THE ORAL CAVITY AND UPPER RESPIRATORY TRACT 705 sarcoma. The tumor is similar to giant-cell granuloma in its division into a central and peripheral zone, its rapid and extensive growth, and its destruction of bone, but differs in its soft consistency, pseudo-fluctuation, and radiosensitivity. Irradiation produces a marked and rapid decrease in the size of the tumor, but the rapid reformation of the growth precludes this as the optimum treatment. Surgical extirpation offers the most satisfactory results. The author feels that from the standpoint of prognosis the distinction between giant- cell granuloma and the tumor here described is important and should always be established by biopsy. Furthermore the possibility of its occurrence in other bones should always be borne in mind. The seven cases are reported in detail and amply illustrated by 36 excellent gross, histological, and x-ray photographs. THEODORES. RAIFORD Deforming Paradental Cyst in an Adolescent, LOUISLEROUX. Kyste paradentaire deformant chez un adolescent, Ann. d’oto-laryng., pp. 315-316, March 1934. This is a report of a large paradental cyst of the superior maxilla in a sixteen-year-old boy, and its successful removal by surgery. WILLIAMJ..HOFFMAN RoentgenologicalFindings in Malignant Tumors of the Nasopharynx, GUNNARJONGSON. Acta Radiol. 15: 1-7, 1934. It has long been known that malignant tumors of the nasopharynx can produce cranial nerve symptoms, although little has been published concerning the roentgenographic findings in such cases. During the past three years, 33 such cases were studied by the author in an effort to demonstrate possible areas of destruction in the base of the skull. The technic is reported which was found most suitable in demonstrating the soft tumor in the nasopharynx and the bone destruction in the base of the skull, the clinical and roentgenological findings in the series are summarized, and some of the most typical cases are described in detail. The differential diagnosis of malignant tumors of the nasopharynx by radiography is also discussed. The paper is illustrated by ten remark- ably clear radiographs. WILLIAMJ. HOFFMAN Nasopharyngeal Fibroma, W. B. ALLAN. Arch. Otolaryng. 19: 216-223, 1934. Nasopharyngeal fibroma is an extremely vascular tumor occurring infrequently-in only one among 16,000 patients complaining of disturbances of the nose and throat. It is seen most often in adolescent boys. It is composed chiefly of connective tissue, and its many blood vessels are almost or entirely devoid of a contractile coat. It arises in connective tissue in the vault of the pharynx and in the posterior nasal space. Pro- fuse hemorrhage may result from sloughing or trauma. These growths often retrogress in early adult life, perhaps as the result of a change in blood supply brought about by ossification of the cartilaginous plate between the sphenoid and the occipital bone. They have been known to undergo malignant change. Surgical removal has led to facial deformity and loss of life from hemorrhage and shock. The best treatment is implantation of radon seeds into the base of the tumor. The resulting regression is often remarkable; small tumors may disappear within a few weeks, while the growth of others can be checked during the period of activity until retrogression takes place, rendering artificial intervention unnecessary. Three cases are reported in boys of fourteen and fifteen. Surgical removal was attempted in each case. Hemorrhage was extremely severe in two patients, one of whom died before a transfusion could be given. Another patient required nine blood transfusions and has since had ten plastic operations to repair the facial defect. In the third patient a bilateral otitis media developed as the result of postnasal and nasal packings employed to control hemorrhage. WILLIAMJ. HOFFMAN

Plasmacytoma of the Nose and Nasopharynx, FREDERICJ. POLLOCK. Arch. Otolaryng. 19: 311-317, 1934. The author reports two cases of plasmocytoma of the nose and nasopharynx, one a proved case of multiple myeloma and the other a case in which there was no demonstrable skeletal involvement. The report is illustrated by five excellent photomicrographs. WILLIAM J. HOFFMAN 706 ABSTRAOTS

Some Annoyances in the Management of Malignancies of the Accessory Sinuses, RALPHA. FENTON.Ann. Otol., Rhin. & Laryng. 43: 39-46, 1934. A brief article describing the difficulties encountered in the management of cancer of the nasal accessory sinuses and containing nothing new. WILLIAMJ. HOFFMAN

Dentigerous Cysts of the Antnun, A. A. LOVE. Arch. Otolaryng. 19: 348-366, 1934. The characteristics of dentigerous cysts are: (1) a bony shell surrounding the entire tumor, separable from the wall of the antrum and from the soft tissue portions of the cyst; (2) a soft tissue layer composed of fibrous connective tissue, sometimes containing thin layers of cartilage or bony tissue, with a lining of epithelium, usually stratified squamous epithelium; (3) a tooth, or teeth, completely or incompletely developed, contained in the cyst, the crown usually facing inward; (4) fluid contaiqed in the cyst. In the absence of infection the wall of the cyst is comparatively thin, the subepithelial fibrous layer is quite dense, the epithelial layer is intact, and the fluid is thin and straw- colored and contains cholesterol crystals. In infected cysts the bony shell does not separate f;om the antral wall easily, the soft tissue layers are thick, vascular, and infiltrated, and the epithelium is partially or completely destroyed; the fluid contents rnrty he purulent, sanguinopurulent, or of a thick caseous consistency. The etiology of dentigerous cysts is not exactly known, but they are probably due to a retention of fluid in the stellate reticulum of the follicle of the tooth that is situiited between the cuticular dentin and the crown of the tooth, with distention of the follicle into an epithelial-lined cyst. The theory held by many, that such cysts develop from the so-called epithelial rests of Malassez, does not account for all the structures found. Treatment consists in removal of the entire cyst by careful dissection through 11s small an opening in the canine fossa as possible, closing the opening, and providing for subsequent drainage through a good-sized naso-antral window under the inferior turbinate. This should be done transantral1.y so as not to traumatize the intranasal structures. With removal of the entire cyst the prognosis is excellent. The cysts do not metastasize, and malignant degeneration has not been reported. The deformity caused by the tumor recedes rapidly except in cases in which it has attained great sire. Secondary infection of the antrum can be controlled or prevented from assuming serious proportions by maintaining the patency of the naso-antral window and instituting antral lavage until any infection has disappeared. The paper is illustrated by ten excellent radiographs and photomicrographs. Two cases are reported. WILLIAMJ. HOFFMAN Suppurating Cyst of the Nasal Floor with Coincident Maxillary Sinusitis, WACKER. Grosse eiternde frontale Kiefercyste des Nasenbodens bei gleichzeitiger Kiefer- Mhleneiterung, Monatsschr. f. Ohrenheilk. 67: 1520-1522, 1933. Wacker’s patient was found to have a maxillary sinusitis coincident to an infected dentigerous cyst which was diagnosed by x-rays. Drainage through punctures relieved the condition temporarily but it was ultimately necessary to excise the cyst in order to produce healing. Two roentgenograms are included. THEODORES. RAIFORD

Mixed Tumors of the Face and Palate, R. FRANBSEN.Tumeurs mixtes de la face et du palais, Ann. d’anat. path. 11: 275-285, 1934. A brief review of the subject of mixed tumors of the face and palate. Fifteen cltsetl are reported, including localizations in the palate, cheek, upper and lower lip, maxilla, and orbit. The author is inclined to believe that this tumor occurs with greater frequency in Orientals, particularly in the Dutch East Indies. WILLIAMJ. HOFFMAN Roentgen Examination of Laryngeal and Hypopharyngeal Tumors, B. WORNINO. Acta Radiol. 15: 8-23, 1934. At the Finsen Institute and Radium Center in Copenhagen, all cases of laryngeal and hypopharyngeal tumors have for the last two yeara been systematically exanlined by roentgenography. The author reports the results obtained by this method. The THE ORAL CAVITY AND UPPER RESPIRA’l?ORY TRACT 7’07 roentgenological examination is made as a supplement to laryngoscopy, and the roentgenograms are interpreted on the basis of the latter examination. The procedure serves to throw light on conditions which, as a rule, cannot be ascertained in any other way, namely: the inferior limit of the growth, its extension behind the larynx, destruction of the laryngeal cartilages, and the early diagnosis of recurrences. Details of the technic are given. Two lateral pictures are taken, one from each side; and in addition a ventro- dorsal and a lateral view during the process of swallowing a mouthful of barium porridge. Twelve case reports are summarized, illustrating the usefulness and limitations of this method of examination. Twenty-eight exceptionally fine radiographs illustrate the roentgenographic appearance of the normal larynx, and the alterations caused by the various types and localizations of malignant tumors of this region. WILLIAMJ. HOFFMAN Cancers of the Larynx and Esophagus. Surgery and Radium Therapy, M. J. GUISEZ. Cancers du larynx et de l’oesophage; chirurgie et radiumthbrapie, Ann. d’oto-laryng., pp. 306-311, March 1934. The author presented two patients who had been treated for intrinsic carcinoma of the larynx, and three others who had carcinoma of the esophagus. The first patient, a forty-four-year-old man, had a bulky squamous carcinoma of the larynx which was apparently successfully treated by thyrotomy, partial resection of the larynx, and surface applications of radium. He had been free of disease three years. A second patient, a woman of thirty-eight, had repeated recurrences of multiple polypoid tumors of the vocal cord, following several attempts at removal through the laryngoscope. Biopsy from a large polypoid recurrence was reported squamous carcinoma. A laryngotomy was performed in order to expose the tumor, which was then treated by five twenty-four-hour surface applications of radium in a rubber sound. This patient had been clinically free of disease for a year and a half. The three patients with carcinoma of the esophagus had had intra-esophageal applications of radium on a flexible sound. A typical course of treatment consisted of 14 daily applications left in place for from five to six hours (the amount of radium is not stated). All three patients regained ability to swallow normally, and this improvement had lasted one year, five months, and four months respectively. All lesions were histologically verified. WILLIAMJ. HOFFMAN

Partial Resection of the Larynx for Carcinoma, M. J. CHARBCHAK.Partielle Kehl- kopfresektion bei Carcinom, Monatschr. f. Ohrenh. 67: 1185-1 192, 1933. Of 240 patients with carcinoma of the larynx diagnosed by biopsy in the Oto- Laryngological Clinic at Kiev, only 130 were operated upon. In 9 cases partial resection of the larynx was done. Two of these operations were done in 1913, and in both complete resection was subsequently necessary. In a third case, operated on in 1923, complete resection was also necessary for recurrence. The remaining 6 patients were operated upon after 1927; the first was free from recurrence for three years and could not be traced after that; two are free from recurrence two and two and a half years respectively; one a year and five months; and two have been operated upon within a year. The results in these cases lead the author to conclude that the usually accepted indications for partial resection in cancer of the larynx can be extended somewhat, and that this operation can be done with good results when both the false and the true vocal cords are involved; when they are not freely movable; and when the tumor involves not more than the anterior fourth of the oppoflite side of the larynx. Six illufltrations and a brief bibliography are included.

Use of Cobra Venom in Treatment of Pharyngo-Laryngeal Cancer, HALPHEN,DJIRO- POULOS AND PASQUALINE.De l’utilisation du vbnin de cobra dans la thkrapeutique des cancers pharyngo-laryngbs, Ann. d’oto-laryng. 2 : 153-157, 1934. The writer reports his experience in the treatment of pharyngeal cancer by injections of cobra venom. Some favorable effects were noted, especially relief of pain. [Others have observed no benefit following the use of cobra venom.] WILLIAMJ. HOFFMAN 708 ABSTRACTS

Subglottic Fibroma Necessitating Tracheotomy; Tracheal Stenosis Treated by Endos- copy, A: LEMARIEY.Fibrome sous-glottique trachbotomis6; st6nose trachbale cons6cutive traitbe par voie endoscopique, Ann. d’oto-laryng., pp. 319-320, March 1934. A seven-year-old child had complained of hoarseness for three years and for the past three months had experienced progressive laryngeal dyspnea. Indirect laryngoscopy failed to disclose a cause for the symptoms. Soon afterward an emergency tracheotomy became necessary. Direct laryngoscopy disclosed obstruction of the subglottic area by a smooth, firm, pink mass attached by a pedicle immediately beneath the anterior portion of the left vocal cord. The tumor was easily removed by a snare inserted through a laryngoscope. Microscopic examination disclosed benign fibroma. WILLIAMJ. HOFFMAN Chondroma of the Larynx: Case Report, HARRINQTONB. GRAHAM.Ann. Otol., Rhin. & Laryng. 43: 299-303, 1934. A brief description of two cases of chondroma of the larynx, illustrated by two radiographs and one photomicrograph. WILLIAMJ. HOFFMAN Case of Papilloma of the Larynx Operated Upon More than 129 Times in Fifty Years, ANDR~MAssrER. Consid6rations sup un cas de papillome de larynx rebelle op6r6 plus de 129 fois en 50 ans, Ann. d’otolaryng., pp. 325-331, March 1934. A sixty-five-year-old woman had been troubled for fifty years by partial respiratory obstruction caused by multiple papillomata of the larynx. During this period she submitted to 129 surgical attempts to remove the tumors, which promptly recurred after each operation. WILLIAMJ. HOFFMAN Lateral Cysts of the Neck and Malignant Branchioma, F. PAQLIANI.Cisti laterale del collo e branchioma maligno, Bull. d. sc. med., Bologna 105: 405-428, 1933. The author reports, with clinical and pathological details, the case of a man of forty- five who had had a slowly growing tumor for twenty years. Originating behind the angle of the mandible, it eventually involved the entire left lateral cervical region. A large cyst was removed at operation. There was a recurrence five months later, which disappeared on x-ray treatment. One year after the original operation there was a second recurrence. Anemia, cachexia, and facial edema developed. The regional nodes became involved. Death occurred eighteen months after the first operation. The author discusses the embryological development of cervical cysts, reviews the literature on malignant branchioma, and discusses its histogenesis, clinical course, differential diagnosis, prognosis, and treatment. The article is illustrated by photographs and photomicrographs, and a long bibliography is appended. JEANNETTEMUNRO Brachial Cyst; Two Instructive Cases, G. BERRY. Ann. Otol., Rhin. & Laryng. 43: 287-293, 1934. After briefly reviewing the embryology of branchial cysts, Berry reports two cases in which the sire, course, and relations of the cyst were demonstrated by radiographs made following the injection of lipiodol. The first case was successfully treated by surgical excision. In the’second case the author injected a sclerosing solution containing alcohol, chloroform, glacial acetic acid, and ferric chloride. The article is illustrated by clinical photographs and three excellent radiographs which clearly visualize the cysts and sinuses. WILLIAMJ. HOFFMAN

THORACIC AND INTRATHORACIC TUMORS

Osteochondroma of Chest-Wall, HUQHAUCHINCLOB~. Ann. Surg. 100: 399-400, 1934. Auchincloss reports the case of a twenty-three-year-old man with an osteochondroma involving the left lateral aspect of the thoracic wall. The tumor was hard, nodular, find firmly attached to the ribs, but not to the overlying skin. It had grown slowly and THORACIC AND INTRATHORACIC TUMORS 709 progressively for four years. Surgical excision of the tumor, together with the underlying portions of the seventh, eighth, ninth, and tenth ribs, was attempted in two stages, with a fatal outcome. Histologic study of the tumor showed it to be a. benign osteochondroma. There are no illustrations. BENJAM~NR. SHORE

Carcinomas of the Bronchus, L. POPPER.Uber Rronchuscarcinome, Ztschr. f. klin. Med. 126: 689-700, 1934. In the last ten years 57 cases of carcinoma of the bronchus have been studied on the First Medical Division of the Vienna General Hospital. During the first five years of this period there were 19 cases and during the last five years 38 cases, which represents an absolute and relative increase in the incidence of bronchial carcinomas. The diseases most commonly predisposing to the development of carcinoma in this series appeared to be infections of the lungs and pleurae, which were observed in 10 cases, and chronic bronchitis, which was present in 11 cases. Active tuberculosis was observed in 3 of the 57 cases. The relation between bronchial carcinoma and syphilis is not exactly clear. In a group of 50 cases studied, syphilis was present in 12 per cent, while it was diagnosed in only 3.9 per cent of 337 cases of other carcinomas, and in 6.4 per cent of 11,400 patients with other diseases. A pleural effusion was present in 5 of the cases and bioody sputum was observed in 11 patients. In 7 the hemoptysis was sufficient to be considered as the cause of death. BENJAMINR. SHORE

Primary Carcinoma of the Lung, D. B. HARDINQ.Kentucky M. J. 31 : 524-525, 1933. Fifteen per cent of primary pulmonary carcinomas, according to Harding, arise from the alveolar structures of the lung, producing symptoms only late in the disease. The remaining 85 per cent arise from the epithelium of the bronchi and produce obstruction, thereby giving rise to early symptoms. Radiological diagnosis of such lesions is sometimes possible from the shadow cast by the tumor itself. At other times the obstruction results in a partial atelectasis below the point of obstruction and is manifested radio- graphically by increased density and deviation of the mediastinum toward the affected side. Among late complications, infection of the lung below the lesion and pleural transudate are likely to confuse the picture. Bronchoscopic examination with biopsy is most valuable in confirming the diagnosis. Occasional upper lobe tumors may be diagnosed by aspiration biopsy. To be differentiated are pulmonary metastases and mediastinal tumors. Treatment is almost entirely radiotherapeutic. It is sometimes possible to insert radon seeds into tumors visible in the upper bronchi, but for the vast majority external irradiation is necessary. Although a few apparent cures have been reported, palliation is all that can be expected in the greatest number. This article is fairly complete from the clinical standpoint but the author evidently overlooks the possibility of surgical treatment, a phase which at present is undergoing rapid development. There are no illustrations. THEODORES. RAIFORD Primary Carcinoma of the Lung, ARCHIBALDYOUNG. Ann. Surg. 100: 1-10, 1934. The two most important hindrances in the way of successful surgical treatment of primary carcinoma of the lung are (1) the relative infrequency of a localized tumor being situated well out in the lung parenchyma, and (2) difficulty and delay in diagnosis. As regards the first of these factors, it is well recognized that in probably over 90 per cent of all primary carcinoma of the lung the disease originates in the region of the hilum and spreads thence Aimultaneously into the lung and into the mediastinum, so that effective surgical extirpation is impossible. It would appear to be unlikely that, by any surgical method known at present, any considerable effective surgical attack can be made upon the tumors constituting this 90 per cent. As regards the second factor, some advance has undoubtedly been made, for cases of cancer of the lung are being diagnosed much more frequently, and at a much earlier period, than even a few years ago. Young describes in detail the successful surgical removal of the upper lobe of the left lung for a primary carcinoma in a forty-two-year-old man. This was done in one stage but was followed by secondary thoraeotomy for drainage and thoracoplasty. Histologic study of the tumor showed it to be a typical carcinoma, probably of bronchial 710 ABSTRACTS origin. At the time of the report the patient had remained well for almost two years. The article is well illustrated by roentgenograms, photographs of the gross specimen, photographs of the patient following thoracoplasty, drawings, and photomicrographs. BENJAMINR. SHORE Primary Carcinoma of the Lung, C. V. KINQ. M. Ann. District of Columbia 3: 36-41, 1934. King believes that there is an absolute as well as a relative increase in the incidence of primary bronchogenic carcinoma. Surgery with irradiation is the method to be employed in favorable cases. Four case histories are presented. In three of these cases the diagnoses were proved microscopically. Metastases to the distal third of the left femur and upper third of the tibia were observed in one patient. W. 9. MACCOMB

Differential Diagnosis between Lung Tumors and Aortic Aneurysms, M. KARZIS. Die Differentialdiagnose zwischen Lungentumoren und Aortenaneurysmen, Med. Welt. 7: 1813-1814, 1933. Karzis discusses the clinical and laboratory aids to the diagnosis of lung tumors and their differentiation from aortic aneurysm. The thoracic mass must be distinguished if possible from the aortic shadow. Aortic dilatation and left ventricular hypertrophy are in favor of aneurysm, as is a positive Wassermann reaction, which oocurs in from 95 to 100 per cent of the cases. Occasionally barium roentgenography of the esophagus is helpful. One must not be misled by pulsations alone. Pulmonary neoplasms may be located at either the hilus or in the lobes. When the hilus is involved, finger-like shadows due to lymphatic extensions are sometimes visible. If the tumor is in the lobe, the shadow is rounded and sharply demarcated but may be confused with an abscesd, atelectasis, or tuberculous cavity. The author’s technic is briefly described but there are no illustrations. THEODORES. RAIFORD

Primary Sarcoma of the Heart, A. R. BARNES,D. C. BEAVERAND A. M. SNELL. Am. Heart J. 9: 480-491, 1934. Lymburner, in a review of 8,550 post-mortem examinations at the Mayo Clinic (Canad. M. A. J. 30: 368, 1934), found 4 primary and 52 secondary tumors of the heart. He was able to find reports of only 220 cases of primary tumors of the heart in the literature. The consensus of opinion is that these tumors are of mesenchymal origin, and may be classified as spindle-cell, round-cell, or mixed-cell sarcomas, the first named being the most common. The auricles are the most frequent site. No case was found in which the diagnosis had been made during life. A sixty-two-year-old woman, when first seen, had had pain in the thorax and dyspnea on exertion for two months. There had been loss of weight and strength and night sweats with daily rise in temperature of three to four degrees, of seven months’ duration. The heart was not enlarged, the tones were clear, and no definite valvular murmurs could be distinguished. Loud friction sounds were heard all over the pre- cordium. The electrocardiogram revealed a rate of 106, sinus tachycardia, exaggerated P-wave in derivation 11, and slurred QRS complexes in derivations If and 111. A diagnosis of subacute fibrinous pericarditis was made. The patient improved under a course of sodium cacodylate therapy, but a second course was discontinued because of an arsenical dermatitis. A tumor-like process appeared in the region of the right deltoid muscle. A diagnosis of abscess was made, but on incision no evidence of an infectious process was found. A specimen removed for biopsy revealed undifferentiated malignant cells but no further decision as to their probable source could be made. The cardiac rhythm later became irregular and the electrocardiogram showed ail auricular rate of 116 and a ventricular rate of 86, with complete auriculo-ventricular dissociation. Another biopsy revealed a highly undifferentiated, infiltrating, degenerat- ing cellular tumor, probably a sarcoma. It was then felt that the diagnosis of tumor of the heart was definitely established. The patient died two months after her first visit to the clinic. THE DIGESTIVE TRACT 711

Autopsy revealed fluid in both pleural cavities. The pericardial cavity had been obliterated in part by adhesions and also by soft, grayish white, neoplastic tissue, which seemed to arise from both parietal and visceral layers and to be entirely confined within the sac. The wall of the right auricle was involved. Above the posterior cusp of the tricuspid valve, the endocardium had been eroded by a tumor nodule. There was less but similar involvement of the wall of the right ventricle. The left auricle was slightly involved and the left ventricle was normal. The heart and the adherent pericardium weighed 325 gm. Metastatic deposits were found in lungs, pretracheal lymph nodes and adrenals. Apparently the diagnosis of rhabdomyosarcoma has been made but once before (see Bradley, E. B. and Maxwell, E. S.: J. A. M. A. 91: 1352, 1928). Rhabdomyo- mas are also rare, Lymhurner finding only 47 cases in the literature and adding one of his own. These benign tumors occur in the early years of life. They are said to be associated frequently with functional or anatomical developmental defects epilepsy and tuberous sclerosis of the brain being the two most often found. W. S. MACCOMB

Myxoma of the Heart Valves, THOMASC. JALESKI.Am. J. Path. 10: 399-405, 1934. This is a report of a case previously abstracted (Am. J. Cancer 21 : 168, 1934), with a discussion of valvular myxomas, a summary of previously reported cases, and a bibliography. It is illustrated by a photograph of the grosR specimen and photomicrographs. THE DIGESTIVE TRACT

Malignancy of the Esophagus with Bronchial Fistula, W. E. ALLEN. Radiology 22: 366-368, 1934. The author reports two cases. A forty-nine-year-old colored man complained of inability to swallow without vomiting. Examination showed marked emaciation, anemia, enlargement of all superficial lymph nodes, and clubbing of fingers. A chest film presented features suggesting bronchiectasis. Fluoroscopy and films after barium swallowing showed complete obstruction of the esophagus at the level of the eighth dorsal vertebra, and a fistula extending between the esophagus and the left bronchus. The patient died twelve hour8 after performance of a gastrostomy. A second patient, an eighty-four-year-old colored man with a similar history aiid complaint, was markedly emaciated and profoundly ill. Examination showed rbles over both lungs and a friction rub over the left base. There were marked rigidity and tenderness in the epigastrium. Roentgenographic and roentgenoscopic examination revealed a fistula between the esophagus and the bronchi, through which the barium entered the middle and lower lobes. The patient died four days after admission. At autopsy a hard, nodular, partly eroded mass the size of a fist was found in the esophagus at the level of the bifurcation of the trachea. Microscopic study showed a round-cell sarcoma. WILLIAMJ. HOFFMAN

Lymphangeioma [Lymphosarcoma] of the Oesophagus, E. WATSON-WILLIAMS.Proc. Roy. Soc. Med. 27: 1288, 1934. A man of sixty-one complained for two months of pain in the lower sternal region, with regurgitation of unaltered food. A barium bolus showed considerable dilatation of the esophagus and apparently complete arrest immediately above the diaphragm. On esophagoscopy the entrance was normal, the lumen about twice the normal diameter, the mucosa whitish and macerated. At 46 cm. from the teeth the lumen was abruptly terminated by five round, smooth, bright red masses. These were not friable or ulcerated nor did they bleed on being touched. The biopsy report was dermal tissue covered by hypertrophic epithelium, numerous small spaces resembling lymph channels, a few muscle cells; diagnosis, lymphangioma, with no evidence of malignancy. Ten radon seeds, 2 mc. each, with 0.5 platinum screen, were inserted. At the time of reporting, ten weeks later, numerous nodules palpated in the abdomen suggested that the 712 ABSTRACTS tumor was a lymphosarcoma with peritoneal metastases. The patient could swallow well, but was losing weight. F. CAVEHS Diagnosis of Cancer of the Gastro-intestinal Tract, R. DEMEL. Diagnose des Krebses des Magen-Darmtraktes (mit Einschluss moderner Hilfsmittel), Wien. med. Wchn- schr. 84: 257-260, 1934. This article is a resume of the clinical aspects of gastro-intestinal cancer from the standpoint of early diagnosis. The newer (but frequently impractical) diagnostic aids, such as gastroscopy, serum reactions, etc., are briefly commented upon, but no substantial contribution is made and the author’s conclusions are not based upon a definite series of cases. THEODORES. RAIFORD

Roentgenologic Aspects of Gastro-Enterology, C. G. SUTHERLAND.J. Michigan M. SOC.33: 275-285, 1934. At the Mayo Clinic roentgenoscopy has proved to be the most rapid, accurate, and at the same time most economical single diagnostic method for diseases of the gastro- intestinal tract. A minimal number of roentgenograms are made to check the roentgenoscopic findings and to provide tangible evidence of the lesion for more comprehensive consultation and as a permanent record. It is desirable for the roentgenologist not to have intimate knowledge of the clinical history at the time of his examination and to leave the correlation of the radiologic and clinical findings to a later date. He thus approaches the examination without prejudice and forms an opinion on the basis of observation alone. Of a large series of patients carefully selected by highly trained clinicians as giving evidence of gastro-intestinal disease, approximately 70 per cent were negative roentgenologically. Apparently, gastro-intestinal symptoms most often have a functional basis. BENJAMINR. SHORE Topographic Distribution of Metastases in the Liver from Carcinomas Primary in the Gastro-Intestinal Tract, F. L. MARTINGAND B. HALPERT.Yale J. Biol. & Med. 6: 541-543, 1934. The purpose of this study was to ascertain whether currents in the portal circulation, if they exist at all in man, play any part in the topographic distribution of metastases in the liver from carcinomas primary in the gastro-intestinal tract. Among 3000 autopsies performed, there were 127 primary carcinomas of the gastro-intestinal tract and metastases to the liver were found in 45 cases. In 20 of these cases the primary tumor waB in the stomach, in 4 in the bile ducts, in 4 in the gallbladder, in 7 in the pancreas, in 2 in the cecum, in 3 in the sigmoid, and in 5 in the rectum. If currents do exist in the portal circulation and play a part in the topographic distribution of hepatic metastases, identical localizations might be expected from primary growths whose venoua return was into the splenic vein, superior mesenteric vein, and inferior mesenteric vein. This contention does not seem to be supported by a study of these cases. It is concluded, therefore, that if currents do exist in the portal circulation they perhaps play little or no part in the distribution of metastases in the liver. BENJAMINR. SHORE

Cancer of the Stomach. Indications for Surgery, C. J. HUNT. J. Missouri M. A. 31: 236-237, 1934. This is a general discussion of the diagnosis and treatment of cancer of the stomach. No new material is added. BENJAMINR. SHORE Unusual Stomach Cases, F. OEHLECKER.Einiges Besondere aus der Magenchirurgie, Bruns’ Beitr. z. klin. Chir. 160: 1-12, 1934. The firat case reported by Oehlecker is that of a fifty-five-year-old man who had a carcinoma of the stomach near to an echinococcus cyst situated in the wall of that organ. The author considers the coincidence of these two lesions in the stomach to be accidental. The second case is that of a thirty-five-year-old man with diffuse polyposis of the stomach, which had in part undergone malignant degeneration. The article is illustrated by drawings, photographs, and roentgenograms. BENJAMINR. SHORE THE DIGESTIVE TRACT 713

Sarcoma and Tuberculosis of the Stomach, C:. 13. RENT~CHLERAND R. C. TRAVIS. J. A. M. A. 102: 686-688, 1934. Emphasizing the extreme rarity of either sarcoma or tuberculosis of the stomach, the authors cite the unique occurrence of both lesions in a sixty-five-year-old female. The symptoms and signs, including the roentgenographic picture, were those of an advanced carcinoma of the pars media. At operation a hard nodular tumor involving lymph nodes along both curvatures was found, necessitating removal of a little more than two-thirds of the organ. Convalescence was uneventful, and examination five weeks after discharge revealed no evidence of recurrence and a normally functioning stomach. Microscopic scrutiny of the specimen showed two types of tissue, one lymphosarcoma, the other resembling tuberculosis, with typical giant cells, tubercles, and fibrosis. [It is well known that sarcomas of various types, especially those of lymphoid origin, may be characterized by giant cells .and even epithelioid cells resembling tubercles. It would therefore seem that one must accept this a8 a unique pathological entity with reservation in the absence of proved tubercle bacilli.] There are six illustrations. THEODORES. RAIFORD

Report and Discussion of a Case of Carcinoma of the Jejunum, J. C. WILSONAND R. A. JOHNSTON.Univ. West. Ontario M. J. 4: 109-117, 1934. The authors report the case of a thirty-two-year-old man who died following resection of a portion of the jejunum for a stenosing carcinoma situated four inches from the duodeno-jejunal junction. The article is illustrated by a photograph and a photomicrograph. BENJAMINR. SHORE

Primary Lymphosarcoma of the Small Intestine with Chyliform Ascites, E. CAPECCHI. Linfosarcoma primitifo dell’intestino tenue ed aRcite chiliforme, Ann. ital. d. chir. 12: 489-518, 1933. A man of thirty-seven had a history of several months of indefinite gastro-intestinal symptoms and on examination showed two ill defined tumor masses near the umbilicus and free fluid in the abdomen. At operation lymphosarcoma of the small intestine was found, together with chyliform ascites. The fluid was milky, with a yellowish tinge, it did not coagulate and formed no sediment on standing. There was no odor, and no change was observed on exposure to air. It contained a large amount of finely emulsified fat, no cells, and no bacteria. The article contains photographs and photomicrographs. JEANNETTEMUNRO

Diagnosis and Surgical Treatment of Malignant Lesions of the Large Bowel, F. W. RANKIN. J. South Carolina M. A. 30: 110-114, 1934. This is a general discussion of the diagnosis and treatment of malignant lesions of the large intestine. No new material is added. BENJAMINR. SHORE

Surgery of the Large Intestine, J. W. GIBBON. South. Med. & Surg. 96: 319-325, 1934. Gibbon reports in tabular form 50 cases of tumors of the large intestine, 39 of which were malignant and eleven benign. In the latter group were one case of tuberculosis and 10 of diverticulitis. Of the 39 patients with carcinoma, 25 had radical resections in one or more stages. Two of these died after operation, both following one stage resections, and 12 are known to be living after three years. BENJAMIN R. SHORE

Treatment of Carcinoma of the Colon, W. W. BABCOCK.Am. J. Digest. Dis. & Nutrition 1 : 342-345, 1934. This is a general discussion of the diagnosis and treatment of malignant tumors of the colon. New material is not added. The article is illustrated by several drawings of operative procedures. RENJ.4MIN R. SHORE 714 ABSTRAOTS

Adenomatosis Coli adCarcinoma of the Colon, J. FELSENAND J. J. WELLS. J. A. M. A. 102: 683-686, 1934. The authors attempt to show the relationship between multiple polyposis of the colon and malignancy by the demonstration of a case in which two separate carcinomas were found, apparently having developed from pre-existing adenomata. The patient was operated on for acute intestinal obstruction. Exploration revealed a constrictiiig malignant growth in the descending colon, and a portion of the transverse and descending colon was removed. When studied pathologically this showed three tumors. The fimt, an adenocarcinoma, grade 111, was the immediate cause of obstruction. A short distance below this a second tumor, grossly resembling an adenoma, was histologically proved to be an adenoma malignum. The third tumor was located above the constric- tion, was smaller, and was diagnosed simple adenoma. Convalescence was uneventful, and the patient was symptom-free twelve months later. Analyzing the reported cases of multiple malignancy the authors find that the colon is by far the most common site of double tumors occurring in the same organ. This is felt to be valuable evidence in favor of the origin of such tumors from benign adenomas. The various theories of origin for adenomatosis are reviewed, but the underlying caune is admittedly unknown. Accumulated evidence seems to favor a familial tendency and an underlying predisposition to neoplasia. Since malignant changes in polyps are frequent, removal at an early stage is advocated; if the multiplicity of the lesions precludes complete removal, careful periodic examinations for the detection of malignant change are indicated. The grade of malignancy is usually low and resection results in a high percentage of cures. The literature is reviewed briefly and there are five illustrations. As usual in di.3- cussions of this type, the illustrative case offers contributory evidence but no actual proof. THEODORES. RAIFORD

Carcinoma of the Upper Colon in Childhood, R. WALKERAND J. F. DALY. J. Oklahoma M. A. 27: 119-121, 1934. Walker and Daly report a primary carcinoma of the cecum in a five-year-old boy. A portion of the growth was removed to relieve symptoms, but local recurrence was rapid and metastases to the lungs and liver were observed one month after operation. The patient died two months postoperatively. Histologic study of the tumor showed it to be an adenocarcinoma. Nine other eases of primary carcinoma of the colon in children fifteen years of age or younger have been collected from the literature. There are no illustrations. BENJAMINR. SHORE

Multfple Polyps of the Colon, F. W. RANICIN.South. M. J. 27: 574-578, 1934. The extirpation of the colon for diffuse adenomatous lesions may be undertaken with two objectives in mind. If the tumors are largely confined to the colon proper, and there are only a few scattered adenomas in the rectum, one considers sacrificing the large bowel and the transplantation of the ileum into the rectum, thus saving the sphincteric mechanism. Small polyps present in the rectum may be destroyed by fulguration. Where the rectum is involved in such a way as to preclude saving it, a three-stage procedure is most desirable. This consists of, first, an ileostomy; second, subtotal colectomy down to or near the recto-sigmoid junction; third, a combined abdomino-perineal resection of the recto-sigmoid and rectum. Six cases of total colectomy without mortality have been previously reported by Rankin (Ann. Burg. 94: 677, 1931). BENJAMINR. SHORE

The Physician’s Responsibility in Rectal Cancer, W. A. FANSLER.J. Iowa M. SOC.24: 280-282, 1934. It is the duty of the physician not only to diagnose the presence of rectal cancer but to see that the patient secures proper and adequate operative and postoperative treatment. BENJAMINR. SHORE THE PANCREAS 715

Radium and Rectal Carcinoma, D. T. QUIQLEY. Nebraska M. J. 19: 138-140, 1934. Over a period of fifteen years Quigley has treated 75 cases of rectal cancer with radium alone, exclusive of operative procedures of any kind. He uses a pack containing 90 to 100 milligrams of radium in the rectum for from sixteen to twenty-four hours. He prefers this to needles or seeds. Of the 75 patients treated, 7 lived over five years and 4 over ten years. Many of the patients were referred for treatment because of other diseases than cancer, and many of them subsequently died of the other conditions. Six per cent of the patients were diabetics. Unfortunately radium does not work well in recurrences following operation, as the disease quickly spreads through the scar and passes the limits of localization which are so necessary for successful radium therapy. BENJAMINR. SHORE

Fistula-An Etiologic Factor in Cancer of the Anal Canal, CURTICEROBBER. Texas State J. M. 30: 203-207, 1934. The association of a fistula and cancer in the same region may be presumed to occur through one of two mechanisms if coincidence is excluded. A primary malignant process may originate in the tract by invasion of the perianal spaces associated with secondary infection, or the prolonged presence of a fistula with its irritation may lead to cancer formation. Eleven cases in which cancer of the rectum and fistula were found in association are reported; in 8 of these it is believed that the fistula was of definite etiologic moment in the causation of the cancer. The article is illustrated by photomicrographs and drawings. BENJAMINR. SHORE

THE BILIARY TRACT Unusual Location of a Carcinoma of the Papilla of Vater, J. LENDVAI.Orvosi hetil. 77: 448-450, 1933. An atypically located opening of the common bile duct may change the clinical picture of a papilla of Vater carcinoma. A man of thirty-four had pronounced jaundice, had lost 44 Ibs. within a year, and had repeated chills. A liver function test revealed nothing. Analysis of the feces showed occult blood, which explained the well marked secondary anemia which was present. The patient refused operation. An autopsy four months later showed carcinoma of the papilla of Vater with dilatation of the bile ducts. The characteristic symptoms of such tumors are jaundice, occult bleeding, chills, and high temperatures, and changes in the function of the pancreas. ANTHONYWOLLNER

THE PANCREAS

Pancreatic Cancer and Its Treatment by Implanted Radium, W. SAMPSONHANDLEY. Ann. Surg. 100: 215-223, 1934. Seven cases of primary carcinoma of the pancreas treated with radium are reported by Handley. One of these patients has remained well for a period of almost fourteen years. The diagnosis in this case was, however, not confirmed by histologic study of a biopsy specimen but was based on the presence of isolated nodular deposits outside the main tumor mass at the time of operation. In a second case life was prolonged for over two years, and in a third the patient remained well ten months after radium treatment. In the remaining four cases death occurred within a short period of the laparotomy, apparently from simple asthenia, a mortality of 57 per cent. Radiation was not considered to be a factor in the mortality, though it is suggested that it might be wise to screen the right suprarenal gland by lead over the posterior aspect of each of the radium tubes. In giving radiation to pancreatic carcinomas three tubes, each containing 2 mg. of radium, are inserted into the growth and left for five days, giving a total dose of 720 mg. hrs. BENJAMINR. SHORE 716 ABSTRACTS

Radical Surgery of Cancer of the Pancreas, G. GORDON-TAYLOR.Ann. Surg. 100: 206-214, 1934. Gordon-Taylor reports the successful surgical removal of almost an entire pancreas for a primary carcinoma of that organ in a fifty-four-year-old man. Because of the location of the tumor and its transmitted pulsation, the preoperative diagnoais of abdominal aneurysm was made. A solid tumor involving the body and tail of the pancreas was found and removed, leaving a small portion of the tail attached to the hilum of the spleen and a slightly larger piece of pancreatia tissue attached to the duodenum. The tumor was nodular and firm, and measured about 12 cm. in diameter. Histologic study showed it to be a columnar-cell carcinoma originating in a duct. The patient is now alive and well almost seven years after the removal of the major portion of his pancreas for carcinoma. He has gained weight, has a normal blood chemistry, and no abnormality of his sugar metabolism can be demonstrated. The article is illustrated by a photograph and drawings. BENJAMINR. SHORE Granulopenia Associated With Carcinoma of the Pancreas, C. H. RICHARDSON.South. Surgeon 2 : 234-238, 1933. The case of a fifty-seven-year-old man who died without operation of what was thought to have been agranulocytosis associated with gallbladder disease is reported. Autopsy showed a normal gallbladder but a primary carcinoma of the pancreas. During the three months of the patient’s illness the leukocyte count had been as low as 1800, with 29 per cent neutrophiles. The exact relation between the carcinoma of the pancreas and the leukopenia is not clear. BENJAMINR. SHORE

RETROPERITONEAL TUMORS

Retroperitoneal Cysts, F. H. LAHEYAND E. B. ECKERSON.Ann. Surg. 100: 231-237, 1934. Mesenteric, omental, and retroperitoneal cysts must actually be grouped in the same category, since the mesenteric and omental varieties are merely anterior extensions or inclusions of those originally retroperitoneal. Pathologically and embryologically they are alike and can actually be classed as retroperitoneal cysts. A simple classification suggested by the authors is as follows: (1) Wolffian cysts derived from persistent rem- nants of any part of the early urogenital system; (2) lymphatic or chylous cysts; (3) dermoid and enteric cy&; (4) mesocolic cysts formed from pockets of peritoneum left between the opposed serous surfaces of the mesentery and parietal peritoneum in the early rotation of the colon; (5) parasitic and inflammatory cysts, notably those of the echinococcus and broken-down tuberculous lymph nodes; (6) traumatic blood cysts. The surgical treatment of these cysts is usually simple, enucleation and marsupialization being the two available procedures. Abstracted reports of two cases are included. The article is illustrated by a drawing, photomicrograph and roentgenogram. BENJAMINR. SHOI~E THE ADRENAL GLANDS

Clinical Manifestations of the Chroma5 Cell Tumors Arising from the Suprarenal Medulla, A. E. BELTAND T. 0. POWELL.Surg., Gynec. & Obst. 59: 9-24, 1934. The authors report the case of a forty-five-year-old woman who died following the administration of a spinal anesthetic preparatory to surgical excision of a retroperitoneal tumor thought to be a hypernephroma. Autopsy showed a large cystic chromaffin-cell tumor weighing 1000 grams completely replacing the right suprarenal gland. Quantita- tive chemical analysis of a portion of the tumor proved it to contain the enormous quantity of over 2 grams of adrenalin per 100 grams of tissue. A review of the clinical features of this and other cases of pheochromocytomas reported in the literature shows many strikingly similar characteristics. The typical clinical features of this syndrome are hypertension or paroxysmal hypertension, gly- THE ADRENAL QLANDS 717 cosuria, evidences of instability of the sympathetic nervous system, such as periodic attacks of sympatheticotonia with tachycardia and vasoconstriction followed by vaso- dilation; nausea, vomiting, headache, nervous manifestations, with sensations of con- striction in the epigastrium, dyspnea, suffocation or choking, attended by an increased susceptibility to shock, and pulmonary edema. When surgical removal of a tumor is successful, it completely relieves the patient of all signs and symptoms typical of this syndrome. For the association of pheochrornocytomas of the suprarenal medulla with clinical evidences of instability of the sympathetic nervous system, the authors have chosen the descriptive term “ suprarenal sympathetic syndrome.” The article is well illustrated with roentgenograms, photographs, and photomicrographs. Abstracted histories of sirniIar cases reported in the literature are given in tabular form. BENJAMINR. SHORE Suggested Test for Functional Cortical Adrenal Tumor, ROBERTT. FRANK.Proc. SOC. Exper. Biol. & Med. 31: 1204-1206, 1934. A clinical syndrome characterized by facial and trunk obesity, hirsutism, pig eyes, either persistently high blood pressure or attacks of hypertension, amenorrhea or menstrual irregularity, pinkish skin striae, rarefaction in the bones, polycythemia, cyanosis of the extremities, and susceptibility to infection has attracted increasing attention, particularly since Cushing described basophilic adenoma of the pituitary as a probable cause. Previously a number of these cases had been found due to cortical adrenal tumors and Cushing suggested that pituitary hyperfunction, perhaps limited to the basophilic type of cell, might conceivably induce changes in the cortex of the adrenal. The author describes two patients with large carcinomas of the adrenal cortex (but no pituitary adenoma) who presented all the cardinal symptoms; in one of these, hepatic metastases are mentioned. In both cases there was a high female sex hormone excretion in the absence of a positive pregnancy reaction, and the author suggests that such findings may in the future serve as a means of recognizing adrenal cortical neoplasms at an early and operable stage. In a footnote it is said that 10 more patients had been examined after the paper was submitted for publication, all with at least some of the characteristic symptoms, and all with negative results. This makes the author all the more anxious to have the test applied as widely as possible, in order to determine whether the high female sex hormone titre in the urine is limited to cases with metastases. WM. H. WOGLOM History of a Case of Carcinoma of the Adrenal Cortex with Cushing’s Syndrome, F. G LESCHERAND A. H. T. ROBB-SMITH.Proc. Roy. SOC.Med. 27: 404-406, 1934. A woman of thirty-five had ceased to menstruate three years before. She had grown stouter and her body had assumed a dusky red hue with some dryness of the skin. There had been loss of hair of the scalp and there was a coarse growth of hair on the upper lip and chin and around the nipples. The external genitals were normal and the pubic hair of feminine distribution. The heart was enlarged and the blood pressure raised. There was indefinite pain in the epigastrium and left renal region but no palpable tumor. The urine contained albumin and sugar. X-ray studies revealed a generalized decalcification of the bones of the trunk, multiple fractures of the ribs, and partial collapse of the sixth to the eighth dorsal vertebra, but the appearances were not those of osteitis fibrosa or metastatic carcinoma. A shadow in the left renal region was interpreted as a partially calcified suprarenal tumor. Operative removal was followed by death with symptoms of hyperadrenalism. Microscopically the tumor had the appearance of an adrenal cortical carcinoma. All the bones showed marked osteoporosis, and the uterus and ovaries were atrophic. The pituitary body was not enlarged but showed an excess of basophile cells. Small collections of basophile cells were found, but it is doubtful whether this can be regarded as a true adenoma. There are no illustrations. Tumors of the Suprarenal Cortex with Reports of Three Cases of Carcinoma and a Li- poma, FORDK. HICK. Arch. Path. 15: 881-882, 1933. A brief mention of four cases, with no details. 718 ABSTRACTS

Fibrosarcoma of the Suprarenal Gland, B. 8. CRAN. Brit. M. J. 2: 1018-1019, 1933. The author describes a case of fibrosarcoma of the suprarenal gland in a woman of thirty-eight which he believes arose in the supporting connective tissue of the organ. Preparations stained by various methods for the demonstration of nerve cells and their processes showed no evidence of nerve tissue elements. Secondary tumors in the liver, lungs, and lymph nodes were similar histologically to the suprarenal growth. A photograph of the gross specimen and a photomicrograph illustrate the report. Case of Melanotic Sarcoma of the Adrenal Glands with a Secondary Tumour in the Bladder, R. A. MCCOMBAND DONALDB. SMITH. J. Urol. 30: 49-59, 1933. A man of sixty-five years with a history of increasing frequency of urination, hematuria, and sudden anuria was found to have a melanotic sarcoma of the bladder, which was removed. A search for a primary tumor elsewhere was fruitless. The patient remained in apparent good health for about eleven months, after which he failed rapidly, complaining of general weakness and a sense of heaviness across the abdomen. A palpable mass appeared in the right side of the abdomen, several nodules developed in the skin, and death ensued from circulatory failure thirteen months after operation. Autopsy revealed a bilateral tumor of the adrenal glands which the authors regard as the primary growth. They believe that the tumor arose from the medullary portion of the gland rather than the cortex but find it impousible to state positively what cell in the medulla gave rise to the new growth. The possibility of this tumor being an unusual pheochromocytoma is considered. Photographs of the adrenal tumors and a number of photomicrographs illustrate the report.

Case of Suprarenal Blastoma, G. GR~NBERGER.Acta Paediat. 15: 142-145, 1933. This is a report of a suprarenal tumor occurring in a female child two and a half years old. At operation a tumor the size of a large orange was removed from the site of the left suprarenal. The kidney was easily separated from the tumor, but the left dome of the diaphragm was rather closely adherent to it. Although no metastases were found, the child died three weeks after operation. Autopsy revealed a liver densely permeated with tumor nodules and involved retroperitoneal nodes. The diagnosis was sympathetic suprarenal neuroblastoma. W. S. MACCOMB THE FEMALE GENITAL TRACT

Evaluation of Radiation Therapy in Malignant Digease of the Female Genital Tract, W. P. HEALY. Am. J. Obst. & Gynec. 25: 789-803, 1933. Although our knowledge regarding the action of radiotherapy upon malignant growth is limited by the relative youth of this form of treatment, it is generally conceded that tumors composed of immature, poorly differentiated, and anaplastic cells respond more readily than those of a lower grade of malignancy. Attempts to unify these responses, however, have met with failure, since from the standpoint of long cures, one finds little difference in the differentgrades of malignancy. The most important factor in successful irradiation, as in surgical management, is early diagnosis. Carcinoma of the Vulua: Since the majority of cancers of the vulva are composed of squamous epidermoid cells which are relatively radio-resistant, successful treatment necegsitates heavy dosage. The normal tissues of the vulva, however, will not often tolerate the dosage required for cure, and the optimum treatment, therefore, consists in surgical removal of the primary growth with dissection of the inguinal glands. Irradia- tion plays little part, being confined to preoperative or postoperative application to the nodes in the drainage area. On the author’s service, 8 patients survived from five to ten. years after operative treatment. Vagina2 Carcinoma: In view of the poor results after surgical handling of vaginal cancer, it has been largely supplanted by irradiation. Three gross types of tumor are commonly recognized: the fungating type, which occurs in older women and relicts THE FEMALE GENITAL TRACT 719 readily to radiation therapy; a circuniscribed infiltrating lesion which responds well in its early stages but is prone to recur and metastasize; and a stenosing lesion which sur- rounds the vagina and offers a prognosis so poor that palliation is usually the most to be hoped for. Of 99 patients treated at the Memorial Hospital from 1918 to 1931, 12 per cent have lived five years or more, 14 for three years, and 26 per cent are well two years after treatment. Carcinoma of the Corpics: Although surgery is generally thought to be indicated for carcinomas of the corpus, the age and poor condition of the patient have necessitated the use of a less radical form of treatment in many cases. The method commonly accepted confiists in the application of radium within the cervical canal and x-ray irradiation over the surface of the body. The results have more than justified this procedure, five-year cures being reported in from 50 to 77 per cent of cases by various authors, figures which in some instances are better than those after surgery alone. Two distinct histological types of tumor are recognized, the so-called adenoma mtlignum and adenocarcinoma. The first responds to surgical treatment satisfactorily, as is shown by the author’s figures-only 7 per cent recurrences in three years. In the same length of time, however, 39 per cent of the adenocarcinomas recurred. It is urged, therefore, that, unless the diagnosis be accurately ascertained, operation be followed by a series of x-ray treatments. Ovarian Carcinoma: In view of the complexity of histological types encountered in ovarian carcinomata, it is difficult to foretell the effect of irradiation. Surgery is indicated unless the growth is clearly inoperable. From the histological type it is then possible to advise intelligently as to postoperative irradiation. Surgical statistics for five- year cures vary from 10 to 15 per cent. Intensive treatment with high-voltage x-rays following the surgical procedure has improved these figures and has contributed much to the comfort and length of life in hopeless cases. CervicaE Can,cer: Irradiation is almost unanimously preferred to surgery in the treatment of cervical cancer, although radical hysterectomy is still practised in a few clinics. The mode of treatment most popular at present consists of x-rays externally and radium at the site of the lesion. The radium is usually applied first, but the author personally prefers a reversal of this order, for the purpose of preparing the lesion for the radium. The figures from different clinics agree quite closely, five-year absolute healing being obtained in from 20 to 27 per cent of all cases. THEODORE8. RAIFORD

Radiation Therapy in Gynecologic Malignancy, I. I. KAPLAN.Am. J. Obst. & Gynec. 25: 368-373, 1933. Kaplan’s report is based upon 280 primary nialignaut tumors of the female genital tract treated by irradiation during the years 1924-1931. Four primary carcinomas of the urigiviu were treated by local application of radium to the lesion and x-ray therapy to the lymphatics draining the area. Three patients were alive in 1929 and one was reported dead [date of treatment not given]. The same form of treatment was employed in two urethrnl carcinomas, one receiving radium within the tumor. Both of these patients were alive after three years but in poor condition. Carcinnmas of the cervix are mofit amenable to radiotherapy. The author uses deep x-ray therapy to the pelvis followed by local application of radium to the lesion, and finally a second series of x-rays to the pelvis one month after the first for recurrences or pain. A total of 167 cases have been treated but the results are not given in this paper. (For a statistical report on an earlier series see Kaplan: Am. J. Roentgenol. 26: 746, 1931.) Twelve carcinomas of the vulva were treated by a combination of radiotherapy and surgery. Following a preliminary course of radiation, the lesion was removed, by the electrocautery when possible. In extensive cases intratumoral radium was employed before resection. Four of the patients were alive in 1931,5 were dead, and the remaining three were not followed. Fifty-four carcinomas of the body of the uterus were treated during the eight years. All were of the adenocarcinoma type and the diagnosis had been confirmed by biopsy. Hysterectomy had been performed previously in 20. Of the 54 patients 21 are known to be alive, 12 are dead, and in 21 the result is not known. 720 ABSTRACTS

C!arcinomas of the ounr!j can best be treated by surgery with preoperative and postoperative irradiation. Twenty-six of the author’s 30 patients received both irradiation and surgery, the remaining 4 receiving irradiation alone. Seven are living and well at present, 9 are known to be dead, and in 14 the result is not known. It is important to remove ascitic fluid if present, before irradiation. Similarly removal of the bulk of nn inoperable lesion facilitates palliative treatment. Surgery followed by x-ray therapy was used in the treatment of two carcinomas of the fallopian tubes not recognized before operation. One patient died from metastases and the other is living at the present time. Among the rarer conditions treated were one each of chorionepithelioma, hydatidiform mole, and teratoma. The first two patients are living at one and two years after treatment respectively while the third died shortly after treatment. Six carcinomas of the bladder received radiotherapy, primarily as a palliative adjunct to surgery. The,author believes that irradiation is an essential aid to treatment in all gynecologic malignancy and that in cancer of the cervix it is the treatment of choice. Its use, however, should be restricted to those adequately trained. There are no illustrations. THEODORES. RAIFOI~D

Results of the Exclusive Use of Radium in the Treatment of Female Genital Carcinomas, P.IKEDA (JKEDA) AND K. IKEDA(JKEDA). dber die Ergebnisse der ausschliessliohen Radiumbehandlung bei weiblichen Genitalkarzinomen, Zentralbl. f. Gynak. 57 : 1651-1655, 1933. The authors have analyzed the results of the treatment of female genital carcinomas by means of radium alone from 1914 to 1927. During this period 1295 carcinomas were seen, and of this number 652 were treated by radium. In ceruica2 carcinoma the results were as follows: Total Cured Per Cent (5 to 18 years) Grade I (operable)...... 151 63.45 Grade I1 (borderline)...... 79 60 75.95 Grade I11 (inoperable) ...... 41 16.53 Grade IV (incurable)...... 3 5.45 - - -- TOTAL...... 620 255 41.13 Carcinoma of the bodv of the uterus showed the following results: Grade I...... Grade ...... I1 - TOTAL...... 13 62 With regard to the effect of age in this group, 6 out of 11 patients between the ages of forty-one and fifty-five were cured and 7 out of 10 between the ages of fifty-six and seventy. Of 7 vaginal carcinomas, 2 were grade I and 5 were grade 11. Both patients with Grade I tumors and one of the other group were living between five and eighteen years after treatment. Of carcinoma of the vulva 3 cases were treated. A carcinoma of the clitoris was excised and treated with radium but recurred seven years and a half later, causing death. A carcinoma of Bartholin’s gland was similarly treated and the patient is living and well eleven years after treatment. The third tumor, a carcinoma of the urethra, was trested with radium; the patient died six years later from uremia. The technic and dosage employed by the authors are discussed briefly and the complication of pregnancy commented upon. It was found that healing occurs in the highest percentage of carcinomas of the cervix between the ages of thirty-six and forty-five years, while in carcinomas of the body the optimum results are obtained between forty-six and fifty-five years of age. Treatment appears to be more successful among urban than country folk. THE FEMAIJ? QENITAL TRACT 72 1

This is an interesting and valuable collection of statistics. One hundred and seventeen cases were observed between 1928 and 1932 but insufficient time has elapsed to determine the percentage of cures in this group. THEODORES. RAIFORD

Crusade Against Cancer of the Female Genital Tract, R. T. v. JASCHKE.Der General- angriff gegen das Karzinom der weiblichen Geschlechtsorgane (und Bruste) Fortschr. d. Therap. 10: 1-4, 1934. This is a general article concerning the early diagnosis and treatment of cancer of the female genital organs. Routine semi-annual examination of women in the cancer age is advocated. BENJAMINR. SHORE

Postmenopausal Bleeding, S. H. GEISTAND M. MATUS. Am. J. Obst. & Gynec. 25: 388-397, 1933. The authors have analyzed the underlying cause in 182 cases of post-menopausal bleeding: 42 per cent of these were due to benign lesions, 10 of which were located in the ovary, and the remaining G8 in the cervix or uterus. These lesions included ovarian tumors, uterine polyps, fibroids, hypertrophic endometrium, endometritis and cervicitis. The malignant growths which were responsible for bleeding were: carcinoma of the vulva, vagina, cervix, fundus, and ovary, and sarcoma of the ovary. There are five photomicrographs and a short bibliography. THEODORES. RAIFORD

Uterine Bleeding in the Aged, W. SCHULZ.Korporale Blutungen im Greisenalter. Zentralbi. f. Gynak. 57: 1890-1893, 1933. In an attempt to determine the rBle of malignant growths in uterine bleeding in the aged, Schulz reviews 232 cases in which bleeding was a major symptom. Fifty of these were segregated for analysis, including only those cases in which there was no complicating disease and in which the menopause had definitely been eliminated as a factor. Surprisingly enough, in only 10 per cent was the bleeding caused by cancer. In 15 per cent mucous polyps were responsible, and in 10 per cent hyperplasia of the endometrium. Ovarian tumors were a contributing factor in 12 per cent. In the remainder the bleeding was believed to be brought about by necrotizing processes affecting the endometrium. If carcinoma is clearly indicated either by history or physical findings, a radical operation should be done; but since cancer is preflent in so few cases, if there is nothing in the clinical findings to suggest malignancy, and uterine scrapingd are microscopically negative, curettage should suffice for the alleviation of symptoms. THEODORES. RAIFORD

Diagnostic Curetment, with Special Reference to Uterine Bleeding About or After the Menopause. An Analysis of 100 Cases, J. T. WITHERSPOON.South. Surgeon 2: 239-243, 1933. One hundred consecutive cases of curettage for diagnostic purposes have been studied. The average age of the patients was 45.7 years, and in 54 per cent the bleeding was about or after the menopause. Fibroids and pregnancy accounted for the hemorrhage in 50 per cent of the cases. Malignancy was found in 9 instances. In addition to curettage radium was used in 5G cases. The advantages of a diagnostic curettage far outweigh its disadvantages and dangers, most of which can be eliminated or guarded against. BENJAMINR. SHORE

Recurrent Bleeding after Roentgen Castration, DEKER. Rezidivblutungen nach Rontgenkastration, Zentralbl. f. Gynak. 57: 2257-2258, 1933. Two cases are cited in which radiotherapy was used for bleeding after curettage had shown hyperplasia and atrophy respectively and no evidence of malignancy. Later examination for recurrent bleeding revealed uterine sarcoma in each patient. The indications and contraindications for radiotherapy in the presence of bleeding are discussed, and the reader is warned against its use alone in the presence of possible malignancy. In such cases operative treatment is to be preferred. There are no illustrations. THEODORES. RAIFORD 722 ABSTRAUTS

Tumors of the Uterus and Ovaries, W. HANNEB.Die Geschwiilste der Gebarmutter und der EierstGcke, Fortschr. d. Therap. 9: 603-612, 1933. This is a general article concerning the treatment of benign and malignant tumors of the uterus and ovaries. No new material is added. BENJAMINR. SHORE Colposcopic Diagnosis of Carcinoma, H. HINSELMANN.Ausserste Leistung der kolpo- skopischen Karzinomdiagnose, Zentralbl. f. Gynak. 57: 1922-1925, 1933. Hinselmann again sets forth the merits of the colposcope as a means of early diagnosis'in cancer of the cervix, and cites an instance in which it was successfully used. There is one illustration. THEODORE5. RAIFORD Histologic Grading in Carcinoma of Uterine Cervix. Its Relation to Clinical Grouping and Prognosis, L. H. JORSTADAND E. S. AIJER. Surg., Gynec. & Obst. 57: 583-587, 1933. From an analysis of the grading of all the cervical cancers treated by radium in The Barnard Free Skin and Cancer Hospital in St. Louis from 1917 to 1927, it is concluded that grading alone is of no prognostio value. Due to the location of the tumor and the absence of early subjective symptoms in the majority of cases of cancer of the cervix, it is impossible to formulate ideas in regard to these neoplasms on the basis of conformity with similar squamous epitheliomas of the lower lip. That grading is, or may be, of great value in the radium treatment of a specific case of carcinoma of the cervix is true; furthermore, grading may be the deoiding factor in the decision to employ surgical treatment rather than radiation. Clinical grouping and extent of the disease are more important than grading from a prognostic standpoint. The article is illustrated by photomicrographs and several charts are included. BENJAMINR. SHORE

Clinical Obsemation of the Histological " Malignancy-Index '' of the Carcinoma in Cervix Uteri, J. TOYOSHIMA.Japanese J. Obst. & Gynec. 16: 538-541, 1933. In this article the author has attempted to correlate the so-called '' malignancy- index ,, with the degree of invasion of malignant cells in carcinomas of the cervix. On the basis of the histological findings in 30 such cases, he concludes that the malignancy index roughly parallels the degree of invasion. This index varies greatly with the degree of infiltration of pelvic tissues, that is, the index is high when the pelvic connective timue is extensively involved. As is to be expected, the prognosis varies directly with the malignancy index and the degree of invasion. THEODORE8. RAIFORD Quantitative Study of Epithelial Nuclei of the Body of the Uterus in Carcinoma and in Non-Malignant Hyperplasia, DONALDMAINLAND. Proc. Nova Scotia Institute of Science 18 (part 3): 77-105, 1933. The material studied was the hyperplastic human endometrium and uterine carcinoma. The conclusions are that the average nuclear size is greater in carcinoma than in hyperplasia, when the section technic is the same. The nuclear size varies more in hyperplasia than in carcinoma. The size of the nucleus in individual specimens varies more in carcinoma than in hyperplasia. urinary Tract Complications from Uterine Cancer, FLETCHERH. COLBY. New England J. Med. 209: 231-232, 1933. The author cites Faerber's post-mortem study of 150 women dying of uterine cancer, 58.7 per cent of whom showed coincident disease of the bladder, 56 per cent dilatation, compression, or infection of the ureters, and 72 per cent pathological conditions of the kidneys (Ztschr. f. Geburtsh. U. Gynlk. 99: 213,1930). Such changes result from direct extension of the tumor, pressure of the growth on the ureters, extension of infection or radium necrosis. The author's own study was based on 37 cases of malignant neoplasm of the uterus, of which 35 had been treated by radium. In 8 cases (21.6 per cent) there was cystoscopic evidence of tumor involvement of the bladder. Pyelograms showed partial or complete ureteral obstruction by tumor in 13 (35.1 per cent). Bladder gymptoms of THE FEMALE GENITAL TRACT 723 varying severity were present in nearly 50 per cent of the irradiated cases; fistulae, vesicovaginal or rectovaginal, resulted in 7 cases (20 per cent). Such reactions charac- teristically appear a long time after treatment, an average of eighteen months in one series cited. The author concludes that the high incidence of urinary tract complications in uterine cancer should be borne in mind and cases studied from this point of view, as such involvement may alter the prognosis and radically change the treatment. Changes in the Bladder During the Evolution of Carcinoma of the Uterine Cervix, F. AMAN-JEAN.La vessie au cours de 1’6volution du cancer de l’ut6rus, Bull. Assoc. frang. p. 1’6tude du cancer 22: 556-590, 1933. For five years routine cystoscopy combined with vaginal palpation has been done in every case of cervical cancer before, during, and after irradiation treatment at the Can- cer Institute in Paris. It is stated that over 1000 cystoscopies have been done, but the number of patients examined iu not given. The author describes various changes, especially in the appearance of the trigone and the ureteral orifices, observed in the four stages of cervical cancer, and the modifications seen during and after treatment with radium and x-rays. Before treatment, cystoscopy reveals vesical changes indicating the extent of growth of the uterine tumor: in the submucosa, projections, ridges and grooves; in the mucosa, vascular congestion and edema; at the ureteral orifices, lipping and stenosis. During treatment, it shows whether the foregoing changes have increased or diminished, thus affording a check as to dosage and frequency of irradiation. After treatment, it leads to the detection of injuries due to irradiation, such as radionecrosis in the mucosa and ureteral stenosis. The author claims that cystoscopy ranks with biopsy as the method of choice in determining the stage of growth of cancers of the cervix and in assessing the results of radiotherapy of these tumors. There are twelve illustrations, but no bibliography. Hartmann and Chevassu, in discussing this paper, agreed that cystoscopy afforded useful indications in the treatment of cervical cancer, but pointed out that such bladder changes as folding and grooving may be due simply to adhesions, which may be inflammatory and not neoplastic, while, on the other hand, cancerous infiltration of the broad ligament may cause suprameatal stenosis of the ureters, with resultant anuria, without producing any change in the cystoscopic appearance of the bladder. [As a matter of fact, all this was discussed in an earlier excellent paper by Gouver- neur and Fabre (Gyn6c. et obst. 11 : 189, 1925), in which similar findings were reported.] F. CAVER~ Radium Therapy in Uterine Cancer, M. BERTOLOTTI. SulIa radiumterapia del cancro uterino, Boll. d. lega ital. p. 1. lotta contro il cancro 7: 80-84, 1933. The author considers irradiation superior to surgery in treatment of cancer of the cervix. In cancer of the corpus uteri he advises preliminary radium treatment and later hysterectomy only in adenocarcinoma cases. In advanced cases with extension or metastases he advises the use of radium and the roentgen ray. He deplores the use of radium and x-rays in unskilled hands and favors a movement to permit treatment of cancer cases only in large specially equipped centers. The gist of considerable discussion of the paper is given. JEANNETTEMUNRO

Superiority of Radiation Therapy in Uterine Cervical Cancer, HAROLDSWANBERG AND ARTHURE. PERLEY.Arch. Phys. Therapy 14: 604-610, 1933. The authors consider that radium therapy has the following advantages over surgery in cervical cancer: it is attended by a low primary mortality; it is applicable to growths of all grades; the technic is simple; convalescence is not prolonged. The authors’ technic is deucribed, the advantages of heavy filtration are set forth, and the importance of individualized treatment is brought out in the discussion. Carcinoma of the Cervix Uteri. Five-Year Results of Radium Treatment, L. A. POMEROY.Surg., Gynec. & Obst. 57: 071-673, 1933. Pomeroy reports 79 cases of histologically proved carcinomas of the cervix uteri treated by him with radium during the years 1924 to 1926 inclusive. The gross ex- 724 ABSTRACTS aminntion was the greatest single aid in estimating the prognosis, extremely good results being obtained in cases where the disease was limited to the cervix, the diagnosis being made early and treatment started promptly. The average total delay before treatment was 4.8 months in the five-year cures, and eight months in the entire series. The proliferative tumors gave better results than the ulcerative ones, as to duration of bleeding control, duration of life, and percentage of five-year cures. The degree of cell differentiation seemed to have little influence on the percentage of five-year cures obtained in each group. However, the best results, two five-year cures among five patients treated, were obtained in patients with adenocarcinomas. Glass seeds were used for all implantations, and x-ray was used to supplement the radium in only 9 of the 79 cases. The maximum radium dose was 10,464 milligram hours, the average dose being 4,287 milligram hours. Seventy-seven per cent of the patients received one radium treatment, 16.5 per cent received two radium treatments, and 6.3 per cent received three treatments. Of those showing five-year cures, 76.9 per cent received one treatment and 23.1 per cent two treatments. There were no five-year cures among the patients receiving three treatments. The author believes it useless to try to accomplish much by increasing the radium dosage [an observation which also has been made by others in connection with both radium and x-ray therapy]. Two patients developed rectovaginal fistulae, and 4 developed vesicovaginal fistulae. Counting an unstated number of untraced patients as dead, Pomeroy secured 16.4 per cent of five- year cures for the entire series of 79 cases. BENJAMINR. SHORE Results of the Treatment of Uterine Cancer at the Aarhus Radium Center (Denmark), K. F. B. BUSCH. Acta Radiol. 15: 47-60, 1934. Busch reports the cases of uterine and vaginal cancer treated at the Radium Center in Aarhus from Jan. 1, 1914, to Dec. 31, 1931. There were 653 cases of carcinoma of the uterine cervix, 63 of the body of the uterus, and 17 of the vagina. Of those of the utcrine cervix 21.2 per cent could be classified as Stage I, 18.5 per cent as Stage 11, 33.7 per cent as Stage 111, and 26.3 per cent as Stage IV. The percentage of cures for the entire series is 17. Ten of 69 patients treated with radium alone remained well, 46 of 254 patients treated by surgery and radiation remained well, and none of 6 patients treated by roentgen rays alone remained well. A study of the cases in regard to the social status of the patients shows 10 per cent better results in those belonging to the higher class of society. This is believed to be due to better living conditions, nutrition, and more careful after-treatment. Thirty-one patients with carcinoma of the body of the uterus were operated on prior to December 1927, and of these 14, or 45.2 per cent, are still well. There were 4 deaths, an operative mortality of 11.1 per cent. All the 8 patients with carcinoma of the vagina treated prior to December 1927 are dead. In computing the figures for all cases of cancer of the uterine cervix recorded in the literatsure,irrespective of the stage of the disease and the form of radiation treatment applied, a total of 5246 cases is obtained. Of these, 913, or 17.4 per cent, were cured. Of 1093 patients with operable and border-line disease, 444 are alive after five years, giving a relative rate of curability of 42.7 per cent. The corresponding figure for the inoperable and hopeless cases is 11.1 per cent. BENJAMINR. SRORM Effect of Radiation Technic and the Early Diagnosis of Carcinoma of the Uterine Cervix on the Five-Year Good End-Results, HENRYSCHMITZ. Radiology 21 : 311-318, 1933. The author has made a study of five-year end-results in 488 primary carcinomas of the cervix treated by combined radium and roentgen therapy. An increase in the roentgen dose was followed by better end-results. The chance of cure, however, varies inversely with the development or extent of the growth, the percentage of good results by groups being as follows: group 1, 80 per cent; group 2, 41.94 per cent; group 3, 16.36 per cent; group 4, 1.72 per cent. Since the group 1 cases are symptomless, the discovery of the disease at this favorable stage must depend upon the physician and upon routine yearly examinations following labor, abortion, and the puerperium. THE FEMALE GENITAL TRACT 725

Radioactive Bismuth as a Supportive Treatment in Irradiation of Cancer of the Cervix, F. KELLER. Radioaktives Wismut als unterstutzendes Mittel in der Strahlen- behandlung des Collumkarzinoms, Zentralbl. f. Gynak. 57: 1859-1868, 1933. In view of the beneficial effect sometimes exerted by the heavy metals upon malignant growth, Keller studied the results in a group of 79 carcinomas of the cervix, 46 of which were treated with irradiation alone and 33 with irradiation supplemented by radioactive bismuth. Of the 46 patients treated by irradiation alone, 33 were operable and 13 inoperable; one- to two-year healing occurred in 50 per cent. Of the 33 cases receiving radioactive bismuth (12 intravenous injections each), 20 were operable and 13 inoperable, and one- to two-year healing occurred in 33 per cent. It would appear, therefore, that the results following the administration of bismuth were not as good as those following irradiation alone. However, as the author points out, the percentage of inoperable cases was higher in the bismuth-treated group. A point of value in the use of bismuth is the ability to outline the tumor by x-rays to which the bismuth is opaque. There are nine illustrations. The literature is reviewed thoroughly from the standpoint of animal experimentation as well as the clinical use of heavy metals in the treatment of cancer. THEODORES. RAIFORD Coincident Surgical Exposure and Radium Therapy in the Treatment of Extensive Cervical Cancer, A. H. CURTIS. Surg. Gynec. & Obst. 56: 1052-1055, 1933. Also in Am. J. Obst. & Gynec. 26: 569-575, 1933. Relatively early it was learned that the pelvic viscera are highly susceptible to injury from radium and particularly that many cancers cannot be cured because proximity of the bladder prohibits efficient radiation. With this in mind Curtis has made a practice of separation and upward displacement of the bladder to permit more extensive use of radium in this region without introducing the danger of vesical fistula. The additional area thus made available for radiation has permitted vigorous treatment of several cases of cervical cancer which could not otherwise have been satisfactorily radiated. The value of dissection and retraction not only of the bladder but also of the other vulnerable tissues has become more apparent and has eventuated in a method of surgical exposure and coincident radium application. This pertains particularly to the treatment of Stage I1 cases and to less advanced cases of the Stage I11 group in which there is some hope of cure. The technic consists in treating the necrotic cervical growth with surgical diathermy or prophylactic radiation three weeks prior to operation. Under anesthesia exposure of the cancer-bearing uterus and adjacent celfular tissue is now undertaken. By blunt dissection, the bladder is mobilized upward, the cervix encircled with an incision, and the vaginal mucosa carefully dissected laterally and posteriorly along the natural lines of cleavage. With the uterus half delivered vaginally, the bladder safely anchored in its elevated position with a catgut suture holding it high on the uterus, and the paracervical tissues exposed, a massive radium treatment is possible. Radium needles or radon seeds are inserted where needed, near to or into the cervix or far from it, as indicated, with assurance of safety of the adjacent vulnerable organs. Possibility of damaging the ureters or uterine arteries is not great. After burying the radium needles as described, a chain tandem of radium capsules is inserted into the uterine canal. A vaginal pack completes the procedure. Until further experience warrants, the total radiation should not exceed 3500 millicurie hours. The article is well illustrated by drawings, and three case histories are appended. BENJAMINR. SHOIZE Vindication of the Preoperative Radiation of Uterine Cancers, A. MAYER. Zur Ehren- rettung der ‘I Vorbestrahlung ” beim Uteruskarzinom, Wien. klin. Wchnschr. 46: 1270-1271 , 1933. Bacterial sterilization of infected growths so as to prevent the development of postoperative peritonitis is one of the reasons given by the author for preoperative radiation of uterine cancers. In 91 cases so treated from July 1, 1926, to October 1, 1931, there were 4 operative deaths, a mortality of 4.3 per cent. In only one case was death due to peritonitis. The amount of radiation given and the time allowed to elapse before operation are not stated. BENJAMINR. SHORE 726 ABGTRAOTS

Pelvic Sympathectomy for Pain in Carcinoma of the Cervix, C. A. BEHNEY. Am, J. Obst. & Gynec. 25: 687-693, 1933. In spite of the fact that sympathectomy for the relief of pain has been practised widely in various portions of the body, and has been recommended by foreign authors for pelvic lesions, Behney has been unable to find records of its application for the relief of pain from inoperable malignant growths of the pelvis in this country. [Chordotomy is done with some frequency in the United States for uncontrollable pelvic pain.] After reviewing thoroughly the anatomical and surgical features of the procedure, the author reports his experience with 7 patients suffering from aancer of the cervix. In 6 the superior hypogastric plexus was resected and in 3 of these-internal iliac peri-arterial sympathectomy was also done. In one case it was impossible to reach the plexus on account of dense adhesions. The operation was a complete success in five instances, the patient being completely relieved of all pain. In the other two the section apparently failed to include all fibers. Four of the patients are dead. One succumbed to uremia nine days after operation and another died two and one-half months later from the same cause. The remaining two died three and one-half and four and one-half months after operation from malignant disease. Three patients are living at three, fourteen, and eighteen weeks after operation respectively and all are completely symptom-free. Only one patient, in the opinion of the author, died as a direct result of the operation. It is concluded, therefore, that while no great change in the length of life has been effected, the symptomatic relief afforded warrants further investigation of the procedure. There are two schematic drawings illustrating the distribution of the sympathetic plexi involved in the pelvic region. THEODORE8. RAIFORD

Treatment of Carcinoma of the Fundus, T. P. FARMER.New York State J. Med. 33: 1332-1335,1933. This is a general article concerning the treatment of carcinoma of the fundus of the uterus. Panhysterectomy is recommended. BENJAMINR. SHORE

Prevention of Cancer of the Cervix Uteri, H. S. CROSSEN. Am. J. Obst. & Gynec. 26: 686-695, 1933. Crossen believes that the main reason for the apparent standstill in the percentage of cures in cervical cancer is the frequent absence of symptoms in the early stage of the disease. Reducing the. mortality embodies more than recognition of early symptoms. It entails use of ocular magnification of the vagina and the chemical tests recently developed; second, and more important, the removal of chronic irritation. The success of such a plan depends upon the work of the physician with his patients and the educa- tion of women as to the importance of periodic local examinations. THEODORHS. RAIFORD Carcinoma of the Cervical Stump, G. SCHAFER. Beitrag rur Frage des Cervixstumpf- karrinoms, Zentralbl. f. Gynlk. 57 : 2068-2074, 1933. Schafer reports two cases of carcinoma of the cervical stump developing after hysterectomy. The first was in a fifty-three-year-old woman, nine years after removal of the uterus for fibrornyorna. Apparently inoperable, the lesion was irradiated in- tensively, and the patient is living and well today, six years after treatment. In the second patient, a woman of fifty-one, the tumor occurred eleven months after hysterectomy for uterine myomata. Surgical removal of the leRion waR performed with satisfactory results. Polak was able to find 265 cases in the American literature, and 175 have been reported from the foreign literature. The percentage of all carcinoma of the cervix varies with different authors from 0.6 to 2.3. For a critical study of the condition, Schiifer has selected 37 cases in which the interval between removal of the uterus and the development of the cancer was one year or more, and on which accurate follow-up data were available. In 22 cases the lesion was removed by operation. The remainder were irradiated. Of the total number of patients, 30 per cent were living from one to two years after treatment and 20 per cent from three to four years. Jeanneney has THE FEMALE QENITAL TRACT 727 placed the mortality rate after operation and irradiation at 50 per cent (Rev. franp. gynec. 24: 273, 1929). From these figures it is apparent that the prognosis of cancer of this type is much less favorable than in carcinomas of the cervix unassociated with other pathology of the genital tract. The clinical data for the 37 cases are tabulated in detail. There are no illustrations. THEODORES. RAIFORD Illustrative Case of Carcinoma of the Stump after Supravaginal Amputation of Myoma- tous Uterus, Y. IKEDAAND K. IKEDA.Zur Kasuistik der Stumpfkarzinome nach supravaginaler Amputation myomatoser Uteri, Zentralbl. f. Gyniik. 57: 2074-2075, 1933. A case report of a thirty-six-year-old woman in whom a carcinoma of the cervix was found three years after the uterus was removed for myomata. THEODORE8. RAIFORD

Carcinoma of the Cervix in a Girl of Sixteen, M. GLASS. Am. J. Obst. & Gynec. 26: 104-107, 1933. Glass reports the unusual occurrence of a carcinoma of the cervix in a girl of sixteen. She complained of a foul vaginal discharge for one year before admission to the hospital, and examination revealed a large cauliflower mass proved by biopsy to be an embryonal carcinoma. The growth was excised by cautery and 75 milligrams of radium were inserted in the cervical canal. During the following month a series of 17 deep x-ray treatments was given. The immediate result was good, and the patient was symptom- free for three years. At the end of that time, however, she began to complain of anorexia and a cough, and ten days later entered the hospital with pneumonia, from which she died in a few days. Autopsy showed pulmonary metastases from the cervical lesion but no evidence of recurrence in situ. There are three illustrations. THEODORES. RAIFORD Early Carcinoma of the Cervix in a Twenty-three-year-old Nullipara, HINSELMANN. Ein Portiokarzinom in statu.nascendi bei einer 23 jahrigen Nullipara, Zentralbl. f. Gynak. 57: 1538-1539, 1933. Hinselmann cites the case of a twenty-three-year-old nullipara in whom a carcinoma of the cervix was first recognized as an ulcerated area 5.2 mm. in diameter and 1.4 mm. deep, by means of the colposcope. The diagnosis was confirmed by biopsy. Amputa- tion was considered the optimum treatment, but in view of the age of the patient and her desire for children a local excision was performed. There is no note as to the ultimate result. THEODORES. RAIFORD

Myeloid Leukemia and Carcinoma of the Uterus, HEIM. Myeliische Leukamie und Uteruskarzinom, Zentralbl. f. Gynak. 57: 1840-1841, 1933. Heim reports the unusual coincidence of carcinoma of the cervix and myeloid leukemia in a thirty-three-year-old woman. Two years after receiving x-ray therapy for myeloid leukemia the patient complained of vaginal bleeding and on examination was found to have a carcinoma of the cervix the size of a walnut. At this time the leukocyte count was 300,000. Following an application of radium to the tumor, its size decreased and ulceration occurred. The leukocyte count decreased to 14,000. The tumor was then removed by operation. When the patient was last seen, four weeks after operation, the wound had healed except for a small granulating area. Of especial interest was the presence of myelocytic elements in the pus from the wound and the granulation tissue. In discussing this case Thies suggested the possibility, since no microscopic section was seen, that the cervical tumor might be a leukemic nodule instead of carcinoma. There are no illustrations. THEODORES. RAIFORD

Case of Sarcoma of the Uterus, LEONG~RIN-LAJOIE. Considhrations Bur un cas de sarcome de l’uthrus, Union m6d. du Canada 62: 1127-1130, 1933. A twenty-five-year-old woman had profuse uterine hemorrhages and a uterus enlarged to the size of a three months’ pregnancy. The Aschheim-Zondek test was negative. The abdomen was opened, revealing what seemed to be a pregnant uterus, and carefully closed. The vaginal hemorrhage became so severe that packing was necessary. Ten 728 ABSTRACTS days later, at which time there had been no expulsion of the products of conception, a severe hemorrhage occurred, and it was decided to explore the uterine cavity. During dilatation and curettage of the uterine canal a mass of necrotic debris was removed tmd several hard fibromatous nodules were palpated. At a second laparotomy a total hysterectomy was performed. Pathological study showed a hard, fibrous tumor 8 cm. in diameter, diagnosed microscopically as a sarcoma. WILLIAMJ. HOFFMAN Sarcoma of the Uterus Complicating Pregnancy, M. G. DERBRUCKE.Am. J. Obst. & Gynec. 26: 457-459, 1933. A thirty-two-year-old primipara came to the clinic in the fourth month of pregnancy, complaining of lower right quadrant pain of three days' duration. On examination a mass the size of an orange was palpated to the right of the normal uterus. A diagnosis of twisted ovarian cyst was made, and operation was advised in view of the severe pain. A fibroid tumor was found attached by a small pedicle to the right side of the uterus, which was twisted upon itself. The pedicle was ligated and the tumor was removed. Convalescence was uneventful and five months later a normal child was delivered. Examination of the tumor showed it to be a myosarcoma. The rarity of this particular condition is emphasized by the fact that from collected statistics the incidence of fibroids complicating pregnancy is only 0.4 per cent, while the incidence of sarcomatous degeneration among fibroids is only 1.0 per cent. Only three cases have been found in the literature during the past sixty years [unfortunately references are not included]. There is one illustration. THEODORES. RAIFORD Metastases from a Myosarcoma of the Uterus, N. CHRIBTOPHORAKOS.Metastasen von wechselndem Geschwulstcharakter bei Myosarkom des Uterus, Zentralbl. 1'. Gynak. 57: 1935-1940, 1933. A patient of fifty-eight years was operated upon for fibromyoma, the uterus and adnexa being removed by the vaginal route. The histologic diagnosis was myoma with suspected malignant change. Three recurrences were removed surgically, one seventeen months, one twenty-five months, and a third thirty-one months later. Several months after the fourth operation multiple metastases developed and the patient died five years and eight months after the first operation. Unfortunately no post-mortem examination was allowed and it was impossible to determine the extent of the tumor at death. Four illustrations are included and there is a short bibliography. THEODOREIS. RAIFORD

Report of a Case of Teratoma of the Uterus, J. E. LACXNERAND L. KROHN. Am. J. Obst. & Gynec. 25: 735-743, 1933. Of the few cases of uterine teratomata thus far reported, the majority are of questionable authenticity. So rare is the condition, in fact, that R. Meyer has stated that the diagnosis must be made with extreme caution. Mann (Virchows Arch. f. path. Anat. 273: 663,1929) and Hellendall (Zentralbl. f. Gynak. 54: 2398, 1930) have reported cases in which there seems to be no doubt as to the diagnosis. To these the authors add a third case. The patient, a thirty-four-year-old white woman, was admitted because of vaginal bleeding for fourteen weeks. At one time she had expelled per vaginam a hard mass 2% inches long, following which there was a temporary remission of bleeding, with recurrence two weeks later. Examination revealed only a slightly enlarged uterus. Diagnostic curettage showed endometrial hyperplasia, and the patient was discharged. Two months later, after an exacerbation of symptoms, she was again examined and a pedunculated mass was found protruding from the cervix. The uterus was removed and was found to contain a soft, pedunculated tumor arising from the cervical mucosa and a hard fibrous nodule in the wall. In histological sections from various locations it was possible to identify cartilage, smooth muscle, myxomatous tissue, fatty tissue, ganglion cells, nerve fibers, squamous epithelium with sebaceous glands, hair follicles, sweat glands and stratified columnar epithelium. Glands typically like those of intestinal epithelium were found and the arrangement of the cartilage and ciliated epithelium strongly suggested bronchial structures. In other words, derivatives of all three germ layers were found. The diagnosis was therefore teratoma. THE FEMALE GENITAL TRACT 729

The question naturally arises as to whether this was a true teratoma or an atypical pregnancy. The rapid growth as shown by its appearance after the first curettage speaks for the latter, but the absence of clinical signs of pregnancy, together with the fact that no decidual cells were found, is thought to support the diagnosis of a true teratoma. In the discussion following the paper it was agreed that, while there must of necessity remain some doubt as to its identity, the diagnosis as given was probably correct. There are six excellent illustrations and a bibliography. THEODORES. RAIFORD

Adenomyoma (Adenomyosis of Frankl) of the Uterus with Tuberculous Infection, R. H. RIGDON. Am. J. Obst. & Gynec. 25: 902-906, 1933. The uterus and a cyst of the left ovary were removed from a forty-nine-year-old woman complaining primarily of irregular menses. The uterine tumor, the size of a cocoanut, was found to consist largely of myomatous tissue with scattered areas of glandular proliferation. In addition there were caseous areas containing typical tubercles with epithelioid and giant cells. The entire left ovary was converted into a cyst, the walls of which also contained tubercles and giant cells but little normal ovarian tissue. The patient made an uneventful recovery. The author believes that in this case the fallopian tubes were involved first and the infection reached the uterus by secondary extension. There are three photomicrographs and a short bibliography. THEODORES. RAIFORD

Gonad-Stimulating Hormone in Urine of a Patient with a Chorioepithelioma Uteri, C. F. FLUHMANNAND P. E. HOFFMANN.Proc. SOC.Exper. Biol. & Med. 31: 1014- 1015, 1934. Although it is now well known that the urine of women with hydatiform mole or chorionepithelioma uteri contains large amounts of a gonad-stimulating factor, there is no information yet available respecting the nature of this hormone. The authors found that the urine from a woman of twenty-nine who developed a chorionepithelioma following a hydatiform mole, and died with extensive metastases in the liver and the lungs, contained a gonad-stimulating hormone with certain biologic characteristics similar to those of the substance occurring in normal gestation, not in anterior pituitary extracts. WM. H. WOGLOM Early Detection of Chorionepithelioma by means of the Anterior Pituitary Hormone Tests, with Report of a Case, M. A. CASTALLO.Am. J. Obst. & Gynec. 26: 893-895, 1933. Using the Aschheim-Zondek test, the author was able to make an early diagnosis of chorionepithelioma. Following an initial diagnosis of hydatidiform mole the uterus was first curetted. When the reaction remained positive, panhysterectomy was advised and carried out. Although there was no gross pathology, the microscopic study showed chorionepitheliorna. The patient has remained well to date, eighteen months after operation. There are three photomicrographs. THEODORES. RAIFORD Significance of the Aschheim-Zondek Reaction in the Diagnosis of Hydatid Mole. w. ROBENSTEIN. Die Bedeutung der Aschheim-Zondek’schen Reaktion fur die Indikationsstellung nach Blasenmole, Zentralbl. f. Gynak. 57: 1380-1381, 1933. Also in Arch. f. Gynak. 152: 320-321, 1933. Rosenstein regards the Aschheim-Zondek reaction of great importance in the diagnosis and prognosis of hydatid mole and chorionepithelioma. He cites the case of a twenty-eight-year-old primipara from whom a mole was removed by curettage. The Aschheim-Zondek reaction at this time was positive. Four weeks later it was negative, but further examination revealed a villus with characteristic chorionic cells. Six weeks after this the reaction again became positive and, in spite of the fact that no evidence of uterine malignancy could be found on curettage, a vaginal panhysterectomy was done. Pathological examination showed a true chorionepithelioma in the right tube. The Aschheim-Zondek reaction remained positive thereafter, and three months later pul- 730 ABSTRACTS monary metastases appeared and the patient died. Autopsy showed widespread metastases throughout the body. Recognizing the difficulties in the diagnosis of these two lesions, the author considers this test a valuable diagnostic aid. If, after the removal of a mole, the test becomes negative and remains so, the presence of a chorionepithelioma is unlikely. If, on the other hand, such a lesion is removed by operation and the test becomes positive within two months, a recurrence is indicated, and the prognosis is poor. THEODOREs. RAIFORD

Survey of a Series of Myomectodes with a Follow-up, H. E. MILLERAND C. H. TYRONE Am. J. Obst. & Gynec. 26: 575-581, 1933. This article is a statistical review of the salient clinical features in a series of 128 myomectomies. The operative mortality in the series was only 0.77 per cent; recurrence was observed in 3.08 per cent. Almost complete relief was afforded from dysmenorrhea and menorrhagia due to the presence of fibroids. In 69 cases in which subsequent pregnancy was a possibility it occurred in 21 or 33 per cent. During pregnancy myornec- tomy is indicated only in the presence of necrobiotic processes. Obstruction of the bowel occurred aR a postoperative complication in 3 per cent of the ituthors’ cases, either during the hospital stay or as a subsequent complication of pregnancy. There are no illustrations. THEODORE8. RAIFORD Clinical and Therapeutic Aspects of Uterine Hemorrhage Associated with Fibroid Tumors, G. METIVET. Considkrations cliniques et thkrapeutiques sur les hkrnor- rhagies utkrines des porteuses de fibromes, Semaine d. hBp. de Parid 9: 682-683, 1933. This is a brief discussion of the relation of uterine hemorrhage to fibromyoma of the uterus, containing nothing new. WILLIAMJ. HOFFMAN

Colloidal-chemical Examination for the Presence of a Myoma Toxin, A. W. HOCHLOFF. Kolloid-chemische Untersuchungen zur Frage “ Gibt e3 ein Myomtoxin? ” Zentralbl. f. Gynlik. 57: 1880-1882, 1933. According to the work of earlier writers, uterine myomas are capable of giving off a toxin which has a special affinity for heart muscle. Hochloff attempted to demonstrate the presence of such a toxin by testing extracts of myomatous tissue with regard to their effect upon surface tension changes produced by the action of cocain upon certain dyestuffs. Ten extracts were tested and compared with a similar number of extracts from normal uteri. No appreciable differences were demonstrable. THEODORE5. RAIFOI~D Pregnancy and Labor Complicated by Myomatous Tumors of the Uterus, R. E. CAMP- BELL. Am. J. Obst. & Gynec. 26: 1-10, 1933. In a series of 32,870 pregnancies seen in the Johns Hopkins Hospital between the yeam 1896 and 1928 Campbell found 142 in which uterine myomas were recorded during pregnancy, labor, or the puerperium. In 82 of these the tumor was of such she as to constitute a major complication. The incidence was greatest in the colored race and in primiparas. The liability to fibroids was found to be greatly increased between the ages of thirty-five and forty-five years. Associated with the fibroids were sterility, premature labor, and immature birth, the two latter conditions occurring in 25 per cent of cases. Labor was frequently tedious, painful, and prolonged. Early rupture of membranes occurred in 37 per cent and hemorrhage was a disturbing factor in 31 per cent of the cases. Adherent placenta was noted eight times. Operative interference was necessary in 46.2 per cent, major surgical proaedures being required in 31.6 per cent and obstetrical operationa in 14.6 per cent. Necrosis of the myoma was found in 75.8 per cent or nine times as often as in non-pregnant women. The most important and dangeroud sequelae were infections. In the 82 caaes the fetal mortality was 28 per cent, while the gross operative fetal mortality was 33 per cent. The maternal mortality wits 3.66 per cent. Important advances have been made in the treatment of this complication by a better understanding of the obstetrical principles involved and the introduction THE FEMALE GENITAL TRACT 73 1 of major surgical procedures. The prognosis in the majority of instances has been bettered by a proper regard for the importance of necrosis and infection, the evaluation of the less serious complications, and the elimination of unnecessary obstetrical manipu- lations. The literature is reviewed, and there are nine illustrations. THEODORES. RAIFORD

Myomas of the Cervix as a Birth Complication, WLADIKA. Collummyome als Geburts- komplikation, Zentralbl. f. Gyniik. 57: 1900-1901, 1933. The author cites two instances in which the presence of a myoma of the cervix so hindered the course of labor that Cesarean section was necessary. In the first patient, a thirty-three-year-old primipara, a myoma the size of a man’s fist was found arising from the posterior lip of the cervix. In the other case, examination following delivery by section failed to show any pathology. It was not until one year later that the tumor reached a size large enough to be felt on manual examination. In his discussion of this report Benthin pointed out that the most frequent site of tumors causing obstruction is, as in the last case, deep in the musculature. THEODORES. RAIFORD

Report of a Case of Myomectomy for an Interstitial Fibroid Complicated by a Very Early Pregnancy, H. N. VINEBERO. Am. J. Obst. & Gynec. 25: 746-748, 1933. During an operation for appendicitis a white woman of twenty-eight was found to have an extensive myoma involving almost the entire anterior wall of the uterus. Nothing was done at the time but nine months later, following increasing lower back pain, operation was performed for the removal of the myoma. Enucleation was done, after which the uterine defect was repaired. Following this the patient ceased to menstruate and it wad shortly found that she wad pregnant. She progressed to term and eight months after the operation gave spontaneous birth to a macerated fetus. Seventeen months later she was delivered of a normal child. The author points out as features of interest in this case the presence of pregnancy, of not more than three weeks’ duration, at the time of operation, and the fact that this was not interrupted by the rather extensive surgical procedure. It was furthermore of interest that in spite of the operation, the uterine wall remained strong enough to withstand the strain of labor. There are no illustrations. THEODORES. RAIFORD

Submucous Myoma Complicating the Puerperium, 13. MANNAND H. LOWENBURG. Am. J. Obst. & Gynec. 25: 443-445, 1933. Although uterine fibroids not uncommonly complicate some phase of pregnancy, those appearing during the puerperium are comparatively rare, since in many instances the pathological lesion is associated with sterility or abortion. The case here cited is that of a thirty-two-year-old woman who, after having an apparently normal labor, continued to bleed for forty-eight hours in spite of the fact that the uterus was well contracted. Manual exploration revealed a globular mass on the anterior uterine wall. Following its removal all bleeding ceased and the patient made an uneventful recovery. Pathological examination showed typical fibromyoma. Operative removal is the treatment of choke in such cases in view of the possible complications of infection. There are two photomicrographs and a review of the literature, with a short bibliography. THEODORES. RAIFORD

True Sarcomatous Change in a Uterine Fibroid, 1’. D. YCOFIELD. Am. J. Obst. & Gynec. 25: 920-921, 1933. Scofield cites the case of a forty-five-year-old woman from whom a tumor, supposedly a fibrornyorna, was removed together with the entire uterus and the left tube and ovary. Pathological examination showed sarcomatous change in a leiomyoma. The patient died from pelvic sarcomatosis with widespread metastases one year later. Histological sections proved the identity of the two lesions. There are no illustrations. THEODORES. RAIFORD 732 ABSTRACTS

Cystic Fibroid Weighing Forty-seven Pounds and Simulating an Ovarian Cyst, J. P. GREENHILL.Am. J. Obst. & Gynec. 25: 440-443, 1933. A forty-seven-year-old negress complained of abdominal swelling present for seven years. When she was first seen there was marked abdominal distention and a large umbilical hernia was present. Pelvic examination revealed the uterus and cervix pulled upward. A diagnosis was made of multilocular ovarian cyst but on account of the poor condition of the patient operation could not be done. Death occurred twelve days after admission. At autopsy a huge mass was found attached to the uterus measuring 16 x 13 x 15 inches and weighing 47 pounds. Loops of intestine were firmly adherent. The mass contained four liters of foul smelling brownish gray fluid in a large central cavity. Histologically the tumor was a fibromyoma with central degeneration. There are two illustrations. THEODORES. RAIFORD

A Case of Cystic Degeneration of a Large Myoma Simulating Pregnancy, ELLISKEL- LERT. Arch. Path. 16: 596-597, 1933. Report of a leiomyoma of the uterua which had undergone cystic degeneration, with an illustration showing the symmetrical enlargement of the organ.

Case of Acute Fibroid Degeneration with Complete Torsion of the Uterus, A. J. FLEIS- CHER AND J. I. KUSHNER. Am. J. Obst. & Gynec. 26: 120, 1933. A forty-five-year-old white woman entered the hospital complaining of vaginal bleeding, lower abdominal pain, nausea, and fever. Examination showed a nodular mass in the lower abdomen, apparently apart from the uterus, which was thought to be a twisted ovarian cyst or twisted pedunculated fibroid. At operation the uterus was found twisted upon its long axis and attached to it was a large fibroid showing acute degenerative changes. A simple parovarian cyst was found in the left ovary. Follow- ing a supravaginal hysterectomy, the patient recovered. The author points out that torsion of the uterus, although rare, must be considered in differential diagnosis of pelvic disease. There are no illustrations. THEODORE8. RAIFORD

Effects of Uterine Conditions upon the Barium Meal; Fibroid8 Simulating Carcinoma Coli, A. C. HILL. Brit. M. J. 1: 664-665, 1934. A case is reported in which the roentgen picture following a barium meal was charac- terist,ic of carcinoma of the colon but which at operation was found to be due to a mass of uterine fibroid8 to which the colon was densely adherent. There was no evidence of malignant disease.

Rhabdomyoma of the Uterus, WARRENG. HARDINGAND FRANKLYND. HANKINS. Arch. Path. 16: 480-486, 1933. The authors review the various theories advanced to explain the pathogenesis of rhabdomyoma and comment on the rarity of the tumor. In 9,000 consecutive autopsies performed at the LOBAngeles General Hospital, only one case was discovered, and more than 30,000 surgical specimens examined in that hospital revealed no growth of this type. The authord patient was a three-year-old Negro girl with a vaginal discharge of two weeks’ duration. Exploratory laparotomy revealed a necrotic mass filling the anterior portion of the pelvis, lying between the bladder and the uterus and extending into the broad ligaments. A diagnosis of embryonal tumor was made and high-voltage roentgen therapy was given. Anuria developed after three weeks and death occurred several days later. At autopsy a firm nodular tumor was found apparently arising in the anterior wall of the uterus, below the uterovesical fold, The bladder was located on the upper anterior surface of the tumor and both ureters were compressed as they passed through the surrounding tumor tissue. Both broad ligaments were involved and the entire uterus was replaced by neoplastic tissue. The greater portion of the tumor consisted of well differentiated tissue resembling adult striated muscle fibers with multiple nuolei and cross striat,ions. Other areas especially at the advancing margin of the growth resembled THE FEMALE GENITAL TRACT 733 fibrosarcoma but were less dense and more edematous. The blood vessel walls were not formed by the tumor cells. Three photomicrographs illustrate the report. A bibliography is appended.

Endometrial Hyperplasia, Review of Experimental Work, L. E. BURCHAND J. C. BURCH. Am. J. Obst. & Gynec. 25: 826-833, 1933. The authors find that the histological changes in endometrial hyperplasia are brought about by the action of the oestrin hormone, and that bleeding may occur in any stage of these changes. Of importance in diagnosis is the determination of pathological bleeding from an interval type of endometrium. This is best done by taking tissue for biopsy near the onset of bleeding. Removal of ovarian tissue apparently predisposes to hyperplasia in later years. The changes in the oestrin content result from altered anterior pituitary secretion. An inter-relationship exists between the ovary and the hypophysis, and any disturbance in this cycle results in a disturbance of the oestrin hormone and subsequent bleeding. Urinary hebin (more commonly known as prolan) has been found of value in the treatment of these cases, acting probably through anterior lobe stimulation. THEODORES. RAIFORD

Endometrial Hyperplasia and Its Relation to Endocrine Dysfunction, J. E. KING. Am. J. Obst. & Gynec. 26: 582-587, 1933. In this more or less theoretical discussion the author considers the relation of endocrine dysfunction to endometrial hyperplasia. He discusses also the clinical and therapeutic features. From the clinical standpoint, endometrial hyperplasia accounts for about 50 per cent of abnormal bleeding between puberty and the menopause, but the degree of hyperplasia is not always related to the amount or character of bleeding, a8 Novak has even found it associated with amenorrhea. Clinical diagnosis is therefore largely a matter of presumption, Since the explanation of the actual bleeding is still a matter of controversy, treatment is not standardized. There are undoubtedly some cases in which radical surgery is justified. In a much greater number, however, curettage and radium may effect total relief. There remains a group in which treatment is largely experimental: Irradiation of the pituitary gland has been accredited with some success and the same can be said for injections of the luteinizing hormone of the anterior lobe. Frequent failures, however, have been observed in cases which should theoretically respond to such treatment. THEODORES. RAIFORD

Effects of Extracts of the Urine of Pregnant Women on the Hyperplastic Endometrium, H. H. KLINQLERAND J. C. BURCH. Am. J. Obst. & Gynec. 26: 17-21, 1933. The authors report a case of uterine hemorrhage which was treated successfully by the use of prolan, a substance extracted from the urine of pregnant women. The patient, a thirty-eight-year-old married nullipara, had complained of irregular menstruation for four years and profuse bleeding for seven weeks. Biopsy of the endometrium showed a marked proliferation of glands and dense stroma. Intramuscular injections of prolan were given and within a few days the bleeding had diminished, Within two weeks it had stopped completely. Except for two short recurrences, which were controlled by further injections of the extract, the patient has had no more bleeding. Biopsies taken during the course of treatment showed that the effect was brought about without causing progestational proliferation, although it is possible that this may occur at some future time. There are four photomicrographs and one diagram 'illustrating the effect of prolan upon the bleeding. THEODORES. RAIFORD

Clinical and Experimental Study of Endometriosis, E. ALLEN. Am. J. Obst. & Gynec. 26: 803-814, 1933. Allen bases his study upon 112 cases in which operation and subsequent microscopic study demonstrated the definite presence of ectopic endometrial tissue. TWO- thirds of these patients were between the ages of thirty and fifty. Relative sterility was present in sixty per cent of the group. Among the more common symptomatic 734 ABSTRACTS manifestations were menorrhagia, metrorrhagia, backache, dysmenorrhea, and lower abdominal pain. The lesions were distributed as follows: Ovaries...... 80 Abdominal...... 3 Utenls...... 53 Bowel...... 4 Peritoneum...... 16 Bladder...... 8 Rectovaginal septuni...... 37 Appendix...... 1 Some of the patients were found to have lesions in more than one location. Fibroniyo- mas were coincident in 46 patients. The primary aim of treatment was to preserve function while removing the disease, The various procedures employed included hysterectomy in 82 cases, resection of tlie growth in 41, unilateral oophorectomy in 36, and bilateral oophorectomy in 13, ovarian function being preserved in all but the latter group. Following conservative treatment, eight of the women gave birth to nine babies. The majority of the surgical procedures can be carried out through the vagina with low operative mortality. Only one patient died following operation. The author regards this condition as a manifestation of cellular metaplasia secondary to glandular dysfunction. Coincident fibromyomas and fibroadenomas are additional results of altered cell stimulation. It is possible that the difference between benign and malignant tumors is merely a qualitative or quantitative measure of hormonal activity. Although glandular extracts have in certain instances produced beneficial results, their prolonged use in large quantities may be a dangerous procedure. There are 14 illustrations and a short bibliography. THEODORE8. RAIFORD

Important Surgical Localizations of Keterotopic Endometriosis, A. F~~RSTAND F. ~KORPIL. Chirurgisch wichtige Lokalisationen der heterotopen Endometriosen, Arch. f. klin. Chir. 179: 485-501, 1934. Of especial surgical importance are endometriosis of the umbilicus, the inguinal ligament, abdominal scars, intestine, and urinary bladder. Abstracted case reports of three patients with endometriosis of the umbilicus, inguinal ligament, and rectum respectively are given. In considering the treatment of these lesions the author concludes that radical surgical excision should be restricted to those tumors which, bec'ause of their size or position, are causing symptoms. Smaller lesions which are symptomlees may be satisfactorily treated by irradiation of the ovaries. The article is well illustrated by photomiorographs. BENJAMINR. SHORE

EndomeMoses of Lymph Nodes, G. H. HANSMANNAND J. R. SCHENKEN.Am. J. Obst. & Gynec. 25: 572-576, 1933. In two patients dying of unrelated causes, the authors were able to demonstrate the presence of endometrial tissua in peri-uterine lymph glands at autopsy. One of these died from a chorionepithelioma and the other from gunshot wounds. In addition the second patient was found to have a chronic pelvic inflammatory condition. Two theories are offered for the occurrence of heterotopic endometrium, first peritoneal inflammation followed by metamorphosis into pseudo-endometrial tissue, and second, peritoneal implantation of viable endometrial cells by menstrual blood which has guined access to the peritoneum through the oviducts. In both of the cases here cited the circumstances were favorable to the implantation theory as suggested by Sampson. Furthermore, the distribution of the endometrial tissue in the peripheral sinus and the germinal centers of the nodes lends added evidence to the theory of absorption from the peritoneal cavity rather than a metamorphosis. That the tissue had grown within the nodes was evidenced by the fact that it had become an integral part of their structure. There are four illustrations and a brief bibliography. THEODORES. RAIFORD Endometriosis of the Bladder, H. KOHLER. uber Blasenendometriosen, Zentralbl. f. Gyngk. 57: 1762-1776, 1933. Among the less frequent sites of endometriosis is the urinary bladder. To the 23 cases previously reported in the literature Kohler adds four of his own. In two the THE FEMAJIE GENITAL TRACT 735

tumor was removed at operation with complete alleviation of symptoms. Radio- therapy was used in another, with marked improvement. The fourth case is still under observation, and treatment has not been instituted. In the majority of cases the diagnosis can be made from the clinical history. There is usually a history of hematuria during the menstrual periods, a symptom which is almost pathognomonic. Confirmatory evidence is obtained by cystoscopic examination and biopsy. Other bladder tumors to be differentiated on cystoscopy are varices, angiomatous tumors, and occasionally papillomata. A great deal of information can be gained by cystoscopic observation of the tumor during the menstrual cycle. During menstruation the tumor becomes larger, edema of the mucosa is apparent, and the color is darker. According to R. Meyer, three general types are recognized, adenomyosis vesicalis interna, adenomyosis vesicalis peritonealis, and adenomyosis peritonealis and vesicalis propria. The characteristics of these types are discussed in detail. Radio- therapy is indicated in women near the menopause and in younger patients when the tumor is located near or involves the ureters. Operation suffices if the tumor is ap- proachable without endangering vital structures and is to be preferred in young women where x-ray therapy would produce castration. There are 12 illustrations and a short bibliography. THEODORES. RAIFORD Two Examples of Endometriosis, Both of the Rare External Circumscribed Form, H. FUCHS.Demonstrationen zu dem aktuellen Gebiet der Endometriose, die beide dem sclteneren Formenkreise der Externa angehoren, Zentralbl. f. Gynak. 57: 1386-1387, 1933. Fuchs reports two unusual examples of endometriosis. In the first the tumor was located in the retrocervical region, wa8 the size of a walnut, and complicated a two months pregnancy. As the mass increased rapidly in size, pregnancy was terminated and the lesion treated by 2400 milligram hours of radium placed within the cervix. It rapidly decreased in size until it appeared only as a small scar. The second tumor was found at exploratory laparotomy in the mesosalpinx and was excised. This tumor, as well as uterine scrapings taken before operation, showed the typical histological-picture of endometriosis. The fate of the patient is not mentioned. The origin and nature of the condition and the relation between it and the endometrial hyperplasia of the menstrual cycle and an ovarian hormonal influence are discussed. THEODORES. RAIFORD Tumors of the Round Ligament, C. F. HORINE. Am. J. Obst. & Gynec. 25: 446-448, 1933. A fifty-four-year-old married woman homplained of lower abdominal swelling. Examination showed masses in either inguinal region about the size of an English walnut. The diagnosis of bilateral hydrocele of the canal of Nuck was made and the region8 were explored. The diagnosis was confirmed on the right side and the sac removed. On the left side an encapsulated, fatty tumor arising from the extraperitoneal portion of the round ligament was found and excised. The exact origin of the mass could not be ascertained. The ultimate outcome is not mentioned. Reviewing the literature, the author found 36 reported cases of round ligament tumors, in practically all of which the diagnosis was made by histological section. This unusual group of lesions is classified as follows: Adenomyoma, 4 cases Fibromyxoleiomyoma, 1 case Cystic fibroma, 1 case Leiomyoangioma, 1 case Cystic lymphangioma, 1 case Lipoma, 1 case Dermoid cyst, 2 cases Lymph gland in ligament, 1 case Fibroma, 6 cases Osseous tumor, 1 case Fibroleiomyoma, 1 case Sarcoma, 2 cases Fibrosarcoma, 2 cases Tuberculous cyst, 1 case Fibromyoma, 5 cases Varicosities, 2 cases Fibromyosarcoma, 1 case Wolff’s tumor, 2 cases Fibromyxoma, 1 case There is one gross photograph and an excellent summary of the literature. Un- fortunately, however, the author omits a photomicrograph or even an histologica1 description of his own case. THEODORES. RAIBORD 736 ABSTRACTS

Large Tumor of the Sacro-uterine Ligament, R. VORBTER.Selten grosser Tumor des Lig, sacro-uterinum, Zentralbl. f. Gyntik. 57: 2129-2130, 1933. Vorster reports the successful removal of a tumor from the right saoro-uterine ligament in a forty-one-year-old woman. It measured 8 x 5 cm. and was diagnosed fibroma with a few myomatous elements. There are no illustrations. THEODORES. RAIFORD

Clinical Study of 403 Cases of Adenocarcinoma of the Ovary; Papillary Cystadenoma, Carcinomatous Cystadenoma, and Solid Adenocarcinoma of the Ovary, L. M. MOINCH. Am. J. Obst. & Gynec. 26: 22-28, 1933. On the basis of 403 malignant adenomas of the ovary operated upon at the Mayo Clinic from 1917 to 1927 inclusive, the author reviews the clinical characteristics of the disease. Three pathological types were recognized: papillary cystadenomas, of which there were 254; carcinomatous cystadenomas, 72; solid adenocarcinomas, 77. The incidence was greatest in the fifth and sixth decades of life. No typical symptoms characterized the tumors; apparently menstrual changes as a result of ovarian dysfunction were the most common finding. These consisted in recent change in periodicity in 24.52 per cent, profuse flow in 28.94 per cent, and scanty flow in 24.12 per cent. Metror- rhagia was present in 19.6 per cent of the cases, and pain was an outstanding fertture in about half. One-fourth of the tumors were bilateral, and this feature seemed to influence prognosis, since 44.11 per cent of these patients died from metastases or recurrences as compared with 17.96 per cent of those in whom the growth was unilateral. Furthermore the length of life after operation was longer in the latter group. This characteristic did not, however, affect the operative mortality. Death from recurrence of intracystic malignancy occurred in only 11.53 per cent of the patients as compared with 28.2 per cent of those harboring extracystic malignancy. The mortality was high (53.84 per cent) among cases of ruptured paeudo-mucinous cysts with peritoneal involvement. Over half of the patients with ascites were dead at the time of this study. As might be expected, deaths from recurrence were much higher among the patients who bad apparent or actual metastases at the time of operation. This is purely a statistical study and contributes nothing more than the figures on a large number of cases. There are no illustrations. THEODORE8. RAIFORI)

Tubular Adenoma (Arrhenoblastoma) of the Ovary, F. SPIELMAN.Am. J. Obst. & Gynec. 25: 517-521, 1933. A twenty-six-year-old female complained of amenorrhea and marked hirsuties and was treated with sex hormone preparation;, which produced a temporary effect only. She was then lost track of but returned to the hospital three years later with broncho- pneumonia, from which she succumbed. Autopsy revealed a tumor of the right ovary 9 x 6 x 4 cm. in size, composed of grayish fibrous tissue. Microscopically the tumor was composed of epithelial cells arranged in an irregular, tubular and cord-like fashion supported by dense fibrous stroma. The normal ovarian tissue was completely destroyed. This lesion, the author believes, belongs to the group of tubular adenomas first described by Langhans (in Kocher : Die Krankheiten der mannlichen Geschlechtsorgane, Billroth and Luecke’s Deutsche Chirurgie, Lief. 50b, 1887, p. 422 ff.) as occurring in tho male gonad, but since being found in the female as well. In the female only 24 such tumors of the ovary have thus far been described. R. Meyer (Studien I. Path. d. Ent- wicklung. 2: 03, 1914) proposed the name “ arrhenoblastoma ” not only in view of the masculiniration exhibited but also because it suggests an origin from a male-directed element. This author has reported 17 cases, 8 of which were personally observed. The relation of the tumor to the masculinization is definitely proved by the regression of these characteristics following its removal. Histologically these tumors are divided into three morphologioal classes by Meyer : those having a regular and typical tubular arrangement, those exhibiting an irregular tubular structure comprised mainly of solid cords of cells, and a group combining the two forms. The studies of this author also demonstrate almost conclusively that the tumor develops from the rete ovarii and the medullary tubules. Although masculiniration is the most striking clinical manifestation, other lesions may produce the same THE FEMALE GENITAL TRACT 737 effects and are to be differentiated in preoperative diagnosis. There are four illustrations and a comprehensive review of the literature. THEODORES. RAIFORD

Granulosa Cell Tumors of the Ovary, M. SCHULZE.Am. J. Obst. & Gynec. 26: 627- 641, 1933. Among 43 ovarian carcinomad Schulze was able to identify four granulosa-cell tumors of the ovary. On the basis of thesc and two obtained from other sources, the subject is reviewed from the clinical and pathological standpoints. That these tumors have been previously regarded as extremely rare is probably accounted for by the fact that they are frequently mistaken for medullary carcinomas, sarcomas, or endotheliomas by those unacquainted with their pathological characteristics. Three histologic forms are recognized, the folliculoid, the cylindromatoid, and the sarcomatoid, all of which may be found in the same growth. The clinical diagnosis is based upon changes in the sex life of the patient and is easier before the age of puberty. Since there is definite evidence that ovarian follicular hormone is elaborated, thorough investigation from the endocrine standpoint is of the greatest value in preoperative diagnosie. The tumors are usually unilateral and comparatively benign, and removal effects a cure in the majority of cases. Treatment is primarily surgical. In young women in whom the diagnosis is fairly certain conservatism is preferable. In patients past the menopause complete removal is the safer procedure., If the lesion is so far advanced as to preclude complete removal, postoperative irradiation contributes to a good prognosis. The six cases are described in detail and illustrated by nine photomicrographs. There is also a short bibliography. The article contributes to the number of cases on record but adds little to our histogenetic conception of the tumor. THEODORES. RAIFORD

Granulosa Cell Hyperplasia of the Ovary, J. I. BREWERAND H. 0. JONES. Am. J. Obst. & Gynec. 25: 505-511, 1933. Although the majority of authors have considered granulosa-cell hyperplasia of the ovary as a true neoplastic growth, Brewer and Jones present evidence based upon three cases, which they report, that such a lesion is a pure hyperplasia and not a tumor. Two of the specimens were found in ovarian cysts and the third coincidental to uterine fibromas. Since all three patients complained of uterine bleeding though two had passed the menopause, the lesions were thought to produce a hormone. Follicles and ova were present in all three ovaries in association with the hyperplasia. It is believed that the origin in all probability is in embryonic rests of germinal epithelium. Since the growths are benign, surgical removal brings about a cure. There are four illustrations and a bihliography. THEODORES. RAIFORD

Granulosa-cell Ovarian Tumors as a Cause of Precocious Puberty, with a Report of Three Cases, E. NOVAK. Am. J. Obst. & Gynec. 26: 505-519, 1933. Certain endocrine disorders may be associated with marked disturbance in sexual development, but the manner in which this phenomenon is brought about remains in the majority of instances unknown. Tumors of the pineal gland, especially teratomaa, have been found coincident with premature developmental changes, though not usually involving the sex apparatus. Neoplasms of the adrenal glands and the so-called arrhenoblastomas arising from the medulla of the ovary apparently cause pronounced sexual changes, as is evidenced by the masculinization syndrome in adult females. In young children the presence of suprarenal tumors is usually associated with somatic overgrowth and hypertrophy of the external genitalia. It is, however, with ovarian tumors that female sex precocity is usually linked. Elterich (Pennsylvania M. J. 34: 629, 1931) found 21 of 25 reported cases attributed to ovarian tumors, a number of which were described as of an unusual type. Novak believes that a large proportion of these would, on further study, prove to belong to the granulosa-cell tumors, a type described by Robert Meyer (see, for example, Arch. f. Gynak. 145: 2, 1931. Abst. in Am. J. Cancer 15: 3007, 1931) arising from granulosa- cell rests. These tumors are most common in elderly females, in whom they cause 738 ABSTRACTS periodic bleeding, enlargement of the uterus, and hyperplasia of the mucosa. Only a few cases have been observed in children, and in only three has an etiologic relation of the tumor and precocious puberty been clearly established. These were described by Blau (Arch. f. Gynak. 128: 506, 1926), Meyer (see Habbe: Zentralbl. f. Gynak. 55: 1088, 1931), and Pahl (Arch. f. Gynak. 147: 736, 1931). To these the author adds three more which he was able to study. All three patients were under seven years of age and exhibited the uniform clinical features of bleeding, acceleration of skeletal growth, mammary hypertrophy, the appearance of axillary and pubic hair, hypertrophy of the external sex organs, and an abdominal mass. At operation a tumor of the ovary was removed in each case, which varied in sise from a tangerine to that of a child’s head. Following operation two of the patients showed complete regression of abnormal manifestations. The fate of the third is not mentioned. Two of the tumors contained cystic cavities. Microscopically all possessed the more or less characteristic diffuse proliferrt- tion of round or oval cells with large nuclei. Granulosa-cell tumors, with few exceptions, may be regarded as relatively benign and are usually cured by operation. A few instances have been recorded in which pregnancy occurred at an extremely early age, the youngest being six years. These tumors must, according to Novak, be placed in the group of endocrine tumors which can no longer he regarded as purely parasitic growths, but rather as abnormal physiological organs with the capacity for functional activity. There are nine illustrations and a comprehensive bibliography. * THEODORES. RAIFORD

Report of Two Cases of Granulosa-Cell Tumors of the Ovary, S. A. WOLFE AND S. KAMINESTER.Am. J. Obst. & Gynec. 26: 434-441, 1933. The authors report the removal of two granulosa-cell tumors. The first occurred in a twenty-seven-year-old married woman who complained of continuous vaginal bleeding for three months before admission. Palpation of the abdomen revealed a mass the sire of a seven months’ pregnancy. At operation a multilocular cyst replacing the right ovary, measuring 28 cm. in diameter, was removed. The patient made an uneventful recovery and was symptom-free six months later. The second patient, a woman of forty-eight, complained primarily of pain in the lower abdomen. Examination revertled an apparently normal uterus displaced posteriorly by a semi-solid tumor the sire of a grapefruit. At operation the mass was seen td occupy the location of the left ovary. A pan-hysterectomy was done and the patient recovered without complication. Five years later she was perfectly well. Pathological examination of both specimens showed them to conform to the histological type of granulosa-cell tumors. Reviewing the subject, the authors conclude that tumors of this type are usually benign and may be either cystic or solid. The gross and microscopic morphology and the symptomatology are determined by the degree of differentiation. Thus fully ma- ture tumor cells reproduce the pattern of the follicle, and the secretions form cysts of varying size. The retention of physiological function produces mammary and uterine hypertrophy with vaginal bleeding due to excessive follicular hormone. Immature cells forming rapidly growing tumors tend to be solid and exhibit histologically a medullary pattern. Follicles are not reproduced; secretion is lacking; hormonal influence is not marked and its clinical manifestations may therefore be absent. This is an enlightening discussion of the subject though somewhat theoretical. There are eight illustrations, and a short bibliography. THEODORES. RAIFORD

Report of Two Cases of Granulosal Cell Tumors of the Ovary, E. F. DAILY. Am. J. Obst. & Gynec. 26: 733-736, 1933. Daily reports two cases of granulosa-cell tumors of the ovary. The first patient, aged thirty-eight years, suffered no gynecological symptoms. The finding of a tumor of tha left ovary on routine pelvic examination was followed by a pan-hysterectomy, with removal of an ovarian tumor measuring 7 cm. in diameter. Histologically this was a typical granulosa-cell tumor. The uterus and right ovary were normal. The second patient was a twenty-seven-year-old woman who complained of amenorrhea for the THE FEMALE GENITAL TRACT 739 past sixteen months. The left ovary was found at operation to be replaced by a tumor 7 cm. in diameter which was histologically a granulosa-cell tumor. Both patients recovered satisfactorily but no mention is made of their ultimate fate. There are six illustrations. THEODORES. RAIFORD

Rupture of Primary, Unilateral, Solid Epithelioma of the Ovary in a Thirteen-Year-Old Girl, E. POL~HETTI.Rottura di epitelioma unilaterale, solido, primitivo dell’ovaio destro, torto sul peduncolo in tredicenne, Ann. ital. d. chir. 12: 915-932, 1933. The author discusses especially the group of solid ovarian tumors. He reports in detail the case of a girl of thirteen who had sudden severe colic with enlargement of the abdomen. The peritoneal cavity was found filled with blood due to the rupture of a pedunculated ovarian tumor which had twisted on its pedicle. Histologically the tumor was composed of two cell types, one epithelial the other mesenchymal. Many mitoses were present. The patient remained well two and one half years after the operation and has never menstruated. Illustrative photographs and photomicrographs are given. JEANNETTEMUNRO

Squamous-cell Carcinoma in a Dermoid Cyst of the Ovary, J. L. MILLOTAND D. HINARD.Kyste dermoide de I’ovaire avec Bpithdioma spino-cellulaire, Ann. d’anat. path. 11: 632-634, 1934. A woman of forty-six years noticed that her periods had stopped and complained of some vague pains in the back. Then she had a sudden uterine hemorrhage, which caused her to consult a physician. The Aschheim-Zondek reaction was positive. The hemorrhage8 continued and four months after her first symptoms she was found to have a large fixed mass in the posterior culdesac, which was also palpable in the abdomen. A dermoid cyst was found containing teeth and hair. Microscopic examination showed a squamous-cell epithelioma. One of the fallopian tubes was invaded by extension. A photomicrograph shows the tumor. [The most recent survey of these ovarian squamous carcinomata is that of Masson and Ochsenhirt: Surg., Gynec. & Obst. 48: 702, 1929. Some sixty examples have been published in the literature.]

Solid Teratoma of Ovary, R. W. BINKLEY. California & West Med. 40: 42-45, 1934. A thirteen-year-old girl complained of pain in the right lower quadrant of the abdomen, which had occurred at intervals for the past two months. Examination disclosed a tumor mass which occupied most of the pelvis and extended upward to the level of the umbilicus. At operation a solid tumor of the ovary was removed. Histologic study showed teratoma. Eight months later recurrent masses filled the pelvis and lower abdomen. Two courses of roentgen therapy caused temporary regression of the masses, but death occurred three years after the discovery of the original tumor. At autopsy generalized metastases were found throughout the abdomen, thorax, and mediastinum. Excellent photographs of the gross and microscopic appearance of the tumor illustrate the report. There is no bibliography. WILLIAMJ. HOFFMAN

Report of a Case of Ovarian Fibroid, 13. I3. ALYOBROOK.Am, J. Obst. & Gynec. 25: 609-610, 1933. Case report of a fibroleioniyonia in the ovary. There is one illustration. THEODORES. RAIFORD

Ovarian Thyroid Tissue Tumor, R. 0. LYDAY. Am. J. Surg. 25: 89-90, 1934. Lyday reports the case of a nineteen-year-old girl from whom a large multilocular cyst of the left ovary weighing eight and a half pounds was removed. Histologic study of the solid portion near the base of the pedicle showed thyroid tissue which differed little from a colloid adenoma. There were no lymphoid nodules. Evidence of hyperfunction of the thyroid tissue in this case was lacking. The article is illustrated with two photomicrographs. BENJAMINR. SHORBI 740 ABSTRACTS

Unusually Large Ovarian Cyst, G. GIBSON. Am. J. Obst. & Gynec. 26: 264-267, 1933. The advances of modern surgery are responsible for the infreque6cy of the huge ovarian.cysts so common half a century ago. Gibson reports a case in which, 011 an erroneous diagnosis of hepatic cirrhosis, 15 gallons of pseudomucinous fluid were removed by paracentesis. After this the tumor could be palpated and the correct diagnosis made. At operation two more gallons of fluid were withdrawn and the uterus with its adnexa was removed. The upper part of the body was emaciated and the lower half edematous. The patient recovered without complications. There are three illustrations. THEODORES. RAIFORD

Error in Diagnosis of an Ovarian Cyst, P. BRAULT. Hyste de l’ovaire praevia. , Curieuse erreur de diagnostic, Gyn6cologie 32: 94-95, 1933. Also in Bull. SOC.d’obst. et de gyn6c. 21: 668-669, 1932. A report of an ovarian cyst containing bone in the form of a portion of a superior maxilla including two teeth and other dental fragments. The curved portion of the maxilla simulated an abnormal projection of the sacral promontory and led to the diagnosis of contracted pelvis. Ovarian Cyst Subsequent to Hysterectomy, J. P. TOURNEUX.Kyste ovarien chez une hystkrectomiske, Toulouse mCd. 34: 746, 1933. A woman whose uterus and ovaries had been removed three years previously had a large mass in the right lower quadrant which proved to be a typical multilocular ovarian cyst. It may have arisen in a supernumerary ovary or have been due to inclusion of a small portion of para-ovarian tissue in the scar of peritonealization following the first operation. WILLIAMJ. HOFFMAN Two Cases of Rupture of Ovarian Cyst Diagnosed as Perforation of the Appendix, W. CARPENTIER.Deux ruptures de kystes ovariens prises pour des perforations appendiculaires, Bull. et m6m. SOC.d. chirurgiens de Paris 25: 15-17, 1933. Two cases are reported of ruptured hemorrhagic ovarian cysts, with symptoms simulating acute appendicitis with perforation.

Report of a Case of Ruptured Ovarian Cyst in the Newborn, 8. M. DoDEK. Am. ,J. Obst. & Gynec. 25: 914-917, 1933. Following difficult manual delivery at full term, a child died apparently from respiratory failure. The abdomen, which was markedly distended, apparently from ascites, was opened and a tumor mass discovered arising from the pelvis, compressing the other abdominal organs, and almost completely filling the oavity. This was found on further examination to be an ovarian cyst which had ruptured, discharging about 300 C.C. of bloody fluid into the peritoneal cavity. There is a brief discussion of the literature on tumors of the ovary in the young. Three illustrations are included. THEODORES. RAIFORD Tumor of the Pelvis Resembling Embryonal Cell Carcinoma of the Ovary, M. T. GOLDSTINE.Am. J. Obst. & Gynec. 26: 908-009, 1933. Goldstine reports the case of a twenty-three-year-old female in whom there was found at laparotomy a soft tumor the size of a hen’s egg, attached to the posterior wall of the bladder and infiltrating the tissues of the right side of the pelvis. No attempt was made to remove it and the patient died four days later from gastric hemorrhage. Post- mortem examination showed the tumor attached to but not invading the bladder, right tube and ovary, and right ilium. A second tumor was found in the upper abdomen. The histologic diagnosis was embryonal-cell carcinoma in both, and the pelvic tumor was regarded as primary. There are no illustrations. THEODORES. RAIFORD

Some Tumors of the Ovary, L. 0. BAUMGARDNER.Am. J. Surg. 25: 82-88, 1934. This is a general discussion of the clinical and pathologic oharacteristics of various ovarian tumors and cysts. Abstracted histories of 7 illustrative cases are included. There are two photomicrographs. BENJAMINR. SHORE THE FEMALE GENITAL TRACT 74 1

Primary Carcinoma of the Oviduct, J. A. MCGLINNAND W. B. HARER.Am. J. Obst. & Gynec. 26. 354-360, 1933. The authors report a primary carcinoma of the right fallopian tube in a thirty-seven- year-old married woman in whom the only positive physical finding was an elongated sausage-like mass in the region of the right tube. At operation this appeared to be a primary malignant growth with metastases in the broad ligament and peritoneum in the region of the appendix. The tube only was removed as a palliative measure. Patho- logical examination showed the tumor to be a carcinoma. Following recovery the patient received intensive radiotherapy and when seen four months later was in perfect health. Reviewing the literature, the authors were able to collect about 240 cases of this entity, which previous to 1886 was not recognized. Three histological forms have been described : papillary, papillary-alveolar, and alveolar carcinomas. Most authors regard chronic inflammation as a conducive factor if not etiological. The greatest incidence has been found in the fifth decade, although a case is reported in a woman of twenty- nine. There are no characteristic symptoms or pathognomonic findings and the condition is usually mistaken for an inflammatory mass. Metastases take place by conti- nuity, contiguity, or implantation, and are recorded in more than 30 per cent of the reported cases. Due to the paucity of symptoms most of the tumors are diagnosed late in their course, and the prognosis is therefore poor. Recurrence is common and takes place early. Only three five-year cures have been reported. Treatment consists of prompt and radical surgical removal with as much of the pelvic structures as possible, including the uterus and pelvic glands, followed by radiation with x-rays. There are two illustrations. THEODORES. RAIFORD

Adenocarcinoma of the Fallopian Tube, DE HARVEN.AdCnocarcinome de la trompe utbrine, Scalpel 86: 1487-1494, 1933. Also in J. de chir. et ann. Soc.. belge de chir. 32-30: 126-131, 1933. A woman sixty-one years of age, who had passed the menopause at forty-seven, complained of an excessive discharge, then vaginal bleeding, and some lumbar pain. Curettage showed no evidence of cancer. Moderate bleeding continued for four months, then ceased. Eight months later there was a palpable mass in the left lateral culdesac. The left tube and ovary were removed and histological examination showed the mass in the tube to be an adenocarcinoma. Radium treatment was instituted, followed by deep roentgen-ray therapy, and a year after operation the patient was free from signs of recurrence. There are three illustrations, including a photomicrograph.

Radium Therapy of Carcinomas of the Vagina and Vulva, S. BOXER. Zur Radium- therapie des Scheiden- und Vulvakarzinoms, Zentralbl. f. Gynak. 57: 899-900, 1933. Boxer reports two cases of genital carcinoma, one of the labia and the other involving the posterior vaginal wall. Both were squamous-cell in type. Radium was used, and at the time of the report, five months after treatment, both patients were symptom- free and able to continue their normal activity. Discussing this paper, Fabricius cited two cases in which he had previously removed the cervix for carcinoma. Vaginal recurrences appeared in both. ' Excision followed by irradiation had not been followed by further recurrence. THEODORES. RAIFORD Case of Carcinoma of the Vagina in a Five-Months-Old Child, HEROLD. Ein Fall von Scheidenkarzinom bei 5 Monate altem Kind, Zentralbl. f. Gynkk. 57: 1610-1612, 1933. Herold reports the rare and interesting case of a malignant growth in the vagina of a child five months old. The birth and development of the child were normal. Noting vaginal bleeding, the mother brought the child to the clinic. On examination there was found a bleeding growth partially filling the vagina; on rectal examination this seemed to be approximately the size of a walnut. Two small pieces removed by a curette proved to be mixed-cell carcinoma. In view of the age of the child, operative removal of the tumor was considered inexpedient, and radium was therefore used (1200 milligram hou'rs). 742 ABSTRACTS

The response of the growth was rapid and in a short time it had entirely disappeared. When last seen, about nine months after this, there was no evidence of a recurrence and the child appeared to be in excellent health. There are no illustrations. THEODORES. RAIFORD Sarcoma of the Vagina in a Two-Year-Old Child, v. MIKULICZ-RADECKI.Scheiden- sarkom bei einem 2 jahrigen Kinde, Zentralbl. f. Gynilk. 57: 1902-1963, 1933. The author reports the unusual case of a vaginal sarcoma in a child of two yearn. On examination a mass the size of a cherry was seen arising from the left vaginal wall and obstructing the vaginal orifice. It was of firm consistency, bleeding and discharging a purulent secretion, and infiltrating the surrounding wall. Since operation was deemed inexpedient, radium was applied locally and the inguinal nodes were excised. The histological diagnosis was angiosarcoma or endothelioma. Sufficient time has not elapsed to determine the ultimate result, but it is pointed out that the prognosis of such lesions has been uniformly bad. There are no illustrations. THEODORES. RAIFORD Primary Chorionepithelioma of the Vagina, MALLET-GUY.Chorio-BpithBliome primitif du vagin, Lyon mBd. 152: 35-37, 1933. A woman twenty-six years of age complained of continuous bleeding from the vagina for two months after a normal labor. The uterus was normal in siee, and curettage showed no evidence of placental remains. There were, however, two small tumors on the anterior wall of the vagina. These were exoised, and biopsy showed chorionepithelioma. Fifteen days later there was a recurrence at the operative site and a total hysterectomy was done, with resection of the anterior vaginal wall to the meatus. No lesion of the uterus was discoverable in spite of careful histological examination of many sections. Sixteen months after this the patient again complained of slight vaginal bleeding and a small dark nodule resembling those first observed was discovered in the vaginal wall at the meatus. An extensive resection was done, including the urethra. Histological examination showed the tumor to be an angioma, with no elements of chorionepithelioma. Since biopsy seemed unwise in this case, the author believes that an Aschheim-Zondek test would have indicated that the second tumor was not a recurrent chorionepithelioma and would have prevented the extensive mutilating operation. Multiple Epithelial Cysts of the Vaginal Mucosa, 0. WALLIS. Multiple Epithelcysten dor Scheidenschleimhaut, Zentralbl. f. Gynak. 57: 1415-1420, 1933. Solitary cysts of the vaginal walls are not particularly rare, but multiplicity is seldom encountered, so rarely in fact that only a few cases have been reported in the literature. Wallis cites a case in a thirty-nine-year-old woman in which the left wall was involved by an irregular, reddish induration. The involved portion of the mucosa was excised; the patient made an uneventful recovery, and has remained well. Microscopically the excised tissue was found to consist of several epithelial-lined cysts which in certain sections could be seen to communicate directly with the vaginal mucosa. An interesting feature of the picture was hyperplasia of the sebaceous glands. The literature is reviewed briefly, and the various theories of origin are discussed. In some instances the cyst formation can apparently be explained on the basis of heterotopic cervical glandular proliferation. In others the cystic formation was believed to be secondary to an inflammatory process, originating from the vaginal mucosa, as in the author’s case. In the latter, however, the inflammatory nature cannot be determined. Thertr are five good illustrations. THEODORES. RAIFORD Wandering Fibroid in the Rectovaginal Septum, J. P. LONG,JR. Am. J. Obst. st Gynec. 26: 463-464, 1933. At operation for the removal of the uterus from an unmarried woman of thirty-four for fibroids, a mass 4 inches in diameter was found in the rectovaginal septum. This wag shelled out easily, and no attachment could be made out. There were ten tumors on the surface of the uterus. These were fibromyomas, as was the separate tumor. THE FEMALE QENITAL TRACT 743

None showed the presence of degenerative changes. The author was unable to find any reported case of fibroid with complete separation of the pedicle without a parasitic attachment, in which no degenerative changes had taken place. There are no illustrations. THEODORES. RAIFORD

Carcinoma of Bartholin’s Gland. Report of Two Cases, H. STRAUSS. J. A. M. A. 101 : 2116-2117, 1933. Strauss reports the histories of two patients with carcinomas of Bartholin’s gland. The first was a sixty-one-year-old woman with a tumor measuring 8 x 4 x 3 cm., involving the right labium majus and almost occluding the introitus. The lesion was widely excised and postoperative interstitial radium radiation of 1200 millicurie hours was given. This was followed by high-voltage x-ray treatments to the pelvis and perineum. One year after operation a small erosion was observed in the operative scar and further radiation was given. Since then the scar has remained healed. The second patient was a forty-eight-year-old woman with a large tumor in the right labium majus, of two years’ duration. The overlying skin was adherent, red, and partly ulcerated. Radical vulvectomy and bilateral dissection of the inguinal lymph nodes was done. Histologic examination of the tumor showed it to be a squamous-cell epithelioma. The inguinal lymph nodes showed no tumor. This patient has remained well for three months. The article is without illustrations. BENJAMINR. SHORE

Primary Carcinoma of Bartholin’s Gland, W. B. HARER. Am. J. Obst. & Gynec. 25: 714-718, 1933. Of the various malignant tumors of the female genital tract, primary carcinoma of Bartholin’s gland is perhaps the most rare. Harer was able to find less than 30 cases in the literature [though of course many more examples have been observed]. A case is reported in a married woman of thirty-three, whose symptoms were swelling of the labia and profuse irritating vaginal discharge. At operation the tumor was shelled out easily but since the malignant character was not recognized until determined microscopically, a radical operation was not done. Two months later, a course of radium was given and six months after operation the patient was well. There are two illustrations. THEODORE8. RAIFORD

Report of a Case of Fibroma of the Vulva with Sarcomatous Degeneration, H. M. NELSON. Am. J. Obst. & Gynec. 25: 594-597, 1933. A seventy-three-year-old white female had been under observation for thirty-two years, during which time numerous nodules of varying size were removed from the left labium majus and diagnosed histologically “ fibroma molle.” Three years ago a small nodule appeared in the right labium majus. In three months the growth had involved the entire labium and had ulcerated. The mass was removed at operation together with a portion of the vaginal wall, the rectal sphincter, and the perineum. There was no recurrence on this side, but one year later another tumor the size of a bean was removed from the angle of an old incision on the left side. Pathological examination of these two lesions Hhowed definite sarcoma of the spindle-cell type. There are four illustrations. THEODORES. RAIFORD

Voluminous Elastic Tissue Tumor of the Right Labium Minus Simulating a Cyst, J. ROUSSET. Volumineuse tumeur de la petite lBvre droite A tissu Blastique simulant un kyste, BuIl. SOC.franp. d. dermat. et syph. 41: 177-178, 1934. A twenty-eight-year-old woman had a large soft tumor of the right labium minus, which had undergone steady painless enlargement since its appearance eighteen months prior to her admission to hospital. Transillumination showed a clear tumor mass similar in appearance to a cyst. It was excised and proved to be a benign tumor of elastic connective tissue. WILLIAMJ. HOFFMAN 744 ABSTRAOTS

THE GENITO-URINARY TRACT Roentgen Diagnosis in Papilloma of the Renal Pelvis, G. JANSSON. Rbtgendiagnosen vid njurblckenpapillom, Finska 1iik.-siillsk. handl. 75: 111 1-1 118, 1933. Papilloma of the renal pelvis is relatively rare as compared to papilloma of the renal parenchyma. In 1925 Stricker collected 175 cases (Arch. f. klin. Chir. 140: 663, 1926), including papillary carcinoma. Recently Nommel reported a case (Arch. f. klin. Chir. 171: 123, 1932. Abst. in Am. J. Cancer 17: 268, 1933). There is no doubt that the scarcity of reported cases is to some degree due to the difficulties encountered in diagnosis. The clinical symptoms of papilloma resemble those of tumors of the renal parenchyma, and include hematuria, pain, and swelling. The hematuria is painless, of sudden onset without demonstrable cause, and of equally sudden cessation. Pain occurs usually only in cases with retention or inversion of the renal parenchyma. Repeated hemorrhage without the presence of a palpable tumor should arouse suspicion of papilloma of the renal pelvis. So also should disappearance of palpable resistance following abundant hematuria or cessation of hemorrhage with development of a tumor. A definite diagnosis is possible only in those rare cases in which villi from the papilloma are found in the urine, or in which there is simultaneous papilloma of the bladder or about the ureteral openings of the bleeding kidney. In spite of its local benignity, the growth often gives rise to implantation metastases in the urethra and bladder. Up to 1924 only four cases of papilloma of the renal pelvis had been subjected to pyelography. Two cases observed by the author and examined by this method are described in detail. The roentgenologic findings vary with the size and structure of the tumor, as well as with the nature of its bed. Sometimes the growth consists of small racemose formations, in other cases these are much larger, filling the entire pelvis. If the papilloma is small, with a broad base, the picture will show filling defects protruding into the lumen of the pelvis. In such cases differentiation from a parenohymal tumor invading the lumen is difficult. The latter, however, should also be palpable, and should show other characteristic pyelographic changes, as elongation, compression, or closure of the calices. A different pyelogram is seen in cases of diffuse papillomatosis in which the renal pelvis is filled with cauliflower-like masses. Here there are multiple filling defects and irregular areas of rarefaction, some of which may have a sharply defined rounded shape. If the entire pelvis is filled with papillomatous masses, the pyelogrephic picture will be governed by the amount of contrast medium that can force its way between the villi. A similar pyelogram might result from coagulated blood in the renal pelvis. This second example of pyelogram, showing multiple, partly irregular, partly rounded intra- pelvic defects, is considered as typical of renal pelvic papilloma by French writers. A third type is illustrated in the author’s second cue. A single pedunculated polypoid tumor arises from the pelvis on a narrow pedicle, causing a spindle-shaped, rounded defect with a web-like internal structure definitely pointing to a nodular surface.

Carcinoma and Tuberculosis Occurring in the Same Kidney. Review of the Literature and Case Report, E. RUPEL. J. Urol. 31: 57-68, 1934. For nearly a hundred years since Rokitansky called attention to the infrequency of the combination, the discussion of an apparent antagonism between cancer and tuberculosis has gone on. All the evidence negatives the idea that there is any antagonism. Rupel summarizes some of the statements pro and con and adds a case of his own in which the two diseases were present in the same kidney. W. S. MACCOMB

Embryoma.of the Kidney in an Infant with Osseous Metastases. Report of a Case, E. R. MINTZ. J. Urol. 31: 79-86, 1934. A white male child of three years had a tumefaction in the left leg, of one week’s duration. Pain without localized tenderness had been present for four weeks. A firm, smooth, movable mass was found in the left upper quadrant. An x-ray of the abdomen revealed a large soft tissue tumor mass on the left; the left hip showed a mottled decreased THE GENITO-URINARY TRACT 745 density from the epiphysis of the femur to the region just below the lesser trochanter. There was no evidence of new bone formation or soft tissue tumor. Intravenous pyelography revealed marked deformity of the left renal pelvis and calices. The left ureter was not visualized. A left nephrectomy was performed. Grossly the major portion of the kidney was replaced by an irregular, lobulated, soft tumor mass, 7 cm. in diameter. The microscopic diagnosis was embryoma, rapidly growing and highly malignant. The tumor had extended beyond the kidney capsule. While in the hospital the child received two suberythema doses of roentgen radiation to the left femur, but the pain in the hip was not relieved. A short time later it suddenly became worse, the patient was readmitted, and a diagnosis of pathological fracture was made. A soft tissue tumor mass was felt in the region of the proximal portion of the femur. Soon after this, about five weeks before death, a tumor appeared in the right mandible, and two weeks later two tumors were observed on the forehead. All these metastatic masses grew rapidly, those of the forehead each attaining the size of a lemon, that of the mandible nearly filling the buccal cavity with a fungating necrotic tumor mass. Death occurred five months after operation. Autopsy revealed metastases from the kidney tumor in the left hip, femur, spine, retroperitoneal lymph nodes, liver, lungs, skull, right jaw, and left humerus, W. S. MACCOMB

Intrarenal Cystic Myxolipoma, D. R. MELENAND I. GASPAR. J. Urol. 31 : 69-77, 1934. It is stated that of the two types of lipoma associated with the kidney, perirenal and intrarenal, the latter is much less frequently found, although neither is common. Von Wahlendorf (Arch. f. klin. Chir. 115: 751, 1921), in an analysis of 153 cases of retroperitoneal lipomata, found 46 per cent to be pure lipomata and 54 per cent mixed tumors. Of the latter, 40 per cent were fibrolipomata, myolipomata, and fibromyxolipomata, and 14 per cent had the morphology of sarcoma. The most common sites for the occurrence of combined myxomata and lipomata are the retroperitoneal region, the hilus of the left kidney, and the spermatic cord. Tumors of this group not infrequently undergo cystic degeneration, thereby making their diagnosis difficult. Mucinous changes may also occur. Intrarenal lipomata are neoplastic and must be differentiated from replace- ment fatty changes in the kidney, which represent a degenerative process taking place in the presence of long-standing low-grade infection. The authors have reported an instance of intrarenal cystic myxolipoma in a fifty- eight-year-old white male, who was admitted to the hospital complaining of a left renal colic of forty-eight hours’ duration. Frequency of urination was present with hematuria. There was some tenderness on bimanual pressure in the left kidney region, but no other positive findings. A retrograde pyelogram revealed a filling defect involving the middle calyx and the left renal pelvis. The calices were misshapen, widely dilated, and blunted. A left nephrectomy was performed. The gross specimen weighed 325 grams. The hilus was wider than usual, due to the presence of a fatty and gelatinous tumor mass, in the central part of which were several cystic areas. The largest cyst measured 3.5 cm. in diameter. There were many minute cystic areas in the periphery of the tumor infiltrating the neighboring kidney tissue. The structure of the tumor was of two types, myxoma and lipoma. The cystic cavities were due to hydropic degeneration of the stellate tumor cells. The cysts were encircled by degenerated tumor tissue and were, therefore, actually pseudo-cysts. The histologic diagnosis was locally malignant degenerated intrarenal cystic myxolipoma. The patient was alive and free of symptoms three years after operation. W. S. MACCOMB

Pelvic Leukoplakia in a Horseshoe Kidney, L. R. REYNOLDSAND N. J. HOWARD.J. Urol. 30: 653-664, 1933. Kutaman’s study (Arch. Surg. 19: 871, 1929) would indicate that leukoplakia of the urinary tract is the response of the normal epithelium of the urinary tract to long con- 746 ABSTRACTS tinued irritation. The work of Wolbach and Howe (J. Exper. Med. 42: 753, 1025; Arch. Path. 5: 239, 1928) points towards a vitamine-A deficiency causing keratinization and rnetaplasia of epithelium in many parts of the body. The metaplasia of the normal existing epithelium to the stratified keratinired type is usually accompanied but not preceded by infection. It is stated that in experimental animals the renal lesion per- sists long after restoration of health by the addition of vitamine A to the diet. The authors report a case in which leukoplakia of the kidney pelvis was found in a horseshoe kidney surgically removed. Grossly the renal pelvis was lined by a grayish, wrinkled mucosa. The same type of epithelium lined the calices and the ureter for a distance of 3.5 cm., at which point there was a stricture, the lumen being reduced to a diameter of 5 mm. Microscopically this tissue was composed of cornified, stratified, squamous epithelium. The cylindrical-cell layer rested upon a poorly defined basement membrane. The prickle-cell layer varied in thickness. The corium was very thick and extremely vascular. Capillaries and venous sinusoids lay closely packed in infiltrated edematous tissue just beneath the squamous epithelium. The authors believe that chronic pyelitis incident to ureteral stricture and hydro- nephrosis was more probably the inciting cause than avitaminosis. W. S. MACCOMB

Treatment of Malignant Tumors of the Bladder, AND& AND GRANDINEAU.Traitement des tumeurs malignes de la vessie, Gas. d. h8p. 105: 1613-1616, 1932. Also in J. d’urol. 34: 416-430, 1932; Paris m6d. 22: 396-401, 1932; Presse m6d. 40: 1576-1578, 1932; Bruxelles m6d. 13: 335-337, 1933; Rev. g6n. d. clin. et th6rap. 47: 432, 1933. The authors review the various methods of treatment employed for malignant tumors of the bladder and come to the following conclusions. For villous or pedunculated tumors, electrocoagulation by the cystoscopic route may be used if the tumor is single and not very large. For large or multiple tumors of this type, operation by the suprapubic route is indicated and, if possible, excision of the tumor by the electric knife, followed by cauterization of the base either by the thermocautery or the high-frequency current. For sessile or infiltrating tumors, operation by the suprapubic route is alwsys indicated. If the tumor is high in the bladder, so that it can be resected without interference with the ureters, partial resection of the bladder is the treatment of choice, for although this operation gives a higher immediate mortality than the use of the high- frequency current or radium, it also gives a greater chance for permanent cure. In tumors of the base of the bladder, resection is rarely indicated unless the tumor is small and involves only one side, so that it can be resected, with reimplantation of one ureter or the removal of the corresponding kidney. With large tumors of the base, the authors believe that total cystectomy is rarely indicated; in such cases they prefer destruction of the tumor by electrocoagulation, with coagulation of the base, followed, if the tumor is not too large, by implantation of radium needles. Recent statistics indicate that the immediate operative mortality in tumors of tht: bladder has decreased about 50 per cent as compared with twenty years ago; but the end-results have been but little improved. The physical measures employed in recent years, therefore, do not appear to give a higher percentage of cures than surgery alone. The author stresses the importance of cystoscopic examination in all patients showing painless hematuria or slight symptoms of cystitis that do not yield promptly to treatment.

Papillary Carcinoma of the Bladder and a Horseshoe Kidney Occurring Simultaneously in the Same Individual, EARLFLOYD AND J. L. PITTMAN.J. Urol. 30: 239-243, 1933. The authors report the coincidence of papillary carcinoma of the bladder and a horseshoe kidney in a man of eighty-one years. Four similar cases are cited from the literature. A photograph of the autopsy specimen and a photomicrograph of the bladder tumor illustrate the report. THE NERVOUS SYSTEM 747

Radical Operation for Carcinoma of the Penis, W. E. LEIOHTON.West. J. Surg. 42: 226-231, 1934. Of the author’s series of 79 cases of carcinoma of the penis, 70 per cent occurred in the Hixth to the ninth decades. Twenty-five patients refused treatment or for some other reason were not treated, while 54 received treatment. Of this latter group, 6 were treated by x-rays or radium, and of these, 4 died, one was untraced, and one was still alive. Forty patients were operated upon. Five of these were untraced; 15 died, 5 postoperatively, 3 of recurrence, and 7 of causes other than cancer from one month to eighteen years after operation; 20 were living at the time of the report from six months to twenty- seven years after treatment. W. S. MACCOMB

Tumors of the Testis, M. L. H. FREEMAN.Delaware State M. J. 6: 38, 1934. Prolan A is excreted in large amounts in the urine of patients with tumors of the embryonal teratoid or chorionic groups, but is absent in other types. The author reports four proved cases of the embryonal and teratoid types and one spermatocytoma. All the patients were treated by simple orchidectomy. Three died within a year. The patient with spermatocytoma is at present receiving high-voltage x-ray therapy. W. S. MACCOMB

Gonad-Stimulating Hormone in Urine of a Patient with a Teratoma Testis, C. F. FLUHMANNAND P. E. HOFFMANN.Proc. SOC.Exper. Bid. & Med. 31: 1013-1014, 1934. The urine from a man thirty-four years of age, with metastases from a teratoma testis, contained a gonad-stimulating hormone whose characteristics were identical with those of the substance that occurs in the urine of pregnant women. WM.H. WOQLOM

THE NERVOUS SYSTEM

Ophthalmic Aspects of Cerebral Syndromes, J. N. EVANKArch. Ophth. 10: 241-253, 1933. Intracranial lesions are of two types, expansile and non-expansile, and as such give rise to two major classes of symptoms. In some instances the expansile effect may be so slow as to permit adaptation, and a nun-expansile lesion may thus be simulated. An intracranid tumor may produce local damage and, in addition, by virtue of increasing intracranial pressure, may indirectly cause considerable damage to more remote intracranial structures. Local damage from the point of view of the ophthalmologist is recognized primarily through studies of the visual fields. Changes in the fields of vision may be demonstrated in some cases long before atrophy of the optic nerves occure.. There are many theories as to the mechanism of increased intracranial pressure. It may arise directly through interference with the blood and lymph flow or indirectly through increase of the tissue mass within the cranial cavity. With venous stasis, the fluid elements of the blood drop out and edema of the nerve head occurs, ae. indicated by swelling. The swelling is perhaps limited to the nerve head because of the prepapillary membrane, the arrangement of the neuroglia cells, and the loose tissue within the physio- logic cup. There is considerable cvidence to support the idea that swelling of the nerve head originates from the vessels of the circle of Zinn and the associated perivascular spaces, perhaps also the perineurial spaces. Atrophy and swelling may be present in the same nerve, one condition being superimposed upon the other. During recent years there have been many valuable papers presenting groups of symptoms which may now be arranged as syndromes. A common tumor involving the anterior optic pnthwa!l in the midline is the meningioma. When the lesion is situated far forward and in the midline, the characteristic signs are primary atrophy of the optic nerve on the same side, swelling of the optic nerve on the opposite side, and anosmia. Involvement of the adjacent structures, as the damage progresses, causes mental symptoms and sometimes a facial paralysis. Anterior optic pathway involvement elsewhere than it&the midline is represented by 748 ABSTRAUTS such tumors as thoRe arising from the sheaths of the optic nerve. These tumors cause a painless unilateral exophthalmos and primary atrophy of the optic nerve of the same side. As the growth extends backward, it may cause roentgenographic distortion of the optic foramen and swelling of the optic nerve. The chiasmal sijndrome of Harvey Cuehing is an important one. On account of the peculiarly vulnerable position of the optic chiasm and its relation to a wide variety of structures, as well as the fact that its fiber bundles are functionally well defined, it is perhaps the most productive part of the visual pathway in supplying looalieing evidence. With the chiasmal syndrome it is pomible to predicate the pathological nature of the tumor as well as its site. Primary optic atrophy and bitemporal hemianopsia with a normal sellar outline in the roentgenograms, in an adult, are usually due to a suprasellar meningioma. Suprasellar adenomas cause primary optic atrophy, bitemporal defects in the visual fields, progressive enlargement of the sella turcica, as revealed roentgenographically, and mild symptoms of pituitary dysfunction. Craniopharyngiomaa [tumors of Rathke’s pouch] result in primary optic atrophy, bitemporal hemianopsia, a normal sellaf outline, and frequently suprasellar calcification. These tumors are found in childhood and are generally associated with pituitary dysfunction. Dieturbancee of the circle of Willie, particularly aneurysm, may give rise to a chiasmal syndrome. GliomrL of the optic chiasm results in primary optic atrophy, bitemporal hemianopsia, and a normal appearing sella turcica. The tumor occurs in childhood, is of rapid evolution and the patient may show evidence of general neurofibromatosis. Chordoma, a rare tumor, may produce the chiasmal syndrome. Pituitary adenomas commonly produce the chiasmal syndrome. The more common adenoma is composed of chromophobe elements, and thereis usually present a pituitary deprivation syndrome. Less commonly the adenoma is composed of chromophile cells and causes hyperpituitary changes (acromegaly or gigantism). Both types of adenoma cause primary optic atrophy, bitemporal hemianopsia, and alterations in the roentgenographic appearance of the sella turcica. [The chromophobe type produces the most constant enlargement of the sella turcica. 1 The region overlying the aqueduct of Sylvius is known as the quadrigeminal plate. Tumors arising in this location are prone not only to produce internal hydrocephalus but also to give rise to disturbances of the extrinsic and intrinsic ocular muscles. Temporal lobe tumors often damage nerve fibers going to the temporal half of one retina and the nasal half of the retina of the opposite eye (homonymous hemianopsia). Other signs of a temporal lobe tumor include aphasia, a dreamy state, and increased intracranial pressure. Parietal lobe tumors usually provoke characteristic motor signs, an homonymous hemianopsia, paresthesias, anesthesias, defects of muscle sense, and paralysis or spasticity of the face, arm, or leg. Convulsive seizures and increased intracranial pressure are not uncommon. Lesions of the occipital lobe result in an homonymous defect in the visual fields, increased intracranial pressure, visual hallucinations, and direct or indirect disturbances of the adjacent region of visual memory. EDWINM. DEERY

Certain Intracranial Tumours: Their Variability and Multiplicity, W. E. CARNEQIE DICKSON.Brit. M. J. 2: 1016-1018, 1933. The author discusses first what he terms the polyvalency of tumor cells in individual tumors, especially of the meningioma group, describing in some detail two specimens which showed notable variations of structure. . The Recond part of the paper is concerned with multiple neoplastic syndromes. A case of von Recklinghausen’s disease (to be reported in full elsewhere) is described in which there was present an extraordinary variety of tumors including two large acoustic nerve tumors, innumerable smaller tumors on practically all the cranial nerves, about 50 meningiomata or meningiomatous plaques, a large number of small tumors on practically all the posterior nerve roots of the spinal cord, and numerous intramedullary tumor8 of various types. Two cases of single cerebellopontine angle tumors are briefly presented for comparison with this case. The author also describes a case in a woman of forty-two in whom post-mortem ex- THE NERVOUS SYSTEM 749 amination revealed a cavernous angioma of the right parietal lobe associated with multiple tumors at the base of the skull and in the walls of the pharynx, uvula, nose, etc., some of these containing numerous cavernous vascular spaces. In the roof of the pharynx and in the body of the sphenoid bone, etc., there was a very extensive myxo- chondro-adenoma (resembling the congenital mixed tumor of the parotid), but in this case arising, apparently, from mucous glands; and there were also numerous adenoma- like masses of these in the uvula and neighboring structures. The pituitary fossa showed curious developmental abnormalities. Lindau considered that angiomatosis of the central nervous system may be placed in the same group as tuberous sclerosis, and that the multiple tumors which he described were due to a loss of balance in the development of the mesoderm, commencing as early as the third month of embryonic life. The author believes that a similar relation may exist between the multiple tumor syndromes of tuberous sclerosis and von Reckling- hausen’s disease and also that there is a relation between the case of multiple tumors which he described and Lindau’s disease, thus bringing some of the “ mixed cartilaginous and glandular tumors ” into the Name picture, and associating them with certain of the hemangioblastic tumors of the central nervous system and elsewhere. He suggests that there is a distinct refation hetween all of these various groups of cases or types characterized by the presence of multiple tumors involving especially the central nervous system. Sixteen photomicrographs illustrate this paper.

Trauma and Gliomas, R. BENEKE. Noch einmal “ Trauma und Gliom ” Monatschr. f. Unfallh. 40: 505-510, 1933. Beneke continues the discussion with Fischer-Wasels concerning the relation of trauma to the formation of gliomas (see absts. in Am. J. Cancer 19: 219 and 870, 1933). Beneke maintains that there must be some exciting cause for the development of tumors, and that this iR easily ascribed to trauma so far as gliomas are concerned. Little of importance is added to what has already been written on this subject. BENJAMINR. SHORN

Cytology of Gliomas with an Alveolar Structure, C. M. RAMIREZ-CORRIAAND M. CORACHAN.Contribution h 1’Ctude de la cytologie de certains gliomes alvholaires, Ann. d’anat. path. 11: 1G9-172, 1931. This is a brief note describing the occurrence of a tumor in the left frontal lobe, considered by Del Rio Hortega as a glioblastoma with senile cells. Some of them were annular, others curved like question marks, and some resembled pellets to which a long filiform process was attached. There are four photomicrographs. WILLiAM J. HOFFMAN

Cystic Glioma of the Right Frontal Lobe Without Localizing Signs, ROCHON-DUVIQ- NEAUD, SCHAEFFER,DE MARTEL,AND GUILLAUME.Gliome frontal kystique droit sans aucum signe de localisation focale. Intervention opkratoire, GuBrison, Rev. neurol. 1 : 682-685, 1933. A woman of twenty-one years, previously in good health, complained of failing vision, severe headaches, and attacks of vomiting. Within the past few months a definite change in personality had been noted. Except for bilateral papilledema and possibly slight weakness of the right facial muscles, the neurological examination was negative. While under observation, the patient displayed increasing drowsiness and polyuria. Routine tests and x-rays of the Ykull yielded no further information. Because of the paucity of neurological signs, ventriculography was done, and the films demonstrated a filling defect in the right frontal horn. An exact localization having thus been established, a craniotomy was performed. In the prefrontal region an exploring needle encountered yellow cystic fluid beneath the cortex. Through a cortical incision a voluminous cyst was entered and a mural tumor nodule found and removed. Histologically the tissue proved to be that of a protoplasmic astrocytoma. The patient made a satisfactory postoperative recovery. 750 ABSTRACT8

This patient had no definite signs of a right frontal tumor. The absence of pyramidal tract signs, ataxia, and mental symptoms attest to the ability of certain parts of the brain to tolerate a large lesion and still function. EDWINM. DEERY

Left Frontal Lobe Glioma Removed in One Piece, M. DAVIDAND C. RAMIREZ-CORRIA. Gliome frontal gauche enlev6 d’une seule pihe, Rev. neurol. 1: 710-715, 1933. A woman of thirty-eight years suffered from headaches, at first localized to the occipital region, later in the frontal region. Marked personality and mental changes occurred, and later, inoontinence of urine. Upon neurological examination there were found bilateral papilledema, a tremor of both hands, loss of memory for recent evente, and euphoria. The right pupil was larger than the left; visual fields, as far as could be determined, were normal. The examination was otherwise negative. X-rays of the skull gave no further information. The lesion could not be localized clinically, but ventriculography disclosed the presence of a left frontal lobe tumor. A craniotomy followed and a needle inserted into the substance of the brain in the frontal lobe en- countmeredyellow cystic fluid which coagulated upon standing. Through a cortical incision a firm tumor mass was found and finally removed intact. The patient made a satisfactory recovery, with complete restoration of her mental faculties. Histologic examination of the growth showed it to be a moderately cellular tumor composed chiefly of small round to oval cells. With the silver carbonate method of Del Rio Hortega the cells proved to be oligodendrocytes (Type 111 of Hortega). EDWINM. DEERY Large Right Frontal Lobe Tumor; Cystic Fibrillary Astrocytoma; No Focal Signs. Localization Established by Ventriculography, TH. DE MARTEL,A. MONBRUN,AND J. GUILLAUME.Volumineuse tumeur frontale droite (astrocytome fibrillaire kystique). Absence de syndrome focal. Localisation Btablie par la ventriculographie. OpBration, Gubrison, Rev. neurol. 1 : 726-730, 1933. The author reports a further instance of complete removal of the most favorable of the gliomas. A girl of thirteen years complained of headaches, followed within about a month by progressive failure of vision. Upon examination she showed bilateral papilledema, considerable loss of vision in the left eye, and normal visual fields. The general physical condition and mentality were normal. Aside from some nystagmus the cranial nerveR were normal. Sensation and motor functions of the body and limbs were normal. There were no signs of ataxia or incoordination. X-rays of the skull, aside from showing evidence of increased intracranial pressure, were not helpful. Because of insufficient localizing signs, ventriculography was carried out, and established the presence of a large right frontal lobe lesion. At craniotomy no surface tumor was found, but an exploratory puncture of the brain yielded yellow cystic fluid. Through a cortical incision a cystic cavity with a fairly large mural tumor nodule was found. The tumor was removed, and the patient made an entirely satisfactory recovery. The fibrillary astrocytoma, when it occurs in children, does not often arise in the frontal lobes. Its usual site at this age is in the cerebellum. In general this benign type of glioma gives a long clinical history, often years. In the present case the symptoms were of less than three months’ duration. The location within the relatively silent right frontal lobe explains the paucity of neurological signs. EDWINM. DEERP

Hemangioblastoma of the Cerebellum, P. PUECH,J. A. CHAVANY,F. RAPPOPORT,AND C. RAMIREZ.A propos d’un cas d’hbmangioblastome du cervelet, Rev. neurol. 1: 709-710, 1933. A man of twenty years complained of increasingly severe headaches, occasional attacks of vomiting, unsteady gait, and suboccipital discomfort, of some three months’ duration. Upon examination he was found to have bilateral papilledema, hypotonia, a fixed attitude of the head, incoordination, and ataxia. Otherwise he was essentially normal (no nystagmus, no sixth nerve palsy, and no eighth nerve changes). X-rays of THE NERVOUS SYSTEM 75 1 the skull revealed evidence of increased intracranial pressure. A clinical diagnosis of tumor of the fourth ventricle was tentatively made, but for greater certainty ventriculography was carried out. The films revealed a symmetrical internal hydrocephalus and a suspicious shadow in the region of the fourth ventricle. At operation a large cystic and solid tumor involving the cerebellar vermis was found and subtotal removal carried out. Histologically the growth proved to be an hemangioblastoma of mixed cellular and capillary structure. The patient made a satisfactory recovery and at the time of the report was free from symptoms. Hemangioblastoma of the cerebellum is not infrequently a surgically favorable lesion. In spite of the fact that the neoplasm probably takes its origin from a congenital rest or malformation] the symptoms often do not occur until adult life, and may be of sudden onset. EDWINM. DEERY

Pure Chiasmat Syndrome. Melanosarcoma of the Floor of the Third Ventricle Arising from the Hypophysis, F. ROUSSEAU.Syndrome chiasmatique pur. MBlano-sarcome du plancher du 3 ventricule propage l’hypophyse, Bull. SOC.d’opht. de Paris, pp. 556-564, October 1933. A youth of nineteen years complained of failing vision and frequent fronto-temporal headaches during the past year, and more recently of attacks of vomiting. Upon neurological examination he showed decreased visual acuity, primary optic atrophy, and bitemporal hemianopsia. He was drowsy, and the deep reflexes were symmetrical. Roentgenograms of the skull revealed marked enlargement of the sella turcica. Oc- casional athetoid-like movements of the extremities were observed. Clinically the condition was considered a pituitary adenoma, and roentgen therapy rather than surgery was considered indicated. Under the former type of treatment, however, the symptoms became worse and rapid loss of vision occurred, but because of a severe anemia due to hemophilia, surgical intervention was not undertaken. Autopsy revealed an infiltrating tumor involving the floor of the third ventricle, tuber cinereum, optic chiasm, hypophysis, and the under surface of the frontal lobe. Microscopically the growth proved to be a melanotic sarcoma. The author includes a discussion of the neurological signs and symptoms. The anatomical findings are but briefly dealt with, and proof of the tumor arising within the hypophysis is lacking. [It is not unlikely that a large melanosarcoma invading this region actually took origin from melanin cells of the pis, secondarily invading the cerebral parenchyma.] EDWINM. DEERY

Medulloblastoma of the Fourth Ventricle with Metastasis to the Tuber; No Infundibular Syndrome, J. DE BUSSCHERAND A. DEWULF. MBdulloblastome du quatrihme ventricule avec mCtastase tuberienne sans syndrome infundibulaire, J. belge de neurol. et de psychiat. 33: 605-624, 1933. A girl thirteen years of age complained of suboccipital pain and discomfort, soon followed by headaches. Four years previously she had received a severe blow on the occipital region I)irt had been free from complaints in the interval. Vomiting, buzzing sounds in the ears, double vision, and vertigo appeared. A fixed attitude of the head was gradually assumed and viRion began to fail. Neurological examination revealed, in addition to the abovc findings, ataxia, incoordination, and papilledema. The general physical examination was not unusual and there was nothing found clinically to suggest pathology of the infundibular region (sexual dystrophy, obesity, diabetes insipidus, somnolence, narcolepsy, or abnormalities of temperature). Operation followed by autopsy revealed a large soft neoplasm involving the fourth ventricle. Histologically the growth proved to be a medulloblastoma. A metastatic tumor of similar nature was found involving the region of the tuber cinereum. [The medulloblastoma is the only glioma that is apt to spread to other parts of the brain or spinal cord.] EDWINM. DEERY 752 ABSTRACTS

Diagnosis of Pituitary Tumors, VON DER HUTTEN. Beitrag zur Diagnose von Hypophy- sentumoren, Ztschr. f. Laryng., Rhin., Otol. 24: 96-97, 1933. Report of an unusual case, in which the patient was considered to have an hypophyseal adenoma but had something quite different. A woman of thirty years had sufferedfrom headaches and progressive failure of vision for some three months. Upon examination there were found a considerable reduction in visual acuity, atrophy of the optic nerve heads, and roentgenographic evidence of bone erosion in the region of the sella turcica. While the signs and symptoms were not absolutely characteristic of pituitary adenoma, this diagnosis was considered the most likely. The sella turcica was therefore approached by the nasal route, and what seemed to be a cystic lesion was encountered. This procedure and two further attempts within the next six monthR failed to improve vision. Autopsy revealed, not a pituitary adenoma, but some 25 endot,heliomas (meningeal tumors) arising from the basal dura. Some were very large and had greatly compressed and distorted the overlying brain substance. In addition there were marked internal hydrocephalus and a circumscribed meningitis in the region of the sella turcica. EDWINM. DEERY Chromophobe Adenoma of the Hypophysis : Unusual Clinical and Histological Aspects. TH. ALAJOUANINE,TH. DE MARTEL,J. GUILLAUME,AND R. THURIL. Adhome chromophobe de l’hypophyse avec particularitbs cliniques et histologiques, Rev. nourol. 1: 730-735, 1933. A woman of thirty-five years suddenly experienced generalized headaches and failing vision. General physical examination revealed marked obesity limited to the trunk, which was said to have developed during the past five years. Menstrual periods were perfectly normal, there was no alteration in the metabolic rate, and fluid intake and output were not unusual. There were found a considerable reduction in visual acuity, a bitemporal hernianopsia, and primary optic atrophy. Roentgenograms showed a marked enlargement of the sella turcica. The obesity, the chiasmal syndrome, and the alterations of the sella led to a clinical diagnosis of hypophysesl adenoma. The unaltered metabolic rate and the normal menstrual history made it unlikely that the adenoma would be of the chromophobic type. Clinically the patient showed no suspicion of acromegaly, either. The patient was operated upon by way of the right frontal region, and a large anteriorly placed adenoma was found beneath the optic chiasm. Incision into the mass disclosed a softened central portion containing some 10 C.C. of brownish fluid. Follow- ing removal of the tumor the patient did well, headaches disappeared, and vision improved. Diabetes insipidw, which had not been present before operation, appeared after the surgical intervention. Histologic examination of the tumor tissue revealed a characteristic chromophobe type of hypophyseal adenoma. The absence of menstrual disorders in patients with chromophobe adenoma of the pituitary is very unusual. A study of 53 females in a series of 107 cases of this type of tumor (Dott and Bailey: Brit. J. Surg. 13: 314, 1925) revealed irregularity or cessation of menstruation in all but two between the ages of twenty and forty. The relatively sudden onset and progression of visual complaints in the present case are also unusual. They are probably to be explained by the hemorrhagic necrosis that had occurred within the tumor. Such an occurrence is sometimes met with in cases receiving roentgen therapy, but this woman had never been so treated. The development of diabetes insipidus only after surgical intervention provides further evidence that this abnormality depends more upon nervous than upon glandular factors. EDWINM. DEERY btraspinal Tumors, Diagnosis by Lipiodol. L. BERIEL. Tumeurs intrarachidiennes; 1’6peuve du lipiodol et sa valeur diagnostique, J. d. m6d. de Lyon 14: 717-723, 1933. The writer points out that the diagnosis of tumor of the spinal cord requires a careful neurological examination, spinal fluid manometric studies, and sometimes the introduction of lipiodol into the spinal subarachnoid space. The latter procedure often gives valuable additional information. Some clinicians consider it indispensable in the diagnosis of spinal cord tumors. Others, including the writer, reserve it for cases in which a11 exact localization cannot be arrived at otherwise. THE NERVOUS SYSTEM 753

The simplest method of using lipiodol is by injection into the spinal subarachnoid space above the probable site of the tumor. As it descends within the space, it is arrested at the site of the neoplasm and, being a radio-opaque substance, presents a characteristic appearance in the roentgenogram. Descending lipiodol thus used is injected at the atlanto-occipital space (cisternal puncture). Ascending lipiodol may sometimes be used to advantage, the lipiodol being injected into the subarachnoid space at the level of the last lumbar vertebra. The suboccipital injection of lipiodol is a safe diagnostic procedure and may be used without danger to the patient. Because spinal cord tumors obstruct the subarachnoid space at that point, lipiodol will generally be arrested at this point of obstruction. The degenerative and inflammatory diseases of the spinal cord may at times produce signs or symptoms much like spinal cord tumor, but in such cases lipiodol injected into the subarachnoid space meets with no obstruction. The method, therefore, is of value in differentiating tumor from other conditions. From the appearance of the lipiodol shadow in the roentgenogram it is sometimes possible to gain certain specific information about the type of tumor present. A firm, discrete, round, or oval tumor often produces a characteristic concave outline in the mass of lipiodol. Infiltrating growths and Pott’s disease result in more irregular lipiodol shadows. Fully as important as the probable nature of the spinal cord lesion is its exact location, Ordinarily the motor and sensory signs and symptoms found clinically serve to localize the growth. In some cases, however, the clinical findings are not sufficiently clear to warrant laminectomy at any one level. It is in such instances that lipiodol is of the greatest value, as it provides an exact localization. Lipiodol may be injected and observed roentgenographically during its actual descent or ascent to advantage in some cases. Diagrammatic sketches of the lipiodol shadow in various conditions are included. [Lipiodol as a means of localizing spinal cord tumor is used more freely in Europe than in this country. The writer of the above paper is enthusiastic about its use, but insists however that it be employed only when other diagnostic measures have been exhausted. Most spinal cord tumors can be localized without the use of lipiodol. In the occasional case where other methods fail, lipiodol often, but not always, solves the problem of localization.] EDWINM. DEERY

Multiple Hemangioblastomas of the Spinal Cord with Syringomyelia, ABNERWOLF AND SIGMUNDL. WILENS. Am. J. Path. 10: 545-567, 1934. A fuller report of a case previously abstracted in this journal (21: 240, 1934). It includes a review of the literature on hemangioblastomas of the cord and twelve illustrations, of which eight are photomicrographs.

Central Neurinoma Associated with Tuberous Sclerosis, J. H. GLOB,US. Neurinome central associ6 une sclerose tubheuse, Rev. neurol. 2: 1-23, 1933. The term neurinoma was first introduced by Veropay for a group of tumors generally designated neurofibromas. He insisted upon their neuro-ectodermal origin, stating that they arose from sheath of Schwann elements. [The author’s review of the more important literature upon this type of tumor will be of interest to those dealing with the histopathology of these growths.] Two cases are reported. Both are presented chiefly from the histopathological point of view, and there are many excellent photomicrographs. A child of fourteen years showed rapidly progressive signs of increasing intracranial pressure, but aside from establishing the presence of hydrocephalus, exploratory craniotomy was negative. Ventriculography demonstrated third ventricle obstruction, and a surgical approach to the third ventricle region revealed a tumor, which was partly removed. Necropsy, following operation, disclosed the existence of a central neurinoma arising in the region of the bundle of Vicq d’Azyr (the mammillothalamic tract), associated with tuberous sclerosis. Grossly the tumor was a firm mass, 2 cm. in diameter, invading the anterior and inferior portion of the third ventricle. Elsewhere the brain 754 ABSTRACTS showed occasional firm plaques among the convolutions, characteristic of tuberous sclerosis. Microscopically the tumor showed the structure of a neurinoma. A detailed description is included. The second patient was a girl of fifteen years with signs of increased intracranial pressure and convulsive attacks of the upper extremities. A subtemporal decompres- sion failed to relieve stupor, and at autopsy there was found a large tumor, deep within the substance of the left cerebral hemisphere. Microscopic examination showed it to be similar to the lesion found in Case 1, though more centrally the tissue resembled spongioblastoma multiforme. Elsewhere on the cortex of the brain were areas which microscopically revealed spongioblasts and giant neuroblasts, Le., a form of tuberous sclerosis. The co-existence of glioma or other forms of neuroectodermic neoplasia with tuberous sclerosis has been described elsewhere by the writer and others (see, for example, Ztschr. f. d. ges. Neurol. u. Psychiat. 140: 1, 1932. Abst. in Am. J. Cancer 18: 253, 1933). In the cases described by the writer the tumor itself showed a predilection for the region of the thalamus and striatum. In general, the tumors were composed of spongioblasts and primitive neuro-ectodermal elements. There follows a discussion of the association and possible relationship between tuberous sclerosis, von Reckling- hausen’s disease, central neurinomas, and various glial tumors. The writer is of the opinion that all of these lesions can be interpreted upon the basis of a disordered differentiation in the elements constituting the nervous system. EDWIN M. DEERY

Neurinoma of Mixed Nerves; Extracranial Extension of the Growth, G. GUILLAIN, I. BERTRANDAND J. LEREBOULLET.Neurinome des nerfs mixtes; prolongement extracranien de la tumeur, Rev. neurol. 2: 56-68, 1933. , A woman of twenty years complained of diplopia, failing vision, and some unsteadi- ness in walking. Upon examination she showed papilledema, increased deep tendon reflexes on the left, a bilateral sign of Babinski, and loss of abdominal reflexes. There were no convincing evidences of cerebellar dysfunction. The corneal reflex was decreased on the left side and completely absent on the right. The patient also had R peripheral type of facial palsy on the right, a central type of deafness on the right, and nystagmus predominantly to the left. Further special tests of the eighth nerve mechanisms made apparent the presence of a right cerebellopontine angle tumor. At operation the right cerebellar hemisphere was elevated, disclosing a multilobular grayish tumor iri the right cerebellopontine angle. The growth seemed rather more anteriorly placed than the usual acoustic nerve tumor. Partial extirpation was followed by death. Autopsy revealed an extensive tumor arising from the mixed cranial nerves along the right side of the brain stem. Part of the growth had extended out of the cranium, compressing the jugular bulb and carotid. Within the right cerebellum was a cystic gliomatous lesion. Microscopically the angle tumor proved to be a typical neurinoma. The tumor had invaded the brain substance in certain areas of the cerebellum, a feature which is extremely rare. Several gross and microscopio photographs accompany the report. EDWINM. DEERY

Radiologic Examination of the Skull in Neurofibromatosis, R. THIENPONT.L’examen radiologique du crfine dans la neuro-fibromatose, J. belge de neurol. et de psychiat. 33: 786-794, 1933. The paper deals with the roentgenographic signs produced by a variety of intracranial tumors and reflects the generally accepted points of view. Some intracranial neoplasms become the site of a spotted calcification and may thereby be recognized in the roentgenograms. Meningeal tumors are often associated with hyperplasia of nearby bone, which presents a characteristic appearance in x-ray films. The pineal gland is often calcified in the normal adult. A tumor in one hemisphere or the other may result in a displacement of this pineal shadow, which can be demonstrated roentgenographically. When the clinical investigation fails to localiae a tumor, and the x-rays of the skull do not reveal further evidence, encephalography may be carried out, This procedure involves visualizing the ventricular system by the use of either gas or lipiodol. A tumor THE NERVOUS SYSTEM 755 of any size will usually distort or occlude some portion of the ventricular system, which alteration can be demonstrated in the encephalogram. A knowledge of the roentgenographic appearance of the base of the normal skull is essential to the recognition of early pathology of this region. Bony tumors, hyperostoses, or erosion of bone from an overlying neoplasm may be found along the skull base. A rare tumor known as a glioma of the optic chiasm may sometimes be diagnosed by changes in the appearance of one of the optic foramina. Technical details for the taking of films to demonstrate various intracranial structures are included. EDWINM. DEERY

Enlargement of the Optic Canal, Visible in the Roentgenograms in Patients having Neuroflbromatosis and Tumor of the Optic Nerve, E. HARTMANN.Elargissement du canal optique visible & la radiographie chez des malades atteints de neuro-fibromatose avec tumeur du nerf optique, J. belge de neurol. et de psychiat. 2: 763-772, 1933. Three cases are reported. A child of two and a half years had an orbital tumor which necessitated enucleation of the eye. Roentgenograms had revealed an enlarged optic canal. The tumor, considered a fibrosarcoma at the time, involved the optic nerve within the orbit. The child was subsequently found to have evidence of von Recklinghausen’s disease and a review of the sections from the optic nerve tumor led to a corrected diagnosis of meningoblas- toma. A woman of twenty-seven years complained of headaches of some three years’ duration and failing vision for the past three weeks. The right optic canal was shown to be enlarged in the roentgenograms. The general physical examination revealed bilateral exophthalmos and a large nevus of the scalp, both conditions being considered congenital in origin. Autopsy, shortly after admission to the hospital, revealed multiple neuro- fibromata attached to most of the cranial nerves, including the right optic nerve. A right acoustic nerve tumor had attained a large size, distorting the right peduncle and pons. The third case, while histologically unverified, seemed clear enough to include in the present group. A boy of seven years had left exophthalmos and progressive loss of vision in that eye. The general physical examination revealed areas of brownish pigmentation on the trunk and subcutaneous tumor nodules along the right arm. Roent- genograms of the skull demonstrated enlargement of the left optic canal. The child is believed to have a neurofibroma of the left optic nerve, but no operation has been carried out. EDWINM. DEERY

Bilateral Tumors of the Acoustic Nerves and Neurodbromatosis, J. HELSMOORTELJR. AND R. THIENPONT.Tumeurs bilat,krales de l’acoustique dans la neurofibromatose, J. belge de neurol. et de psychiat. 33: 779-785, 1933. A woman twenty-seven years of age had one brother who was subject to epileptic attacks. Another brother showed a large cajk nu lait area on the trunk. The family history was otherwise negative. The patient herself had shown no evidence of disease until adult life, when a small firm and painful tumor appeared on the right arm. The neurofibroma was excised but without relief of pain. Some two years later a Schwan- noma was removed from the seventh cervical nerve. A diffuse brown pigmentation then appeared over the body and mental changes ensued. Because of further neurological developments, the patient was operated upon again and a “ fibro-glioma ” was removed from the sixth cervical nerve. Some months later symptoms of increasing intracranial pressure, bilateral diminution of hearing, and vestibular symptoms developed. Roentgenograms of the skull showed changes considered suspicious of bilateral tumor of the eighth nerve. The presumptive diagnosis of bilateral acoustic neurinoma is therefore made. The author includes a brief review of the literature. EDWINM. DEERY 756 ABSTRAOTS

Fatty Substances in Neurinomata of the Acoustic Nerve, U. DE GIACOMO.Sulle sos- tanze grasse dei neurinomi del nervo acustico, Schweiz. Arch. f. Neurol. u. Psychiat. 31: 73-94, 1933. The literature of the neurinomas is reviewed, the characteristic histopathological features of such growths are described, and two cases of acoustic neurinoma are reported. The two tumors were studied histologically, and various chemical tests were carried out on each in an attempt to study the fat content. The fats, which consisted chiefly of lipoids and phospholipoids, occurred for the most part in the so-called reticular areas. Judging from the nature and distribution of the fat, the cells containing it seemed to be mesodermal macrophages. EDWINM. DEERY

A Malignant Form of Neuroibromatosis, A. DE GROODT,A. DELHAYEAND L. VAN BOQAERT.Sur une forme maligne de la neurofibromatose, J. belge de neurol. et de psychiat. 33: 773-778, 1933. Case report to illustrate the occurrence of a malignant tumor in a patient known to have neurofibromatosis. The malignant growth appeared on. the patient’s right thigh after the age of fifty, and increased in size rapidly. Microscopically it proved to be a round-cell sarcoma. A short review of the literature reflects the generally known facts upon the subject. EDWIN M. DEERY

Case of von Recklinghausen’sDiseaae, J. GAT^ AND P. CUILLERET. Un cas de maladie de Recklinghausen, Bull. SOC.franp. de dermat. et de syph. 40: 355-358, 1933. A report of a case of typical von Recklinghausen’s disease in a man thirty-eight years of age, with multiple painful cutaneous tumors and several areas of pigmentation. Two years before there had been a single tumor in the region of the right shoulder blade. Following trauma to this tumor, a “ veritable eruption ” of nodules liad occurred all over the body. THE BONES Tumours of Bone. I. The American Registry of Bone Sarcoma. II. Schtiller’s Dis- ease, J. M. W. MORISON. Brit. J. Radiol. 7: 208-226, 1934. In the first portion of the paper the author deacribes the inception, purposes, and maintenance of the American Registry of Bone Barcoma. In the second portion he reviews the historical and clinical aspects of Schtiller’s disease and reports two case8 of his own, the first, in his knowledge, to appear in the British literature. He regards Schtiller’s disease as a reticulo-endotheliosis which is a response of the reticulo-endothe- ]id system to an unknown infective agent having a predilection for the bones of the skull and other flat bones. The presence or absence of exophthalmos and diabetes insipidus depends cntirely on the localization of the disease. If, in the course of the disease, a disturbance in the lipoid metabolism occurs, then it may be classified under the generic term xanthomatosis. The latter should not be regarded as a disease in itself, but merely as a manifestation of a disordered lipoid metabolism which may occur in the course of various diseases. It should also be noted that the lipoid is not always the same; in Gaucher’s disease it is mainly kerasin, in Niemann-Pick’s disease phosphatids, and when present in Schtiller’s disease chiefly cholesterin fatty acid esters. The article is illustrated by photographs, roentgenograms, and photomicrographs. BENJAbfIN R. SHORE Tumours of Bone, J. F. BRAILSFORD.Brit. J. Radiol. 7: 233-236, 1934. This is a general disoussion of the differential diagnosis of infectious, metabolic, and neoplastic diseases of bones. Three illustrative roentgenogram8 are included, BENJAMINR. SHORE Turnours of Bone, J. E. A. LYNHAM.Brit. J. Radiol. 7: 237, 1934. Lynham reports the cases of three patients with somewhat unusual bone tumors. The first was a sixty-year-old woman with cystic disease of the bones associated with an THE BONES 757 adenoma of a parathyroid gland. The second was a three-month-old child with a rapidly growing endothelioma arising from the occipital bone. This tumor was removed surgically but recurred almost immediately. Following an unstated amount of roentgen and radium irradiation the child made a perfect recovery and is now free from symptoms at the age of ten years. The third patient was a fifty-year-old man with an adamantinoma of the right mandible. The end-result in this case is not given. The article is illustrated with roentgenograms. BENJAMINR. SHORE

Experience in Irradiating All Types of Bone Tumors, MAX KAHN. Radiology 20: 428-433, 1933. Among radiosensitive tumors of bone the author includes the benign giant-cell tumor (which he explains is not the typical giant-cell tumor, but a variant type, namely a bone cyst containing giant cells), Ewing's sarcoma, and chondroblastic sarcoma. Chon- dromas, secondary chondromyxosarcoma, and metastatic carcinoma are partly radiosensitive, while typical bone cysts, exostoses, and sarcoma are non-sensitive. In multiple myeloma irradiation is of value as a palliative measure and in some cases has brought about regression of the tumor and partial recalcification. Irradiation is indicated following amputation for malignant tumors and in the presence of malignant tumors which because of their size or inaccessibility are difficult of surgical removal. In tumors discovered early roentgenologically, irradiation may be done while awaiting the results of biopsy and laboratory studies. Five cases are reported in which cure or palliation was obtained by radiation, but in none of these were microscopic diagnoses made. Relationship Between Plasma Proteins and Bone Marrow, As Illustrated in Difierent Cases of Bone Marrow Tumors, A. H. JOHANSEN.Acta med. Scandinav. 82: 276- 287, 1934. Johansen studied a series of patients with primary and secondary tumors of the bones and a few cases of leukemia to determine whether disease processes in the bone marrow involved changes in the composition of the plasma protein. In 4 of 5 cases of multiple myeloma there was a marked variation from the normal in the total protein content of the blood, with an increase of the globulin and a decrease of the albumen fraction. In a group of metastatic tumors involving the skeletal system, these changes could not be demonstrated. The author concludes from these findings that there is a relationship between the maturity of tumor cells in the bone marrow and the proportionate qualitative and quantitative changes of the plasma protein. BENJAMINR. SHORE Notes on Giant-Cell Tumors of Bone and Cysts, F. J. COTTON.New England J. Med. 210: 1095-1101, 1934. Abstracted histories of 18 cases of giant-cell tumors, cysts, and myelomas are given to illustrate the diagnosis and treatment of these lesions. Cotton believes that the practice of waiting for further developments in cases of supposedly giant-cell.tumors or cysts is unjustifiable. Such a policy leaves one in ignorance about the true nature of the condition, deprives the patient of a chance of cure if the lesion should be a malignant one, and allows time for further extension of the process. Furthermore, if the lesion is a cyst, there is no reason to expect a spontaneous cure. Roentgen therapy without operation is not to be recommended because it means x-ray treatment without a diagnosis, and if the growth is already cystic it accomplishes nothing. Cotton prefers adequate surgical exposure of all suspicious lesions, histologic study of a biopsy specimen at the time of operation, and definite permission for the surgeon to deal promptly according to his best judgment with any type of lesion encountered. There are no illustrations. BENJAMINR. SHORE

Benign Giant-Cell Tumour of Bone, C. T. HOLLAND.Brit. J. Radiol. 7: 227-232, 1934. Holland reports in abstract form the histories'of 5 patients with benign giant-cell tumors occurring in unusual positions. The sites of these tumors were as follows: (1) the shaft of a fibula, (2) the shaft of a humerus, (3) a rib, (4) an ischial tuberosity, and ABSTRACTS

(5) a patella. These cases illustrate the possibilities of correct x-ray diagnosis, its uncertainties, and also its impossibilities. The article is illustrated with roentgenograms and a photomicrograph. BENJAMINR. SHORE

Benign Bone Cyst in the Newborn, VITO WITTINQAND J. B. GILLESPIE. Illinois M. J. 65: 451-453, 1934. The authors report the case of a benign cyst occupying the middle third of the left fibula of a newborn baby. During the routine examination of the infant on the day following birth a slight enlargement on the lateral aspect of the left leg was noticed. The blood Wassermann test and the Mantoux test with 0.1 mg. of old tuberculin were negative. Roentgenograms of the leg showed a fusiform expansion of the left fibula extending from its middle third to a point one-half inch above the epiphyseal line. Roentgenograms of the skull and other long bones showed no lesions. Subsequent radiologic examinations have shown a marked decrease in the cystic area and three months after birth the fibula was almost of normal size. Three cases of benign bone cysts in the newborn have been reported in the literature. Clinically the cases were instances of congenital pseudarthrosis associated with fractures, the diagnosis of bone cyst being made by histologic study of a biopsy specimen. The lesion in the case here reported is considered to be entirely different from these other three. The article is illustrated with roentgenograms. BENJAMINR. SHORM Early and Differential Diagnosis of Primary Sarcoma of the Ribs, A. HERZOQ. Das primare Sarkom der Rippen, seine Differeneierung und Friihdiagnose, Bruns’ Beitr. e. klin. Chir. 159: 505-514, 1934. This is a general discussion of the diagnosis of primary sarcomas of the ribs. Of especial importance in the differential diagnosis are syphilis, tuberculosis, osteomyelitis, lymphogranulomatosis, congenital anomalies, multiple exostoses, chondromas, myelomas, and secondary metastatic tumors. Radiologically primary sarcomas of the rib@ are characterized by an elevation of the periosteum and absence, or presence in only small amount, of formation of new bone. The medullary cavity is practically never widened by these tumors. The surrounding soft tissues may become involved, and u. subcutaneous tumor may be felt. Metastases to other areas of the body are late in occurrence. The article is illustrated by roentgenograms of two primary sarcomas of the ribs and of several other lesions considered in the differential diagnosis. BENJAMINR. SHORE A Review of Ewing’s Tumor with Case Reports, I. LATTMAN.Brit. J. Radiol. 7: 194- 207, 1934. The author reviews the histologic, radiologic, and clinical characteristics of Ewing’s bone tumors and includes abstracted histories of three illustrative cases. He concludes that a correct diagnosis may be made in these cases from a complete history, physical examination, roentgenograms, and the radiation therapeutic test. A biopsy is of no more practical value than the radiation test and should be done only after this fails. The disease, as a rule, is confined to individuals under thirty years of age and involves males more often than females. The growths cause diffuse destruction of bone, both cortical and central, and sometimes a limited amount of bone formation. The tumors are usually radiosensitive, but the prognosis is bad. The article is illustrated with roentgenograms and photomicrographs. BENJAMINR. SHORIG Ewing’s Sarcoma, K. DEUTSCHLANDER.Zur Kenntnis der Ewing-Sarkome, Med. Welt 8: 620-622, 1934. Doutschlander reports the occurrence of a Ewing’s tumor of the ulna in a sixty-year- old man. The growth was partially excised and an unstated amount of postoperative radiation given. The lower end of the ulna was resected eighteen months later for recurrence. The article is illustrated by a photograph and roentgenograms. BENJAMINR. SHORE LEUKEMIA, HOWKIN ’8 DISHME, LEUKOSARCOMATOSIB 759

RdLesions Associated with Multiple Myeloma, E. T. BELL. Am J. Path. 9: 393- 419, 1933. Bell has undertaken to determine the structural alterations in the kidneys responsible for the proteinuria and renal insufficiency so frequently associated with multiple myeloma. In order to do this he has studied 79 cases appearing in the literature with data concerning renal function, blood pressure, or histologic structure of the kidneys, and 11 additional cases which he reports briefly. In 24 casm moderate or severe renal insufficiency was demonstrated by functional teeta and in 10 of these post-mortem reports were available. In 25 cases no functional studies were reported but the kidneys were examined histologioally. In some instances the renal insufficiency is due to arteriosclerosis, in others to pye- lonephritis secondary to compression of the spinal cord or to prostatic hypertrophy. The only direct effect of the disease on the kidneys is due to the formation of tubular caste of Benodones protein that obstruct the tubules and cause tubular atrophy. There is no evidence that the Bence-Jones protein injures either tubules or glomeruli. Very rarely a highly concentrated protein solution in the glomerular capillaries may cawrenal insufficiency. Drawings of glomeruli show thickening of the basement membrane and distention of capillaries with protein, while a photomicrograph shows tubular casts and the resulting atrophy.

Multiple Myeloma in a Child, J. J. SLAVENS.Am. J. Dis. Child. 47: 821-836, 1934. Slavens reporh the csse of a four-year-old boy with multiple myeloma of the bones. Bence-Jones protein could not be demonstrated in the urine. Autopsy showed multiple leeions of the bones, spleen, liver, and aortic lymph nodes. The article is illustrsted by roentgenograms and photomicrographs. BENJAMINR. SHORE Metastatic Tumor of the Temporul Bone, H. FREY. Metastatischer Tumor des Schlil- fenbeines, Monatschr. f. Ohrenh. 67: 750-762, 1933. A Hty-eight-year-old individual came to the clinic complaining of severe pain in the right temporal region. Examination showed a swelling over the right temporal bone and x-rays revealed an area of rarefaction in this bone which is assumed to be a metastasis. Since the primary site of the tumor was not ascertained, the diagnosis in in doubt. THEODORE5. RAIFORD Paget’s Dieease and Parathyroid Tumors, R. KIENB~CK.uber die Pagetsche Knochen- krankheit und Epithelki)rperohentumoren, Bruns’ Beitr. 5. klin. Chir. 159: 597-011, 1934. Kienbock reviews the caw of a thirty-eight-year-old patient from whom a tumor of the parathyroid gland measuring 25 x 15 x 12 mm. was removed in 1925 by Mandl, for diffuse generalired osteitis fibroaa. The patient has been followed since then and now has skeletal lesions which are typical of Paget’s disease. The article ie illustrated by roentgenograms. BENJAMINR. SEORE~ I LEUKEMIA, HODGKIN’S DISEASE, LEUKOSARCOMATOSIS Leukemia, P. STAQELSCHMIDT.Zur Klinik der Leukilmien, Folia haemat. 51: 50-05, 1933. During the past twelve years there has been a steady relative increase in the number of cases of leukemia seen in the Medical Clinic in Tiibingen. Of the 187 cases reported, 82 were in men and 55 in women. The myelogenous type was observed in 64 cases, the lymphatic type in 54, and acute unclassified leukemia in 19 instances. From 8 study of the acute cases the author believes that it ie possible to separate all cams of infectious myelocytosis from those of true aoute leukemia. In many cases of the latter, the lack of morphologic and staining characteristics of the cells makes a distinct differentiation into lymphatic and myelogenous forms impossible. The histories of 9 fatal cases of leukemia are given. BENJAMINR. SHORE 760 ABSTRAOTS

Infectious Hemorrhagic Diathesis As a Predisposing Cause of Leukemia, MARGARETE LEVY. Infektibse, hamorrhagische Diathese als pradisponierendes Moment ftir das Zustandekommen der Leukamie, Folia haemat. 50: 48-54, 1933. The author reports the case of a thirty-three-year-old woman who gave a history of an attack of febrile bronchitis associated with an hemorrhagic diathesis ten years previously. At that time the platelets in the blood were decreased in amount and slight trauma of the skin or mucous membranes caused bleeding. The coagulation time of the blood was normal. After an interval of ten years the patient developed a severe myelogenous leukemia, whioh terminated fatally in two years. It is suggested that the reduction in the‘platelets ten years previously may have had some injurious effect upon the bone marrow and other blood-forming organs which was related in some way to the development of the leukemia. BENJAMINR. SHORE Lymphatic Hyperplasia of the Gastric Mucosa in Lymphatic Leukemia, M. LUDIN. Lymphatische Hyperplasie der Magenschleimhaut bei Lymphatischer Leukilmie, Rbntgenpraxis 5: 816-819, 1933. Liidin reports the case of a patient with extensive enlargement of the superficial nodes, who entered the clinic after having received a course of x-ray therapy. Biopsy of an inguinal node showed lymphocytic hyperplasia, and, as the blood picture was not that of leukemia, a diagnosis of aleukemic lymphadenosis was made. Roentgenographic examination of the stomach with contrast media demonstrated an extensive nodular irregularity along the greater curvature so characteristic as to lead to the suggestion that a nodular hyperplasia of the stomach wall waa present. Ultimately the leukocytes rose to 38,000 with 78 per cent lymphocytes, thus establishing the diagnosis of leukemia. The patient eventually came to autopsy, whereby the diagnosis of the gastric lesion was confirmed and, in addition, a chronic hyperplasia was demonstrated throughout the entire gastro-intestinal lymphatic system. The gastric wall was much thickened by a dense lymphatic infiltration, and the perigastric nodes were so greatly enlarged a8 to render it probable that a part of the x-ray filling defect was due to pressure of these nodes. There are four illustrations but no photomicrographs. [For a similar case, see Koch: Fortschr. a. d. Geb. d. Roentgenstrahlen 48: 271, 1933. Abst. in Am. J. Cancer 20: 478, 1934.1 THEODORE8. RAIFORD Lymphatic Leucemia and Pregnancy, H. K. RUSSELL. Am. J. Obst. & Gynec. 25: 493-499, 1933. Russell’s patient, 8 woman twenty-two years old, had given birth to two healthy children. When first seen, in her third pregnancy, one month before term, she presented B picture of advanced leukemia with marked secondary anemia and lymphocytosis. The disease had apparently begun three months before pregnancy. No treatment had been given. There were a large number of mitotic lyrnphoblasts in the circulating blood. The child was born three weeks before term but lived. In spite of x-ray treatment and transfusion the mother died four weeks after labor. The child at six weeks of age showed marked anemia, with 17,100 white cells; 82 per cent of these were lymphocytes, but mitoses were infrequent. Since the fetal and maternal bloods are separate in utero, it is obvious that the immature cells were formed in the infant. The fact that they ultimately disappeared indicates that they represented a response to some maternal influence rather than a characteristic of the child. There are four illustrations, two depicting the various stages of the lymphocytes from the mother’s blood in mitotic division. There is also a table illustrating the progressive changes in the mother’s blood during her period of observation. A comprehen- Rive bibliography is included. THEODORES. RAIFORD Studies of the Erythrocyte Diameter in Blood Diseases, Especially Leukemia, T. DIETRICH. Untersuchungen tiber den Erythrocyten-Durchmesser bei Blutkrank- heiten, insbesondere bei Fallen von Leukiimie, Folia haemat. 50: 313-319, 1933. Dietrich measured the diameter of the erythrocytes in fixed blood smears from 4 cases of myelogenous leukemia, 4 of lymphatic leukemia, and one of micromyeloblastic LEUKEMIA, HODGKIN ’B DISEASE, LEUKOBAROOMATOBIB 761 leukemia. In the 8 cases of lymphatic snd myelogenous leukemias there was no vans- tion from the normal, but in the oam of miaromyeloblastio leukemia the erythrocytes were decreeeed in sise to 7.46 a. There are no illustrations. BBINJAMINR. SHORE

Cue of Myeloid Leukemia Treated with Luminal and Amfdopyrine, M. C. TBIRRY AND A. 0. SANDERS.Proc. Soo. Exper. Biol. & Med. 31: 1164-1166, 1934. A male Negro, thirty-seven years old, had a leukocyte count of 267,000 on admission (September 16,1933) and a spleen reaching to the level of the umbilicus. As irradiation and suboutaneous injection of his own leukocytes exerted no effect, and as reports were 8ppeering at that time of granulopenia following the ridministration of luminal and amidopyrine, these two drugs were administered in the hope that they might be of some value. A total of 6 grains of luminal and 20 grains of amidopyrine in 4 doses was given between April 11 and April 13, 1934. Treatment with the same amounts was repeated beginning May 2 and again beginning May 9, and beginning May 14 6 grains of luminal and 20 grains of amidopyrine were exhibited daily for four days. No untoward symptoms appeared. On the contrary, the patient gained 4 pounds in spite of the fact that the spleen shrank to one-fourth it61 former si5e, and the leukooyte oount, 104,800 on April 13, was 25,550 on June 12. Ae the count fell it was seen that the cells most affected were the myeloblasts and (the myelooytea, the percentage of which in stained elides decreased with a corresponding increase of the lese immature and the normal poly- morphonuolear neutrophiles. WM. H. WOGLOM

Monocydc-Leukemia, B. DUBINSKAYAAND M. BAKALTSCRUK.Zur Frage tiber die MonooytenleukBmie, Folia haemat. SO: .97-107, 1933. The authors report the aase of a fifty-three-year-old woman with the clinical and hematologic pioture of an acute leukemia, The interesting feature of the case was that from 70 to 73 per oent of the leukocytes had large, non-lobulated, single nuclei. The peroxidase reaction was negative or just perceptible. The patient had fever, lost weight and strength rapidly, and died severd weeks after the onset of this acute illness. From a study of the literature, the authors conclude that there are two forms of monoaytosis: (1) amea in which the monoaytes are adult normal cells, and (2) cases in which the monocytes represent immature cells of the myelogenous series. The patients in the btgroup are not suffering from leukemia in spite of their high monocytic count. The article is illustrated by photomicrographs of the blood of the patient reported. BXNJAMINR. SHORE Lymphogranulomntosia (Hodgkin’s Disease), C. KRUCHEN.Lymphogranulomatoae (Hodgkin’sche Erkrankung), Zentralbl. f. inn. Med. 54: 929-942, 946-956, 1933. Thie is an excellent general discussion of the diagnosis, pathology, and treatment of Hodgkin’s disease. The article is without illustrations and no new material is added. An adequate bibliography is appended. BENJAMINR. SHORE Hodgkin’s Disease in Children, I. I. KAPLAN.Arch. Pediat. 51: 326-328, 1934. Kaplrn reporte 16 cases of Hodgkin’s disease seen in children fifteen years of age or younger in the Radiation Therapy Department at Bellevue Hospital and at the New York City Csnoer Institute. The prognosis of thie disease in children is poor, most of the patients dying within one year after the discovery of the condition. X-ray therapy is the only known effective method of treatment. There are no illustrations. BBINJAMINR. Srroaar Eye Changes in Leulrosarcomrtods of Paltaut-Sternberg, E. PREIBBBURGEIR.tfber Augenveriinderungen bei der Leukosarkomatose Paltauf-Sternberg, Ztschr. f. Augenh. 81: 308-313, 1933. The author presents a case of leukosaraomatosis of the Paltauf-Sternberg type in a thirty-dx-year-old patient in whom definite and characteristic pathological changes in the eyes were demonstrable. These changes, observed at autopsy, aonsisted of a dense ABSTRACTS myeloid infiltration of the choroid, especially the posterior portion. This infiltration was also found in the lacrimal gland, although it did not resemble the picture usually neen in leukemic glandular disease. The clinical picture in this case was not typical of leukemic disease nor was the blood picture pathognomonic. Diagnosis was made only by histological study at autopsy of the involved organs. There is one illustration. The author reviews and quotes from Sternberg’s original article on the subject. THEODORES. RAIFOHD

STATISTICS AND PUBLIC HEALTH

Report of Over a Thousand Unselected Cancer Cases, Treated in 1931-1932 at the New York City Cancer Institute, Welfare Island, IRAI. KAPLAN. Radiology 20: 433-449, 1933. The cases included in this study represent chiefly advanced stages of cancer, in patients of all ages, of numerous races and creeds, and differing widely in economic Btatus. Of the 1236 patients, 996 had received previous treatment either by surgery or irradiation. In some 40 per cent the disease was so advanced that no treatment beyond custodial care was possible. Tables show the ex and age incidence and results in cancer in certain sites and the incidence of the various forms of sarcoma. The author believes that a large properly organized custodial hospital is necessary for the care of cancer patients and when so established may succeed in imprqving many cases committed to its care even though only a minute proportion may be cured.

Statistics on Cancer, E. PANCOTTO.Centro per la diagnosi e terapia dei tumori, Boll. d. lega ital. p. 1. lotta contro il oancro 7: 103-113, 1933. This is a report of necropsy records of tumor patients from September 1928 to 1932. Among 1350 autopsies, 150 malignant tumors were reported; among 1800 biopsies the number was 525. Of all the tumors observed both at biopsy and at autopsy, 16.5 per cent were of the stomach, 14.6 per cent of the uterus, 13.5 per cent of the breast, and 10.4 per cent of the mouth. JEANNETTEMUNRO

Cancer Survey of the Philippine Islands in 1929, C. REYEB. J. Philippine Islands M. A. 13: 502-510, 1933. The records of 8,960 necropsies (in 5,810 males and 3,150 females) performed at the Philippine Medical School between the years 1907 and 1923 revealed 233 malignant tumors (173 carcinomas and 60 sarcomas). The highest incidence of primary cancer was in the cheek and the liver. W. S. MACCOMB Discussion of the Results of the Reporting of Cancer Cases in Silesia, C. PANA.Con- siderazioni relative alla pratica dells denuncia dei csncerosi nella Silesia, Boll. d. lega ital. per la lotta contro il cancro 7: 224-226, 1933. Reporting of cancer cases is not obligatory in Silesia but a campaign to secure volun- tary reporting by doctors and hospitals to the medical society is under way. The author finds a larger proportion of cases reported in country districts than in urban areas and that the districts reporting a larger proportion of cancer cases show a lower cancer death rate per population. JEANNETTEMmno Cancer Survey in Baden, M. HECET. Erhebungen iiber Krebserkrankungen in Baden, Ileutsche med. Wchnschr. 60: 719, 1934. This is a short description of cancer surveys now being made in Switzerland and Baden. The questionnaires provide for answers in respect to soil, transfer of the disease by contagion, heredity, diagnosis (whether made merely on the strength of a patient’s statement or confirmed by operation or autopsy), etc. WM.H. WOGLOM STATISTICS AND PUBLIC HEALTH 763

The Making and Enforcement of a Law to Promote Cancer Control, H. TH.SCHHEUR. Schaffung und Durahfiihrung eines Krehsschutzgesetzes, Deutsche med. Wchnschr. 60: 716-718, 1934. So few new ideas have been introduced into cancer campaigns that the interest of educators and public alike threatens to wane, and only some radical change can save the situation. The author therefore suggests that free examination be made available to all Germans over thirty-five to forty years of age. In itself the plan is not precisely new, for it is in effect in other countries, whcre it takes the form of cancer centers, but he proposes a more rigid course-legislative action decreeing examination, issuance of I‘ health-books,” notification, birth-control in cancer families, etc. WM. H. WOOLOM

Are Cancer Campaigns Justifiable? 13. KARITZKY. 1st die Laienaufklirung iiber Krebsfragen berechtigt? Deutsclie med. Wchnschr. 60: 713-716, 1934. Attempts to instruct the laity have led only to carcinophobia, a new epidemic disease which is almost worse than cancer itself. On the whole, the value of cancer campaigns is problematical. [Still, as a pupil of the abstractor’s once remarked, carcinophobia does not metastasize.] WM. H. WOQLOM The Cancer Challenge, N. WEMETT. TJniversity of Western Ontario M. J. 4: 05-97, 1934. The author stresses the need of research in the cancer field. W. S. MACCOMB