ABSTRACTS EXPERIMENTAL STUDIES; ANIMAL TUMORS Relation of Carcinogenicity of Mineral Oils to Certain Physical and Chemical Characteristics of These Oils, R

ABSTRACTS EXPERIMENTAL STUDIES; ANIMAL TUMORS Relation of Carcinogenicity of Mineral Oils to Certain Physical and Chemical Characteristics of These Oils, R. LYTH. J. Industrial Hygiene 15: 226-237, 1933. (Refractive index - 1 The refractivity of a mineral oil seems to afford a Density probable indication of its carcinogenicity. When the refractivity was less than 0.5500 the sample proved inactive, while with values higher than 0.5600 the oil was highly potent. Of oils lying between these extremes, those with low values were almost inert but those with intermediate or high values, while likely to be carcinogenic, were not necessarily so, as in the case of Pennsylvanian and certain mildly treated oils. The iodine value of an oil also appeared to furnish a guide to its carcinogenicity, provided that it had not been treated. If the value was above 26 the oil was likely to be active, and if the value was above 30 it was almost certain to be so. As in the preceding test, the shale oils were characterized by the highest values, while the Russian oils had the lowest. Pennsylvanian samples occupied a position slightly higher than would be expected if their iodine values were directly related to carcinogenic potency. In the case of treated oils the iodine values were less reliable, for mild treatment was found to decrease activity out of all proportion to the fall in iodine value. Still, when a large decrease in iodine value occurred, complete absence of carcinogenic power could be anticipated. Permanganate oxidation values were subject to such great variation, in spite of all precautions, that they were of no use in forecasting carcinogenicity. The carcjnogenic potency of the various samples had been determined in mice by Twort and his collaborators, and their figures are utilized in this paper. WM. H. WOQLOM

Changes in the Liver of Mice Following the Ingestion of Hydrocarbon Oils, J. M. TWORTAND C. C. TWORT.Lancet 1: 448, 1932. In the course of their post-mortem studies of mice treated by skin applications of various carcinogenic and non-carcinogenic agents, the authors have observed certain characteristic microscopic changes in the liver following applications of mineral oils. A periportal infiltration of small round cells, with a few polynuclears intermixed, is succeeded by the appearance of cells giving a definite bichromate reaction. These cells are not unlike endothelial cells in appearance and some of them are similar to the foam cells found in xanthomas. Ultimately the cell is completely replaced by fat, with the resulting picture of a type of fatty infiltration. The authors consider it probable that the chemical substance responsible for these changes gains access to the internal organs by way of the alimentary tract, for there is no doubt that much of the material painted on the skin is ingested by the animal. This condition was not induced by applications of gas tars, synthetic tars, or saponifiable oils. Two photomicrographs show the changes described. 645 31 646 ABSTRACTS

Sympathectomy and Evolution of Tar Tumors in the Rabbit, AYANDIOTAVARES AND ERNESTOMORAIS. La sympathicectomie et 1’6volution des tumeurs du goudron chea le Lapin, Compt. rend. SOC.de biol. 113: 530-532, 1933. If sympathectomy exerts any effect at all upon the origin and development of tar cancer in the rabbit, which is doubtful, it tends to retard; in any case, the stimulating effect reported by some other investigators was not observed. Upon tumors already present at the time of operation, however, sympathectomy seemed to exert a repressing influence, though it must be borne in mind that regression is a common occurrence in tar carcinoma of the rabbit. WY. H. WOQLOM Influence of Denervation of the Ear on the Development of Tar Tumors, AYANDIO TAVARES.De l’influence de 1’6nervation auriculaire sur le d6veloppement des tumeurs du goudron, Compt. rend. SOC.de biol. 113: 763-764, 1933. The results of tar painting after combined sympathectomy and resection of the anterior auricular nerve did not differ from those accompanying sympathectomy alone. Nodules appeared first on the denervated ear in one rabbit, on both ears at the same time in a second, and almost simultaneously in a third. After resection of the anterior auricular nerve only, the results in four surviving rabbits out of 6 were discordant. Severance of both the anterior and posterior auricular nerves, which, between them, supply practically the entire ear, seemed to accelerate the development of cancer, a result which does not accord with the experience of previous investigators. It ia not entirely clear to the abstractor how many rabbite were employed in this last experiment, but the number appears to have been 15, of which 5 died before the fortieth day. WY. H. WOQLOM

Prevention of Tar Cancer with Salts of Barium, J. MAISINAND J. DETROUX. La prophylaxie du cancer du goudron B hide de sels de Baryum, Compt. rend. SOC.de biol. 113: 926-928, 1933. Three groups of mice were painted three times a week for four months with tar. One lot received thrice weekly one drop of a solution of barium saccharate (4.8 X lo-‘ molecular) by mouth, a second received similarly a 4.8 X LO-6 solution, while the third served as controls. All were maintained on the same diet. On the 240th day 5.5 per cent of the first group, 8 per cent of the second, and 37.5 per cent of the third had developed cancer. The result shows that mice can be protected against tar cancer and suggests the extreme importance of diet, and particularly of the drinking water, for prophylaxis in man. [The number of mice in the various groups is not given.] WY. H. WOQLOM Importance of the Anion and of its Dose in the Barium Salts Employed to Prevent Tar Cancer, J. DETROUX.Au sujet de l’importance de l’anion du sel employ6 et de sa dose, dans la prophylaxie du cancer du goudron & l’aide de sels de baryum, Compt. rend. SOC.de biol. 113: 928-930, 1933. These experiments, carried out in conjunction with Maisin (see preceding abstract), were planned to determine the optimum dose of barium for preventing tar cancer in mice. One group served as controls; a second was given one drop of barium chloride solution (1 : 10,000) by mouth three times a week; a third, 1 drop of a 1 : 20,000 solution at similar intervale; a fourth, 1 drop of a 1 : 30,000 solution in the same manner; and a fifth, one drop daily of a 1 : 1,OOO,OOO solution. All the mice were kept on the same diet, and painted thrice weekly with tar for fpur months. EXPERIMENTAL STUDIES ; ANIMAL TUMORS 647

It was found that the animals which received the largest amount of barium (one drop of a 1 : 10,000 solution three times a week) developed cancer more rapidly and in larger numbers (62 per cent) than the controls (37.5 per cent). In those of the two lots following, development of the carcinoma was slightly inhibited, while in the mice of the last group (1 drop daily of a 1 : 1,000,000 solution) the appearance of cancer was somewhat delayed and the number of carcinomas was distinctly lower (12 per cent) than in the controls (37.5 per cent). Hence there is an activating and an inhibiting dose of barium [or possibly the barium has nothing to do with the results]. In a second series of experiments, where the chloride was replaced by the gluconate, it appeared that the amount of barium which activated when administered as the chloride inhibited when given in the form of gluconate. The anion of the barium salt employed evidently plays an important rBle in prophylaxis. [The number of animals in the various groups is not given.] WM.H. WOQLOM

Influence of Temperature on the Virus of Mouse Sarcoma, A. BESREDKAAND L. GROSS.De l'influence de la temperature sur le virus du sarcome des Souris, Compt. rend. SOC.de biol. 113: 48-49, 1933. A fine emulsion of mouse sarcoma was heated for thirty minutes before inocu- lstion. Temperatures above 42O were fatal, as was exposure to 37" for twenty- four hours. The material was attenuated after having been kept for forty-eight hours in the icebox (4" C.) and inactivated after from three to six days. The injection of dried material produced only a transient granuloma. [The abstractor sees no need to assume the presence of a virus in explaining these results.] War. H. WOQLOM

Are Mouse Tumors Caused by an Extra-ceUular Agent? E. HARDEAND P. HENRI. Lee tumeurs des Souris ont-elles pour origine des causes extra-cellulaires? Compt. rend. SOC.de biol. 113: 700-703, 1933. Frankel (Ztschr. f. Krebsforsch. 36: 252, 1932 and 37: 121, 1932, abst. in Am. J. Cancer 16: 1000, 1263, 1932) and Besredka and Gross [see abstract immediately preceding] suggest the existence of an extracellular etiological agent in consequence of their success in transferring neoplasms with blood, liver, and various other organs from tumor-bearers. Frankel later asserted that he had produced bilateral growth by injecting tumor into one flank of a mouse and normal brain into the other [an experiment purporting to demonstrate the neurotropism of the agent]. Harde and Henri have repeated this work, injecting a sarcoma [unspecified] or carcinoma 63 on one side and normal brain on the other; the result was entirely negative in all 37 mice inoculated, and the authors were then informed by Frankel that he himself had been unable to repeat his first success. Livers from animals bearing an American mouse sarcoma [180 11 were introduced into 6 mice; in 2 of these a tumor arose at the inoculation site, but microscopic metastases were discovered in one of the organs employed. It is concluded that the existence of an extracellular etiological agent has not yet been demonstrated. WM.H. WOQLOM Neurotropism of Neoplasms in the Mouse, N. CONSTANTINESCO.Sur le neuro- tropisme des nboplasmes de la Souris, Compt. rend. SOC.de. biol. 113 : 297-299, 1933. Both Costa and Frankel have reported transmission of the Rous sarcoma, mouse sarcoma 37, or the Ehrlich mouse carcinoma by inoculation of brain from 648 ABSTRAOTS hosts bearing these neoplasms, though no metastases were discoverable in the cerebral tissue. Frankel explained this transfer by assuming that the brain affixed a neurotropic etiological agent of some sort [see Am. J. Cancer 16: abst. p. 1263, 19321. Constantinesco has repeated the experiment with a London mouse sarcoma [not further specified]. Sixteen mice inoculated under the skin with brain from those bearing subcutaneous sarcomas developed no tumors, though they were kept under observation for from forty to seventy-five days. In a second series of experiments, sarcoma was inoculated into the brain, and portions of the organ well removed from the resulting neoplasms were engrafted subcutaneously into 13 mice; even under these conditions, however, no tumors arose, though the two groups were watched for fifty-three and sixty days regpectively. Thus the tumor employed is not neurotropic. WM. H. WOGLOM

Chemotherapeutic Experiments on Mouse Carcinoma, M. CSABAAND L. N%METH. Magyar Orvosi Arch. 33: 183-194, 1932. This article reports the resulta of chemotherapeutic experiments on Ehrlich’s mouse carcinoma. The treatment of the mice waa instituted on the day of transplantation. It was found that potassium cyanide is able to arrest the growth if administered in sufficient amount. This kind of treatment is, however, impracti- cable because large doses are required to attain results. Experiments were carried out with hexose cyanhydrine, without noticeable effect. Phloridein proved inefficient. The combination of potassium cyanide with arsenic gave bad results, the therapeutic effect of the potassium cyanide being decreased by the addition of arsenic preparations. X-rays did not increase the curative action of cyanidea. ANTHONYWOLLNER Blood Changes in Mice with Transplantable Tumors, OTTO BACKOFEN.Zum Studium der Blutveranderungen bei Mausen mit Impftumoren, Ztschr. f. Krebsforsch. 39: 318-320, 1933. The blood-changes in mice bearing transplantable tumors have been often investigated, but on small numbers of animals only. According to the author’s observations on 100 mice bearing the Ehrlich carcinoma, there occurred a secondary anemia with a relative neutrophile leukocytosis. The monocytes increased in number for a few days after inoculation, but returned to normal in about two weeks. These changes, which resemble those found in human patients, suggest some disturbance involving the entire hematopoietic system. WM. H. WOGLOM Investigations on the Physico-chemical Properties of Normal and Pathological Tissues. Part 10. Further Investigations on the Treatment of Tar Tumors of the Mouse with Certain Amino Acids, F. VLBS AND A. DE COULON.Ap- pendix: Histology, J. L. NICOD. Recherche8 sur les propribths physico- chimiques des tissus en relation avec 1’6tat normal ou pathologique de l’organ- isme. 10” partie: Nouvelles recherche8 sur le traitement des tumeurs de goudron de la Souris par certsins amino-acides. Appendice: Examen histo- logique des tumeurs. Arch. de phys. biol. 9: 5-28, 1931. This is an amplification of an article already abstracted (Am. J. Cancer 15: 898, 1931), in which it was said that mixtures of alanine, cystine, and proline, or of d-glutamic acid and cystine, exerted an inhibitory effect upon tar cancer in mice when given either subcutaneously or by mouth. The present paper reports a larger number of experiments and contains an appendix describing the histology of tumors in treated animals. These showed, in brief, a cessation of active EXPERIMENTAL STUDIES ; ANIMAL TUMORS 649 invasive growth and often came to resemble more a benign than a malignant neoplasm. WM.H. WOGL~M

Survival of Bronchial Epithelium in E Transplanted Lymphadenoma of the Mouse Lung, L. MERCIERAND L. GOSSELIN.Un cas de survie de l’bpith6lium bronch- ique observe au cours de la greffe du lymphadenome massif du poumon de la Souris, Compt. rend. SOC.de biol. 113: 272-274, 1933. In a sixteen-day-old subcutaneous tumor resulting from the inoculation of a spontaneous pulmonary lymphadenoma there was found a portion of a large bronchus, in which only the epithelium had resisted invasion by tumor cells. The authors inquire whether its preservation is to be ascribed to (1) its unusual vitality, (2) the presence of some stimulating agent in the tumor cells, or (3) negative tropism of these elements in respect to bronchial epithelium. WM.H. WOGLOM

Rat Carcinoma and Injected Colloidal Platinum, M. F. GUYERAND F. E. MOHB. Arch. Path. 15: 796-817, 1933. Intratumoral injections of colloidal platinum, repeated every forty-eight hours, led not only to distinct retardation of growth in the Flexner-Jobling rat carcinoma, but often to regression and final disappearance. Treatment was begun when the tumors were about three weeks old and from 1.1 to 1.2 cm. average diameter, The amount introduced, approximately 0.15 C.C. at first, was varied as the neoplasm increased or decreased in size, 0.3 C.C. being injected into a growth 3 cm. in diameter, for example, while one of 0.6 cm. would receive but 0.05 C.C. The number of injections given at one time also depended upon the size of the neoplasm; on the average, 3 were made into different parts of a growth when treatment was begun. The colloidal suspension used was prepared by sparking platinum electrodes in water. That some of the inhibitory effect might have been due to mechanical injury is suggested by the fact that some slight retardation followed injections of physiological sodium chloride solution; but the effects of colloidal platinum were so much more pronounced that the occurrence of a specific reaction, in addition to general trauma, may be safely assumed. Furthermore, intratumoral injections of colloidal silver not only failed to inhibit growth, but actually stimulated it. Any direct action upon the tumor cell, however, is eliminated by the observation that soaking grafts in colloidal platinum before transplantation caused little or no damage. Nor can the inhibition be referred to increased lymphoid reaction, to general systemic factors, or to adsorbed oxygen or hydrogen. The one interpretation consistent with all the facts is that the injections produced a local response which walled off the tumor from the surrounding tissues and diminished its supply of oxygen. The treatment appeared to act, in brief, by augmenting two of the body’s reserves against cancer-inflammation and fibrosis. At the same time, because of its relative chemical inactivity, platinum did not injure any of the other defenses. In all 342 rats were employed. WM. H. WOGLOM Intravenous Transplantation of a Rat Sarcoma, G. GUCCI. Trapianto di sarcoma spontaneo del ratto per via endovenosa con poltiglia di tumore, Policlinico (sez. chir.) 40: 22-30, 1933. The tumor used by the author was a spontaneous spindle-cell sarcoma which had arisen in a strain of albino rats kept in the laboratories of the Surgical Clinic of the University of Rome. It had given over 90 per cent takes on subcutaneous inoculation. As previous workers had published varying results, mostly negative, with intravenous tumor tissue inoculation, the author tried this method, the site 650 ABSTRACTS chosen being the base of the tail in the mid-dorsal line, and a single injection of tumor emulsion being given to each animal. The lungs were the most frequent sife of tumor formation, 9 animals out of 44 showing pulmonary tumors. There are six good illustrations. F. CAVERS Test for Resistance of Transplantable Rat Sarcoma to Various Factors, S. MORI- MOTO. Acts Dermat. 21: 70-71, 1933. A ten per cent suspension of the Honda rat sarcoma was centrifugalized at the rate of 3000 r.p.m. for from fifteen to ninety minutes, and the supernatant fluid injected subcutaneously into rats. With centrifugation up to sixty minutes the injection was followed by growth of the tumor, but after ninety minutes no growth was observed. The microscopic examination of the supernatant fluid showed a small number of tumor cells, but the transplantation did not succeed unless the cellular content of the injected material reached a certain concentration. K. SUQIURA Experimental Cancer Studies: Evolution and Production of Metastases of Renal Grafts of a Spontaneous Sarcoma of Mus norvegicus (Galliera sarcoma), G. MAZZACUVAAND U. SANTOBONI.Ricerche di oncologia sperimentale; partico- larith di evolusione e produzione di metastasi negli innesti renali di un sarcoma spontaneo del mus norvegicus ” (sarcoma Galliera), Pathologica 24: 309-316, 1932. The authors used a transplantable rat sarcoma-Galliera sarcoma-which gives almost invariably 100 per cent takes into whatever organ of the rat it is transplanted, but which has not been observed to metastasize. They injected tumor pulp through the abdominal wall into the parenchyma of the kidney in ten young rats. The inoculation took in 90 per cent of the animals and in 25 per cent pulmonary metastases occurred. A detailed histological description of the tumor and 13 photomicrographs are included. The authors conclude that the tumor should be claseified as a ‘I large spindle-cell sarcoma.” C. D. HAAQENSEN Cysticercus Fasciolaris and Tumor Caused by Parasites in Rats, ADAAMENDOLA. Cisticerco fasciolare e tumori da parassiti nei ratti, Gior. ital. di mal. esot. e trop. 5: 115-131, 1932. In two old rats which at autopsy were found to have Cysticercus cysts of the liver without malignant change in the cyst walls, Amendola found marked papillomatous hyperplasia and keratinization of the epithelioma of the fore-stomach. Although unable to find Spiroptera neoplastica in the two animals, the author believes that the gastric changes were caused by these parasites. Several microscopic drawings and a short bibliography are included. [Amendola says nothing about the diet of the two rats. Since it is well known that vitamin A deficiency causes this keratinizing metaplasia of the fore-stomach of rats (Fujimaki, Y.: J. Cancer Research 10: 469, l926), it is more than probable that this simple factor was the responsible one in these animals.] C. D. HAAQENSEN

Shock in Guinea-pig Sensitized by Cancer Antigen, CHASTENETDE GERY. Le choc chez le Cobaye sensibilistl par un antigene canctlreux, Compt. rend. SOC. de biol. 113: 140-142, 1933. Earlier investigators have obtained negative or indefinite results in their attempts so to sensitize an anixpal with oancer that the subsequent injection of serum from a cancer patient will cause anaphylactic shock. EXPERIMENTAL STUDIES ; ANIMAL TUMORS 65 1

In the author’s experiments, an extract of mammary cancer appeared to sensi- tire guinea-pigs to the serum of cancer patients, and the sensitization seemed to be specific, not only for cancer but for cancer of a certain organ or of a certain histological structure. [These conclusions are based on eight guinea-pigs sensitized with material from one patient.] WM.H. WOOLOM Application of Vital Staining to the Histogenesis of the Rous Sarcoma I, A. HADDOW.J. Path. & Bact. 37: 149-155, 1933. The author subjected 15 chickens three to four months old to intensive vital staining with trypan blue, 0.5 per cent being used for the earlier and 1 per cent for the later injections into the subcutaneous tissues lateral to the pectoral muscles on either side; the doses, 5 C.C. initially, increasing to a maximum of 12 c.c., were given twice weekly for eight weeks. Toxic effects were marked in 3 birds, which died after large doses, but the remainder showed slight or no changes in general condition. A week after the last injection a filtrate prepared from a rapidly growing Rous tumor was inoculated into the left breast of each of the twelve birds. Forty-eight hours later a block of tissue, cut to include muscle, fasciae, subcutaneous tissues, and skin, was removed from the site of inoculation in the first fowl, similar blocks being excised daily from a fresh fowl to the end of the series. From his observations the author concludes that the normal cell initially affected in the formation of the tumor produced after inoculation of active cell-free sarcoma filtrate is the free bistiocyte, leaving no doubt that the parent and predominant cell of this tumor is of monocytic origin, as stated by Carrel and Fischer and by McJunkin (J. Cancer Research 12: 47, 1928). The most obvious morphologic changes observed in the histiocyte were the extrusion of cytoplasmic processes and pseudopodia and the occurrence of vacuolation of the cytoplasm, giving a characteristic dropsical appearance. Only in these cells was mitosis ever observed, and it appeared that subsequent changes in their daughter cells took the form of a rapid departure from the macrophage type through intermediate forms to typical histioblasts multiplying rapidly by amitotic division to form the anastomosing and branching angular fibroblasts which, as the most obvious in number and arrangement, give this tumor ita characteristic structure In a general discuasion the author points out that if the mode of action of the epecifio agent on the normal cells of the new host is clear, the true nature of the agent remains obscure. If, as seems more than permissible, the conception of the agent as a separate living organism is abandoned, it seem necessary to accept a hypothesis like that of Murphy, who regards the agent as an endogenous substance capable of inducing a specific and permanent character change or mutation in the corresponding susceptible cell. This view receives general support from analogy with the specific soluble substances determining bacterial types with regard to colony form, serologic characters and virulence, and in particular from the study of the capsular polysaccharides of the pneumococci. Dawson (J. Exper. Med. 47: 577, 1928; 51: 99, 123, 1930) produced in uiuo transformation of R forms under the influence of heat-killed S organisms, and the more recent demonstration of the same phenomenon in uitro by Alloway (J. Exper. Med. 55: 91, 1932; 57: 265, 1933) is at least an illuminating parallel to Carrel’s in uitro fabrication of Row agent, if we choose to regard the latter as a transmissible mutagen. In attempts to reconcile the position of avian sarcomas with regard to the somatic cell mutation theory of cancer causation as a whole, it has been suggested that the phenomenon of filtrability occurs in this group because of a fortuitous condition of the fowl chromosome as regards size, or else that the filtrable agent is the mutant gene itself. The crucial problem thus remains the determination of the extrinsic 652 ABSTRAOTS or intrinsic origin of the agent, and experimental proof of the second alternative requires the detection of the agent in tumors produced, preferably, by the use of a pure synthetic carcinogenia substance such as 1 : 2 : 5 : 6-dibenzanthracene1 in fowls acknowledged to be virus-free at the beginning of and throughout the experiment. There is a plate with numerous colored drawings. F. CAVERS Adsorption and Elutriation Experiments on the Filtrable Agent of Rous Chicken Sarcoma, WARONAKAHARA AND HIBASHINAKAJIMA. Gann 27: 202-214,1933. The authors prepared a Berkefeld filtrate from a 25 per cent chicken sarcoma extract and determined first the optimum pH for the adsorption of the chicken sarcoma agent with kaolin and aluminum hydroxide. Adsorbent, buffer solution, and sarcoma filtrate were mixed well and the adsorbate was separated by centrifugation. Supernatant fluid and the suspension of adsorbate were injected into the pectoral muscle of normal chickens. The results showed that the filtrable agent of the Rous chicken sarcoma was very poorly adsorbed on kaolin at pH 7-10, but a good adsorption took place on aluminum hydroxide at pH 7-10. Adsorption on aluminum hydroxide wm very slight at pH 4-6. In a second experiment the authors proceeded to effect the elutriation of the sarcoma agent from the adsorbate. It was found that the sarcoma agent adsorbed on aluminum hydroxide at pH 9 was elutriated by M/7 solution of sodium di- phosphate and also by N/25 solution of ammonia, but not by buffer solutions at pH 4-6, or by glycocoll or ammonium di-phosphate solutions. The sarcoma- producing action of the elutriate was found to be very greatly reduced as compared with that of the original filtrate. This the authors ascribed to the inactiva- tion of the agent attending the process of adsorption and elutriation. K. SUQIURA Active hunisation of Pheasants Against Fowl Tumours, C. H. ANDREWEB.J. Path. & Bact. 37: 17-25, 1933. In an earlier paper (Abet. in Am. J. Cancer 16: abst. p. 1270, 1932) the author reported that while three fowl sarcomsn were successfully transmitted to pheasants, three other fowl tumors failed to give rbe to progressively growing tumors in those birds. Pheasanta which had resisted several inoculations of these less readily transplantable tumors were subsequently immune to filtrates of the Rous sarcoma, to which controls were readily susceptible. During 1932 difficulty was encountered in immunizing pheasants, for several of the fowl tumors studied grew much better in these birds than they had in 1931 ;many birds diedfrom tumors after inoculation, instead of proving refractory and acquiring a strong immunity as had been hoped. The 1932 pheasants were much stronger and healthier than the others, and many observers have reported that tumors are less readily transmissible to feeble than to healthy animals. The Rous sarcoma, though regularly transmissible from fowls to pheasants both with cells and filtrates, could not in 1931 be transmitted in series from pheasant to pheasant. In 1932 this transmission was accomplished without difficulty, the tumors growing vigorously and causing death with metastases in lungs, spleen, liver, peritoneum, and heart. Details are next given of experiments on immunization, the results of which appear to show that it is possible, by repeated inoculation into pheasants of material from tumors to which they are relatively resistant, to induce an immunity to the Rous sarcoma, to whiah they are highly susceptible. Although the injection of fowl protein may play a part in the immunizing process, the following considerations suggest that this immunity depends primarily upon immunity to tumor-virus antigen. (1) The immunity induced by embryo is weaker than that iiiduced by tumor injections. (2) Neutralizing antibodies have been detected in EXPERIMENTAL STUDIES ; ANIMAL TUMORS 653

the sera of tumor-immunized birds, but not of embryo-immune birds, though precipitins for fowl serum are present in both. Purely quantitative differences might explain these first two points, but not the next three. (3) The immunity is probably effective against duck-grown Fujinami sarcoma as well as against fowl-grown tumors. (4) The tumor-immunized birds certainly have a .humoral immunity directed against virus and not merely against fowl protein, for there is considerable specificity in their neutralizing antibodies. (5) Similar immunity may be induced in fowls with heterologous tumors. Finally the author emphasizes the point that immunization against avian tumors bears no relation to the immunity against transplanted tumors which can be induced in mammals by the inoculation of embryo and by other means; immunity to the causative agent of a tumor is not there involved. F. CAVERS Further Serological Studies on Fowl-Tumour Viruses, C. H. ANDREWES.J. Path. & Bact. 37: 27-44, 1933. In previous papers (see Am. J. Cancer 16: abst. pp. 294, 1001, 1932) the author reported that the sera of fowls bearing chronic fibrosarcomas (MH 1 and CT 10) will neutralize filtrates of more rapidly growing tumors (Rous No. 1 and the endothelioma MH 2). The question was left open whether the serological evidence indicated that the viruses studied were identical or merely antigenically related. Particular study has now been devoted to this point, and five more fowl tumor viruses have been included in the survey. In discussing his findings, which are described in detail and set out in a series of tables, the author concludes that the viruses from the different tumors studied are serologically neither identical nor yet wholly distinct. Some sera, as duck anti-Fujinami sera, have probably neutralizing power against all of them, while sera prepared in pheasants show a high degree of specificity. Similar findings are frequently described in serologic studies of bacteria and are commonly held to imply a complex antigenic structure, group and specific antigens giving rise to group and specific antibodies. But the work of Avery, Goebel and Babers (J. Exp. Med. 55: 769, 1932) on the behavior of antibodies to synthetic antigens enjoins caution in attributing multiple antigens to a tumor virus, because if their results prove to be generally applicable, only one antigen in each virus may be concerned, and these may be almost identical for one pair of viruses, while that of a third virus may be more remote. The one-sided relationship of the Rous and Fujinami antisera is especially remarkable: while anti-Rous and other sera neutralize only the Rous virus, anti-Fujinami sera inactivate both viruses. The finding that the sera here described show a certain degree of specificity is regarded by the author as evidence for the view that their neutralizing properties are due to true antibodies and not to a non-specific ‘‘ factor ” of the sort extracted from fowl tumors by Murphy, Helmer, Claude and Sturm (Science 73: 266, 1931) and by Sittenfield, Johnson and Jobling (Am. J. Cancer 15: 2275, 1931). The question whether the fowl tumor viruses are best considered as a single or small number of species is an important one, but cannot be answered in the present state of knowledge, F. CAVERS

Growth of Teutschlaender’s Chicken Sarcoma, E. PALUMBO.Sul sarcoma dei polli tip0 Teutschlaender in varie fasi di sviluppo, Gior. ital. d. mal. esot. e trop. 5: 172-181, 1932. This is a description of the rate of growth and the histological character of chicken sarcoma from Teutschlaender’s stock in seven chickens. No new features of the tumor are described. One microscopic drawing and a short bibliography are included. C. D. HAAQENSEN 654. ABSTRACTS

Animal Experiments with Rndiothorium, with Reference to the Treatment of Leukemia. I. Single Doses. 11. Repeated Injections; Combinations with Roentgen Irradiation, I. ZADEK. Tierexperimentelle Ergebnisse mit dem zur Behandlung der Leuklimie verwandeten Radiothorium. I. Einmalige Injec- tionen. 11. Reinjektionen, Kombinationen mit Rhtgenstrahlen, Folia haemat. 47: 418-450, 1932; 48: 210-230, 279-302, 1932. I Various writers have suggested the use of certain salts of thorium, or of certain radioactive degradation products of thorium, in the treatment of malignant disease, administered by intravenous injection. Much also has been written regarding the ill effects that may follow the introduction of such substances into the body. Zadek is specially interested in the irradiation treatment of leukemia, in which x-rays have been largely used with temporary remission of symptoms. He has experimented with animals in order to ascertain (1) the dosage of radiothorium which can be given intravenously without the production of permanently injurious effects, i.e. the tolerated dosage as compared with that causing acute, subacute or chronic poisoning, (2) the amounts in which this element and its breakdown products are stored in various organs, (3) the quantitative excretion of these substances in the urine and stool. Zadek first discusses the relationships of the breakdown derivatives of the parent element thorium. Since radiothorium is isotopic with thorium and occurs in all minerals which contain thorium, it cannot be isolated in a pure state from these minerals. The intermediate element mesothorium can, however, be extracted, and from it radiothorium is obtained by simple lapse of time, measured in terms of the half value period. When introduced into the body, radiothorium acts as an accumulator which provides a practically uniform stream of thorium X to the tissues. Thorium X, like mesothorium and radium, is an alkaline earth metal, hence it might be expected to be concerned in calcium metabolism and have a special affinity for bone [see Martland: Am. J. Cancer 15: 2435, 19311. Radiothorium, like pure thorium, on the other hand, shows in many of its chemical reactions a similarity to iron and would tend to be deposited in the organs richest in iron-the liver and spleen [see, for instance, Guarini: Arch. di radiol. 8: 462, 1932. Abst. in Am. J. Cancer 18: 794, 19331. Mice were first used in the author’s experiments, but all died within a few minutes or hours after injection of 100 electrostatic unita of radiothorium per kilogram of body weight. When the animal’s body was placed on a photographic plate enclosed in light-proof paper there resulted an “ autophotograph ” of the skeleton, liver and spleen. The animals died with acute toxic symptoms, including hemorrhages, mostly in the large bowel; some animals showed anemia and leukopenia, others showed increase of leukocytes, erythrocytes, and hemoglobin. Having decided that mice were too small for accurate dosage, the author continued his studies with rabbits, giving doses varying from 100 down to 10 units per kilogram of body weight, but most of the animals died within a few minutes or hours. Since smaller animals proved unsuitable for investigation, dogs were used for subsequent experiments. For every animal used the author gives numerous blood counts, the body weight at intervals, and electrometric determinations of the radioactive substances excreted in the urine and stools. For those which died the autopsy findings are given, including histologic descriptions of various organs and determinations of the radioactive substances deposited in these organs. The author’s findings may be summarized as follows: (1) High single doses (50 electrostatic units and upwards) caused early death EXPERIMENTAL STUDIES ; ANIMAL TUMORS 655

(within a few days or at most a few weeks) by acute or subacute poisoning in the sense of early or slightly delayed irreparable damage resulting in cachexia, anemia, leukopenia, and lymphocytopenia with hemorrhagic diathesis. (2) Smaller single doses (50 down to 5 units) caused chronic intoxication manifested by metabolic disturbances and blood changes, which in some instances showed remissions but ended fatally within a period of a few months to nearly four years. During this period there was loss of weight, probably due to increasing deposition of radioactive substances in the liver and spleen. There was marked increase in the hemoglobin percentage and the erythrocyte count, with persistent leukopenia, not however accompanied by lymphocytopenia as in the first group. The leukopenia may be due to a radiation effect, the generalized fixation of radiothorium in the tissues, or to induration of the spleen due to selective fixation in that organ. In autopsied animals radiothorium was chiefly stored in the organs of blood metabolism, especially in the liver and to a smaller extent the spleen. It was not usually found in the bones and marrow until about three years after the injection. Thorium X, given in single or divided doses for comparison, showed wide distribution in the bones (as well as in the liver, spleen, kidneys, lungs, etc.) within a few months. (3) The majority of the dogs were given a dosage of 0.4 to 0.9 units, which was well tolerated. The findings were essentially similar qualitatively to those in series 2, but the animals lived longer on the average, and the effects were much less marked. Zadek concludes that the single dosage of radiothorium used in the treatment of human leukemia should not exceed one electrostatic unit per kilogram of body weight. I1 In the second of this series of papers, Zadek describes experiments in which dogs which had survived for three to four years after injection of one unit of radiothorium per kilogram of body weight were given a second dose similar to the first. One animal which was given one unit per kilogram each time showed symptoms of chronic radiothorium poisoning after the second dose, and died with anemia and cachexia eight months later. Another animal received 0.4 unit per kilogram each time and was alive at the time of reporting, six months after the second injection. The resulta show that the difierence between a chronic toxic and a tolerated dose is very small, and that if a dose has been tolerated it should not be repeated until about four years afterwards and should not exceed the original dose of about 0.4 unit per kilogram of body weight. The author found that in other animals which died during the experiments at a period of about three years after their first and only injection, as well as in one of the animals dying after a second injection, only about 50 per cent of the radiothorium was stored in the tissues. He inclines to the view that thorium X fixation in the tissues is the chief cause of chronic poisoning following radiothorium injections. Before experimenting with combinations of x-ray and radiothorium the author made a hematologic study of several dogs which were given x-rays in divided doses (one skin erythema dose to every 20 to 30 kg. body weight), and found that the resulting leukopenia was a reversible change. The gamma rays of x-ray irradiation never led to the cumulative effect on the blood forming organs that is set up by the alpha radiation of radiothorium and thorium X. In the second installment of this paper Zadek gives in succession the results obtained by (a) a single dose of radiothorium, followed by repeated x-ray exposures; (b) a single dose of radiothorium preceded by x-ray exposures; (c) x-ray treatment with repeated injection of radiothorium; (d) combined radiothorium and x-ray treatment (b) plus splenectomy; (e) combined radiothorium and x-ray treatment (c) plus splenectomy. 656 ABSTRACTS

Treatment by x-rays following a single radiothorium injection results in inhibition of granulopoiesis and high-grade anemia. These changes are largely reversible, though the leukopenia set up by the radiothorium remains long per- eistent. The opposite procedure, x-rays followed by radiothorium, resulted in destructive metabolic disturbances, such as to justify the conclusion that in no case should treatment of this kind be attempted in man. Reinjection with radiothorium, with x-ray treatment between the two injections, was well tolerated, provided the two injections were separated by at least two years and both were small. When splenectomy was first performed, the symptomatology of combined radiothorium and x-ray treatment, the inhibition of leukopoiesis, was less marked or absent entirely. This seems to indicate that the induration of the spleen observed in non-splenectorniced animals after radiothorium injection is not the cause of the chronic anemia. The author attributes this anemia to the action of the stored radiothorium and the continued spread into the tissues of its daughter element thorium X. F. CAVERS Cancer and Tuberculosis, G. AYELLO. Cancro e tubercolosi, Rass. di clin., terap. e so. aff. 31: 12-18, 1932. The author describes a series of experiments with dogs to test the theory of the incompatibility of cancer and tuberculosis. The tuberculous material was inoculated intradermally or intravenously. The neoplasm was transplanted to the scrotum or, to insure a take, material rich in neoplastic cells WBB injected. In the first experiment six dogs were simultaneously treated with cancer and tuberculosis, one with cancer alone and one with tuberculosis alone. Four dogs developed typical signs of both diseases and showed a more rapid and severe decline than the dogs developing either disease alone. In the second controlled experiment six dogs were inoculated with tuberculosis and were treated with cancer after the disease was well established. In these animals rapidly growing cancers developed in the presence of a aevere active tuberculosis. In a third controlled experiment six animals were inoculated with tuberculosis after the development of typical cancer and all showed active tuberculosis at autopsy. In a fourth controlled experiment six animals were splenectomiaed previous to the tumor transplantation, then inoculated with tuberculosis later to see whether the preaence of a tumor of increased virulence would prevent the development of tuberculosis. These animals, too, showed both diseases active at the time of autopsy. The author reviews the literature, giving excerpts of clinical cases showing the presence of both diseases simultaneously. He concludes that cancer and tuberculosis are distinct clinical entities which can exist in the same organism; that one disease may antedate the other and yet both evolve independently without the presence of one affecting the development of the other; that the simultaneous presence of both gives a more severe clinical picture than where either disease occurs alone; in other words that the supposed antagonism is purely hypothetical. [The author fails to state what tumor he used in theee experiments. The only transplantable tumor in dogs is the so-called " infectious " lymphosarcoma which occurs among these animals.] JEANNETTEMUNRO Relation between Local Infections and Cancer, R. VINZENT. Relation entre les infections locales et la canc&isation, Paris m6d. 1: 241-249, 1933. A general discussion of cancer arising in chronic infections such as lupus, syphilis, tuberculosis, and actinomycosis. Animal experiments are reported which are the same as those previously published by Lacassagne in Compt. rend. SOC.de biol. 112: 562, 1933 (Abst. in Am. J. Cancer 18: 628, 1933). EXPERIMENTAL STUDIES ; ANIMAL TUMORS 657

Myeloid Deposits in Tissues Other Than Bone Marrow, K. LIVADAS. uber myeloide Herdbildung, Folia haematol. 49: 388-401, 1933. Some writers on disorders of the hematopoietic system have considered that the myeloid deposits in tissues other than the bone marrow arise from autochthonous cells by a process of metaplasia, others that they are metastatic, the myeloid cells arising in the bone marrow and being carried by the blood to other tissues and organs. Some writers have reported the formation of myeloid deposits in the liver and spleen of animals rendered anemic by being bled, while according to a second group of workers this occurs only when bleeding coincides with infection. The author points out that spontaneous jnfectione are common in laboratory animals, especially the rabbit. Firket (Compt. rend. SOC.de biol. 85: 730, 1921) reported that after intravenous saponin injections the bone marrow of rabbits showed dilatation of the blood vessels, with hemorrhages. The author used 19 rabbits, which are divided into five groups according to whether the animals (1) were treated by saponin alone or (2) by bleeding alone, or (3) were bled once or several times and then given saponin injections, or (4) were given x-radiation alone or followed by saponin treatment, or (5) were bled, splenectomiaed and then given saponin injections. He found that saponin used alone caused myeloid deposits in the spleen or liver or both in healthy animals, while bleeding alone did so only if the animal showed previous infection; similarly, in non-infected irradiated animals myeloid deposits were found only after subsequent saponin treatment. From these findings the author concludes that myeloid changes in the spleen and liver in blood diseases result from the metastatic migration of bone marrow cells. [The number of animals used in these experiments is, of course, very small.] F. CAVERS Influence of Complex Organo-metal Compounds and of Roentgen Rays on the Distribution of Lead in Organs and Tumors, E. FLINT,P. L. GUNTHERAND F. EICHHOLTZ.Wirkung von Komplexbildnern und Rontgenstrahlen addie Verteilung von Blei in Organen und Tumoren, Arch. f. exper. Path. u. Pharma- kol. 169: 618-624, 1933. Several writers have reported that when lead is administered to animals, or to patients, bearing malignant neoplasms, the tumors absorb and store a larger percentage of the lead than do the normal tissues and organs. Other writers have failed to find such a selective absorption either in animals or in man. There appears to be considerable diversity of findings, also, in the reports of those who have attempted to induce or to enhance such selective absorption by (1) combining the lead with various substances, chiefly organic compounds which are capable of building up heavy metal complexes, or (2) supplementing lead treatment by roentgen irradiation before or after the administration of the metal in various forms. The authors report the results of experiments with sarcoma-bearing white rats [tumor strain not stated]. The method of multiple successive tumor inoculation was used, so that the storage of lead could be determined in tumors showing various stages of growth. In one series the lead was combined with a large number of different compounds, and in a second series the animals were given roentgen irradiation to the tumors after the injection. In both series the amounts of lead in the tumor, the liver, and the spleen were determined, and in neither series was there evidence of increased or selective absorption by the tumors. The authors do not draw from the results of their experiments any conclusions regarding the therapeutic use of lead in malignant disease. In their brief discussion of experimental results they make special mention of F. C. Wood’s finding that lead was stored in the necrotic central parts of the animal tumors studied by him; none of the tumors examined by them showed necrosis. F. CAVERS 658 ABSTRACTS

Effects of Necrobiotic Agents on the Walls of Cysts Experimentally Produced in the Brains of Dogs, R. ZOLLINQERAND A. R. MORITZ.Arch. Neurol. & Psychiat. 28: 1046-1055, 1932. An investigation was made to determine the necrobiotic and hemostatic properties of several of the more commonly used fixatives upon cysts. While Zenker’s fluid has been used extensively in dealing with intracranial tumors, this fixative would seem particularly unsuitable because of its slow penetration. Experimental cysts were produced in the frontal lobes of dogs by the injection into the brain substance of a mixture of paraffin and petrolatum. One month after the production of a brain cyst the dog was reoperated upon and the cyst treated with one of several common fixatives. Forty per cent formaldehyde caused extensive changes both in the cyst and in the adjacent brain tissue. Zenker’s fluid likewise caused marked changes in the connective-tissue cyst lining, often with collapse of the cyst. Carnoy’s fluid caused a necrosis which was considered the most satisfactory. Walls of cysts were also treated with glacial acetic acid, phenol and trichloracetic acid, but these agents produced such severe inflammatory reactions even following short applics- tions that they were rejected a8 being unsuitable for further study. With Carnoy’s fluid the treated tiaeue was killed by coagulation for a depth of about 2 mm. following an application of the fixative for between two and three minutes. Blood vessels were thrombosed, and there waa relatively little collateral inflammation or edema in the adjacent tissue of the brain. Other agents, including 40 per cent formaldehyde and Zenker’s fluid, were as efficacious in producing necrosis but were not deRirable because of the severe collateral inflammation of the tissue of the brain. [This should prove of interest to the neuro-surgeon. The authors’ experiments included histological studies and definitely place Carnoy’s fluid above the more commonly used formaldehyde or Zenker’s fluid in treating such cysts.] EDWINM. DEERY

Influence of Acid and Phosphate on Metastatic Calcification, D. J. STEPHENBAND D. P. BARR. Proc. 800. Exper. Biol. & Med. 30: 920-924, 1933. Extensive calcification of the soft tissues was produced in rats by diets containing excess amounts of calcium, phosphorus, and acid. Calcification did not take place unless all three of the above constituents were in excess. The structures most frequently affected were the kidneys and the pulmonary artery. H. Q. WOODARD Behavior of Skin towards Solutions of Various Kinds and Various Concentrations, IV. Examination of the Swelling of Pathological Skins, EIICHI N~SRIMURA. Japanese J. Dermat. and Urol. 33: 204-225, 1933. An artificial ecaematous dermatitis caused by an application of croton oil to the epilated back of a rabbit, a skin sarcoma caused by an injection of emulsion of Kato rabbit sarcoma, and a piece of carcinoma of the human penis were compared with normal human and rabbit skins in 0.2N solutions of KCl, NaCl, LiCl, CaCL, MgC12, BaC12, KI, KBr, KNOs, K&Os and K2S04 at 0’ C. for ten days. The rate of swelling of the pathological skins was much less than that of the normal skin, and some of them even showed shrinking and a decrease in weight. K. SUIXURA EXPERIMENTAL STUDIES ; ANIMAL TUMORS 659

Studies in Tissue Metabolism: I. Vitamin BI and the Coenzyme of Lactic Dehy- drogenase. XI. The Inhibition of Lactic Dehydrogenase by Derivatives of Carcinogenic Compounds, E. BOYLAND.Biochem. J. 27: 786-790, 791-801, 1933. The experiments described in the first of these papers showed that crude vitamin B, concentrates resemble Szent-Gyorgyi’s lactic dehydrogenase preparation in enabling washed heart muscle to oxidize lactate, but purified preparations of the enzyme did not behave in this way. Washed heart muscle, which oxidizes lactate only on the addition of Szent-Gyorgyi’s coenzyme, oxidizes pyruvate and succinate without the addition of any coenzyme. The respiration of Jensen rat sarcoma in the presence of lactate was not increased by the addition of the coenzyme or of vitamin B1 solution. In the second paper the author’s object was to ascertain whether the action of the carcinogenic pure hydrocarbons on enzyme systems might give some indication of the biochemical changes occurring in tumor production. Keilin (Roc. Roy. SOC.104 B: 206, 1929) showed that the respiratory system of most cells can be divided into three parts: (1) indophenol oxidase, or respiratory ferment of Warburg, which activates oxygen; (2) cytochrome, a reversibly reducible pigment which acts as oxygen carrier; (3) the hydrogenases, e.g. lactic dehydrogenase which activates lactic acid so that it can reduce cytochrome or methylene blue. The respiration of tumors is greatly increased by the addition of p-phenyl- enediamine, showing that there is ample oxidase or ‘I respiratory enzyme.” Cytochrome has been found in most malignant tissues examined. The defect of malignant tissue in lactate oxidation is therefore probably due to deficiency in dehydrogenase. The derivatives of carcinogenic hydrocarbons influence the action of indophenol oxidase, but they are able to inhibit the dehydrogenase systems in which cancer cells are deficient. The author gives tables showing the percentage inhibition of lactic dehydro- genation produced by cyclohexane solutions of numerous hydrocarbons irradiated in ultra-violet light. Apart from anthracene, only 4 of the 47 non-carcinogenic hydrocarbons in the amounts used (0.2 C.C. of 1 in 10,000 solution irradiated for twenty-four hours) produced more than 25 per cent inhibition. Most of the known carcinogenic compounds produced over 30 per cent inhibition. The author points out that preliminary work with a few of the hydrocarbons in benzene solution seemed to show that the extent to which the photochemical oxidation products of these substances inhibited dehydrogenating enzymes ran parallel with the carcinogenic activity of the substance. This might have proved a useful rapid test of carcinogenesis, but further work on fifty substances in cyclohexane showed the parallelism to be very rough, since, for example, anthracene and cholesterol, which are non-carcinogenic, were oxidized to powerful inhibitory substances. This effect on dehydrogenase might explain the mechanism of cancer production by carcinogenic hydrocarbons. If the dehydrogenating enzymes of the tissues were destroyed, there would be a tendency to local accumulation of lactic acid. Tumor cells survive and grow in media containing lactic acid and are probably less affected by it than normal cells. If in tissue in which dehydrogenase were destroyed a malignant cell were to appear, it would be at a great advantage and would grow at the expense of normal cells. It is possible that the active oxidation produot of the hydrocarbons studied by the author is of a peroxide nature and destroys the enzyme by oxidation. Such an oxidation to a peroxide may occur in the body, and the oxidative destruction of the enzyme might yield a product capable of reoxidation to an active product. By this means a small quantity of hydrocarbon may inactivate many molecules of enzyme in the body. F. CAVERS 660 ABSTRACTS

Note on Glutathione and Vitamin C in Tumour Tissue, E. BOYLAND.Biochem. J. 27: 802-805, 1933. Vitamin C and the hexuronic acid of suprarenal tissue (ascorbic acid) were found to be identical by Svirbely and Szent-GyBrgyi (Nature 129: 576, 1932). The identity has been confirmed by later writers, and led to the chemical estimation of vitamin C by Burch, Harris and Ray (ibid. 131: 273, 1933). It has recently been found by Birch and Dann (ibid. 131: 469, 1933) that determinations of glutathione in tissues by the methods of iodine titration are probably too high, because in such a titration iodine would be reduced not only by sulphydryl groups but also by ascorbic acid. Thus in an acid extract of suprarenal cortex as much as 77 per cent of the total iodine required may react with ascorbic acid and only 23 per cent with glutathione. Simultaneously Bierich and Rosenbohm [Ztschr. f. phyeiol. Chem. 215: 151, 1933, cited incorrectly in the author’s bibliography, owing to the transposition of two titlea] found that the figures normally given for the glutathione content of tissues by iodine titration were about three times too high and that some other reducing substance, which they called “ x,” was preaent. This conclusion was arrived at by comparison of results obtained by iodine titration and by a colorimetric method of estimating glutathione, and the suggestion was made that the other reducing substance might be the hexuronic acid (ascorbic acid) of Seent-GyBrgyi. Boyland has made determinations of this acid and of glutathione in normal and in tumor tissue (sarcomas of mouse, rat, and fowl, and carcinoma of mouse). The ascorbic acid was estimated by titration against 2 : 6-dichlorophenolindo- phenol, and the glutathione by a colorimetric (nitroprusside) method similar to that of Bierich and Rosenbohm. The findings show that the method of iodine titration of acid extracts of tissues, using starch as indicator, gives a value which includes both the ascorbic acid and the glutathione. The amounts of glutathione in the tumors, determined colorirnetrically, were about the same as in muscle and less than in liver. In a footnote it is stated that later biologic tests on Jensen rat sarcoma indicate that the substance in tumors which reducea 2 : 6-dichloro- phenolindophenol, and is called ascorbic acid in this paper, is not ascorbic acid. Hence malignant tissue must contain considerable quantities of some unidentified reducing substance. [The author’s experiments on animal tumors agree with those of various writers who have studied the distribution of glutathione in human tumors and have failed to establish any relationship between malignancy and glutathione content (for instance see Jura: Policlinico (ses. chir.) 37: 371, 1930. Abst. in Am. J. Cancer 15: 2877, 1931).] F. CAVERS

Respiration of Brain in Vitro in the Presence of a Carcinogenic Agent 1 :2 : 5 : 6- dibenzanthracene, Y. POURBAIX.Respiration des coupes de cerveau in uitro en presence d’un corps pur canc6righne, le 1-2 5-6 dibenehne anthrachne, Compt. rend. Soc. de biol. 113: 930-933, 1933. The respiration of brain in vitro was diminished by the presence of a carcinogenic agent, 1 : 2 : 5 : 6-dibensanthracene1though large amounts of this substance inhibited less than smaller ones. Brain respiration was not so much depressed as liver [see Am. J. Cancer 19: 415, 19331. WM.H. WOGLOM Influence of Roentgen Irradiation on the Carbohydrate Metabolism of Normal Animal Tissues, T. ULLMANN.tfber die Einwirkung der RSntgenstrahlen auf den Kohlehydratstoffwechsel normaler tierischer Gewebe, Strahlentherapie 46: 705-712, 1933. It was reported by Jaroschka (Strahlentherapie 28: 784, 1929) that the glycogen content of the malignant tissue in a case of carcinoma of the uterine cervis EXPERIMENTAL STUDIES ; ANIMAL TUMOILS 66 1 increased by nearly 300 per cent after x-ray treatment with a dosage of 100 per cent skin dose. Hence he concluded that the x-ray treatment had caused considerable inhibition of the glycogen-splitting enzyme. On the other hand, various writers have found that animals exposed to x-ray irradiation show a decided increase in blood sugar and diminution of the glycogen in the liver, suggesting that the loss of liver glycogen had caused the hyperglycemia. The author determined the glycogen content of various normal organs and tissues of the rat before and after exposure to x-ray irradiation. He found that the greatest reduction (by 42 per cent) occurred in the testis. For each organ investigated, the loss of glycogen was in direct proportion to the time duration and size of the dose. The conclusion is reached that the inhibition of glycolysis following irradiation can be explained only as resulting from primary changes in cell structure, probably consisting in a disturbance of the colloid-electrolyte system of the cell, set up by the radiant energy. F. CAVERS

Influence of Methylene Blue, Neutral Red and Malachite Green on Basal Metab- olism in the Rat, A. H. ROFFOAND R. LOPEZRAMIREZ. Metabolism0 basal y colorantes: azul de metileno, rojo neutro y verde de malaquita (en ratas), Bol. Inst. de med. exper. para el estud. y trat. del chncer 9: 91-95, 1932. The present investigation was suggested by the results of Roffo's earlier experiments on the action of methylene blue and other dyes on the growth of normal and neoplastic tissues. It is assumed that methylene blue acts mainly as an oxidising body, and to a lesser extent as a reducing substance, that neutral red causes reduction alone, and that the action of malachite green remains in doubt. The three dyes were used in solutions of 1.75, 1.58, and 1 per cent respectively, and in each case 10 control and 10 intravenously injected rats were used in the determination of the basal metabolism. The tabulated results show that methylene blue caused an average reduction of the basal metabolism of nearly 40 per cent, while no constant variation was observed in animals injected with the neutral red and malachite green. The dosage of each dye was very close to the fatal toxic dose for the rat. F. CAVERS

Infiuence of Methylene Blue on Glycolysis, in Normal and Neoplastic Tissues in Vitro, A. H. ROFFO. Acci6n del azul de metileno sobre la glucolisis. Estudi- ada en 10s cultivos de tejidos normales y neopl6sicos desarrollados in uitro, Bol. Inst. de med. exper. para el estud. y trat. del chcer 9: 27-43, 1932. The author set up eleven series of tissue cultures; in five embryo chicken heart waa used and in the remainder spindle-cell rat sarcoma. In each series he added glucose to the plasma used as the medium, and determined the amount of diminution of glucose after the addition of three dilutions of methylene blue (1 : 5000, 1 : 10,000, 1 : 20,000) to (1) the plasma-glucose medium alone, kept at room temperature, (2) the same, kept at 38" for forty-eight hours, (3) the same plus either chicken heart or rat sarcoma, kept at 38" for forty-eight hours. In the cultures of normal chicken heart and rat tumor the glycolysis was about the same, being about twice as great as in the cultures with plasma and glucose alone. [As no mention is made of the glycolysis of cultures to which no methylene blue had been added, this paper throws no light on the question of the influence of methylene blue upon tissue glycolysis, such as might have been obtained had control cultures been studied.] In the tissue cultures to which the highest concentration of the dye was added, glycolysis was greatest and the amount of tissue growth least, being, indeed, absent or extremely feeble, and vice versa. Since roughly half as much glucose disappeared when the dye was added to glucose plasma without tissue, it occurred to the author that this result might be attributed to catalysis or to enzyme action. He therefore repeated the experiment 32 662 ABSTRAOTS determining the amount of glucose in the medium immediately [time interval not stated) after adding the dye instead of after forty-eight hours, and found that a considerable amount of gluoose had disappeared. The author says in hie conclusion that his experiments show that another factor than oxidation is concerned, a factor related to the growth of the cells, because the percentage of glycolysis was highest when there was abundant cell development and lowest when growth WBB absent or hardly visible. [This contradicts the tabulated results given in the body of the paper, which show that, as might be expected, high concentration of methylene blue inhibited the growth of the tissues used, though, according to the author’s findings, causing the disappearance of a larger amount of glucose. This confusion makes it difficult to follow the author’s de- ductions. Some of his conclusions are certainly not supported by any results reported in this article. Other workers have obtained very irregular results in experiments on the influence of methylene blue and other reversibly oxidized or reduced dyes on respiration and glycolysis (Barron: J. Exper. Med. 52: 447, 1930; Soffer: Bull. Johns Hopkins Hosp. 49: 320, 1931, abst. in Am. J. Cancer 16: abet. p. 526, 1932).] F. CAVERB Cholestero~y8isInduced by Methylene Blue in Cultures of Normal and Neoplastic TiSSUQS, A. H. ROFFO.Colesterolisis provocada por el azul de metileno. Experimentacih desarrollada en las culturas de tejidos normales y neoplhicos in uifro, Bol. Inst. de med. exper. para el estud. y trat. del cancer 9: 185-199, 1932. The experiments here reported were arranged in much the same way as those made on glycolysis (see preceding Abstract). The tables give the results of four series of cultures of embryo chicken heart and four of rat sarcoma. The amount of cholesterol which disappeared wagl increased in culture media, without tissue, kept for forty-eight hours at 38’ in comparison with those kept at room temperature, while with the addition of normal or neoplastic tissue the cholesterolysis was in most cases increased further. The tables also show for the most part only slight differences in respect of cholesterol diminution between the cultures of normal and those of neoplastic tissue. [All the same, the author’s method of using for comparative experimentation tissues from two remotely different species is quite indefensible.] F. CAVERS

Influence of Fluorescein Dedvatives on Growth of Normal and Neoplastic TiSSUeS in Cultures, A. H. ROFFOAND 0. CALCAQNO.Los derivados de la fluoresceins y su influencia sobre la multiplicaci6n celular en 10s cultivos de tejidos normales y neoplhsicos in uitro, Bol. Inst. de med. exper. para el estud. y trat. del cancer 9: 69-90, 1932. The authors have investigated the influence of one hundred and seventeen daerent salts of fluorescein halogen derivatives on the growth of normal and neoplastic tissue (ten-day ohicken heart and spindle cell rat sarcoma) in uitro. The results are interpreted as showing that all these compounds exerted an inhibitory action, whose magnitude was directly proportional to the atomic mass of the halogen entering into the molecular structure of the resorcin group. The nature of the base present in the salt did not influence the action of the latter, with the exception of the calcium Balt of tetra-iodofluorescein, which required to be more highly diluted than any of the others to allow of tissue growth. There was observed in most cases a greater inhibition of the growth of neoplastic rat tissue than of normal chicken embryo tissue, usually about twice as great but rising to five times as great with some of the compounds used, notably some of those containing chlorine. The results are set out in tabular form. [Since for the majority of the compounds tested five dilutions were used, thie EXPERIMENTAL STUDIES ; ANIMAL TUMOFt8 663

article represents the results of well over one thousand tissue culture experiments. It is a pity that so much energy should be expended on a piece of research vitiated by the adoption of the strange method of comparing results which are not strictly comparable. Cultures of rat fibroblasts should have been used for comparison with rat sarcoma.] F. CAVERS

Serologic Analysis of Human Sarcomatous Tissue, E. WITEBSKYAND E. MORELLI. Zur serologischen Analyse des Sarkomgewebes, Ztschr. f. Immunitatsforsch. u. exper. Therap. 78: 179-196, 1933. The complexity of the antigen problem has been emphasized by various writers, especially by Lehmann-Facius [see Frankfurt. Ztschr. f. Path. 41: 521, 1931, and a later more condensed account of the same work-not cited by the authors- abstracted in Am. J. Cancer 16: abst. p. 1250, 19321, and by Klopstock and Simon (Abst. in Am. J. Cancer 16: abst. p. 1277, 1932), who agreed that the existence of tumor-specific antigens had not been definitely proved. Reference to the two abstracts cited, particularly the second, will enable the reader to understand the two main questions which Witebsky and Morelli attempt to answer in this paper: (1) whether tumor-specific substances actually exist in human sarcoma cells and can be recognized by serologic methods; (2) whether serologic relations exist between sarcoma and carcinoma. The authors subjected to extensive serologic analysis two human sarcomas, both occurring in individuals of blood group A. The findings are set forth in eight detailed tables, which cannot be abstracted here. An unusual and welcome feature of this paper is that the authors, after describing and tabulating each series of experiments, give a clear summary of their findings for the series. The gist of these findings is as follows. The antisera obtained by injection of emulsions of human sarcoma into rabbits gave a marked reaction with human sarcoma extracts and a feebler reaction with extracts of normal human tissues. The sarcoma-specific quota was enhanced by the addition of lecithin. The two human sarcoma extracts used differed from the human carcinoma extracts so far investigated serologically in being devoid of a group-specific quota, and they did not contain a larger amount of unspecific and species-specific lipoids than the normal human organ extracts tested. Alcoholic extracts of rat sarcoma like those of Rous sarcoma, failed to react with human sarcoma antiserum. In absorption experiments, treatment of the sarcoma antiserum with normal organ extracts inhibited the corresponding antibody function (tissue-specific antigen), leaving unchanged the antibody quota against sarcoma and carcinoma extracts; treatment with sarcoma extracts left the antiserum deprived of all antibodies; treatment with Carcinoma extracts deprived the antiserum of the antibody quota against carcinoma extract, but left intact, and in some cases solely, an antibody against sarcoma. The authors, as might be expected in view of their extensive experience in immunologic research and realization of the complexity of the problems involved, refrain from theoretic discussion of their own findings and those of others. F. CAVERS Hemolysis in DiiTerent Species of Animals, A. H. ROFFO. La eritrosinhemolisis en relaci6n con la especie animal, Bol. Inst. de med. exper. para el estud. y trat. del c&ncer 9: 59-68, 1932. Also in Rev. Asoc. m6d. argent. 46: 1684-1690, 1932 and Rev. mbd. latino-am. 18: 294-301, 1932. Various writers have stated that the erythrocytes of cancerous animals and man are more fragile and more readily hemolysed by various agents than those of normal individuals. The author in an earlier paper confirmed this, using a fluorescein derivative as hemolytic agent. In the present paper he has determined by this method the hemolysis time for the blood of normal animals of various species. No hemolysis was observed in animals with nucleated erythrocytes 664 ABSTRACTS

(frog, toad, and four species of birds) and in some of the herbivorous mammals (sheep, ass, horse) ; in other herbivora (guinea-pig, rabbit, cow) hemolysis was present, but in the cow it was very slow. It was observed in the carnivorous and omnivorous species tested (man, rat, pig, cat). In man the age, and in rats the body weight, had no influence on the rate of hemolysis. The author considers that the fact that hemolysis induced by fluorescein derivatives is greater in proportion to the amount of lipoids in the food supports the view that high cholesterol content is an important factor in carcinogenesis, since a similar relationship between lipoid (especially cholesterol) content and such hemolysis has been demonstrated in tumor-bearing animals and men. F. CAVERS Hemolyds in Relation to Feeding, A. H. ROFFO.La eritrosinhemolisis en relaci6n con la alimentacih, Bol. Inst. de med. exper. para el estud. y trat. del c&ncer 9: 200-209, 1932. Using fluorescein as a hemolytic agent (see preceding Abstract), the author has determined the hemolysis time in twenty lots of rats, those of one lot being killed after twenty hours of fasting, while the others were killed from one to nineteen hours after being fed. In the latter, there was on the whole an average (but individually very irregular) diminution in the rate of hemolysis with increase in the interval after which the animals were killed. A curious feature is that the animals killed after a fast of twenty hours showed a slower average hemolysis rate than those which predeceased them, until we go back to those killed six hours after a meal, when the average hemolysis time is the same as for the twenty-hour fasting animals. [The author’s conclusions, in so far as they are baaed on the experiments here reported, are o$n to objections. For instance, the number of rats which fasted for twenty hours was very much larger than any of the lots killed hour by hour up to the nineteenth hour. The only fair method of obtaining comparable averages is, surely, to use the same number of animale in each lot; not to compare a lot of over 20 with much smaller lob (nine of only five, animals, two of eight, and seven of ten). Averages obtained in this way cannot be used as a baais for any conclusions whatever.] The author in his summary ascribes the diminution of the hemolysis after meals to “ the lipoid increase caused by an exogenous (nutrition) and an endogenous influence, principally 4f the spleen. This is, on the other hand, in relation to the fact observed in the red blood corpuscles of patients suffering from cancer, in whom hemolysis provoked by erythrosin is also notably diminished, and this [diminution] is equally in relation to the lipoid increase in these patients.” The author believes that the explanation of all these things depends on the osmosis- regulating properties of the cell membrane, the lipoid content of this membrane being apparently increased in cancer patients, and also in normal persons during digestion.. F. CAVERS On the Physiological Effects of Radio Waves, JOSEPH L. DONNELLY.Science 78: 290, 1933. The statement is frequently made that only living material is heated when exposed to short wavelengths of radio frequency. The authors submitted concentrated solutions of various electrolytes such as potassium chloride, barium chloride, acetic acid, sulphuric acid, and sodium hydroxide to the influence of these waves. Concentrated solutions were slightly heated and the intensity of the heating increased to a maximum with dilution, decreasing with further dilution. The amount of heating varied with the specific electrical conductivity of the solution. Thus, normal acetic acid, having a higher resistance, was heated more than normal sulphuric acid. It is probable that the heating of egg white, sugar solutions, and gelatine is EXPSRIMENTAL STUDIE6 ; ANIMAL TUMORS 665

due to contaminating electrolytes. Dilute solutions of purified dextrose were not heated by high-frequency currents. Pure phenol was not heated, nor did solutions in water show any rise in temperature. The author feels that these experiments have a bearing on the results obtained by Schereschewsky and Andervont (Public Health Reports 43: 927, 1928) and McLennan and Burton (Canadian Journal of Research 5: 550, 1931) on transplantable tumors. The writer believes that the selective effects observed are due to the fact that neoplastic tissues are richer in water than normal tissues, hence the electrolytes are diluted so that a maximum effect occurs in contrast to the drier normal tissues.

Changes in Susceptibility of Drosophila Eggs to X-Rays. 1. A Correlation of Changes in Radiosensitivity with Stages in Development, P. S. HENSHAW AND C. T. HENBHAW.Radiology 21: 239-251, 1933. The authors, after a long series of experiments, confirm the results which Packard has obtained in measuring x-radiation with the eggs of Drosophila.

Impromptu Remarks on Cancer, CHARLESH. MAYO. Wisconsin M. J. 31: 383- 384, 1932. Brief remarks touching, among other things, on the occurrence of cancer in plants and animals.

Gastric Cancer in the Mouse, L. MERCIERAND L. GOBSELIN. Cancers gastriques chez la Souria, Compt. rend. SOC.de biol. 113: 669-670, 1933. A papillary carcinoma of the prostomach and a lymphosarcoma involving the glandular portion of the organ are described. The former was discovered in a male mouse that died four months after having received an intraperitoneal injection of 0.5 C.C. of tar diluted with olive oil. Mice that have been thus treated often suffer an extensive loss of hair, much of which ultimately reaches the stomach to collect in the form of a hair-ball; in the present instance the fur had been soiled with the injected material and the hair-ball which was present, and to which the authors refer the tumor, was no doubt contaminated with tar. As the lymphosarcoma Occurred in a female with generalized lymphosarcoma (lungs and lymph-nodes), it is impossible to decide whether it was a primary or a secondary growth. WM.H. WOGLOM Association of an Abdominal Tumor and a Parasite in a Fish (Preliminary Note), HARANTAND VERNI~ES. Association parasitaire et tumeur abdominale chez un Poisson (Note prbliminaire), Arch. SOC.d. sc. med. et biol. de Montpellier 14: 154-159, 1933. The authors describe a nodular granuloma in a minnow. WM.H. WOQLOM

Cervical Chordoma in a Dog, V. BALLAND L. AUGER. Chordome cervical chez un chien, Bull. de 1’Acad. de m6d. 107: 663, 1932. A cocker spaniel, aged six years, showed on the antero-superior region of it8 neck a hard tumor which was flattened against the spinal column and measured 6 cm. in diameter and 3 to 4 cm. in thickness. At operation the tumor was found to be ill-defined in its deeper portion. Histologically it was a typical chordoma; some of the neoplastic columns showed a central cavity. Twenty days after operation there was local recurrence, nearly a8 extensive as the original tumor. X-ray treatment did not cause diminution of the mass, and two months later the tumor had grown so much larger that the animal had to be killed. The owner refused to allow autopsy. F. Camas 666 ABSTRAOTS

Removal of a Tumor from the Cervix Uteri of a Cow, H. 5. CALDWELL.Veterin. Rec. 13: 688, 1933. A cow at her fourth calving had been straining for several hours. Above the calf’s fore feet, the author found a large, smooth, round tumor growing from the postero-superior region of the cervix. He gave an analgesic injection, passed the wire of an embryotome over the top of the tumor and enucleated the latter, the cow continuing to eat hay throughout the operation. The tumor, a fibroid, weighed 10 pounds. The calf pushed its head through the cleared passage and was easily delivered, and the cow made an uneventful recovery after vaginal cleansing and the insertion of pessaries. F. CAVER0

THE CANCER CELL

The Cancer Problem, W. CEELEN. Uber das Krebsproblem, Ztschr. f. iirzt. Fortbild. 30: 313-317, 1933. In this excellent general statement of the present state of knowledge and opinion concerning malignant disease, the author aptly remarks that theoriaing about cancer is not a new thing but has been indulged in for many centuries [see Haagen- Ben’s valuable historic review, Am. J. Cancer 18: 42-126, 19331. Even now there exists considerable confusion between true tumors and various tumor-like prolifera- tions which have either been already proved, or are likely on further investigation to prove, to have their origin in infective, regenerative, or reparative tissue formation. The author then deals with the morphologic, physical, and chemical characteristics of the malignant cell. [Some of the recent findings, or at any rate the interpretations founded on these, which are mentioned here seem fated to fall before long into the category of the older erroneous speculations to which the author refers earlier in this paper.] Ceelen believes that recent researches indicate that in a final analysis the transformation of a normal cell into a cancer cell will be found to depend upon changes in the pericellular fluid, and that the cancer problem will therefore resolve itself into a metabolic problem. Setting aside these still unsettled problems, the author stresees the importance of thorough casuistic and clinical investigation of single cases. In this the family physician can play a large part, by increasing the proportion of cases diagnosed at a sufficiently early stage for successful treatment and by promptly referring these and all doubtful cases to hospitals or Specialists with modern equipment, for fuller and more accurate study. F. CAVERS The Nature of the Cancer Cell, R. ROOBEN. Die charakteristische Eigenschaft der Krebszelle, Fortschr. d. Med. 51: 387-388, 1933. This paper consists merely in a summary of material previously published by the author [see abstract in Am. J. Cancer 15: 2892, 1931, and book review, ibid. 16: 223, 19321. His theory is that the one and only cause of malignancy is the increased osmotic pressure set up in the cancer cell by virtue of its greater power, as compared with normal cells, of imbibing fluid from the intercellular spaces. In a single paragraph on treatment, he points out that the obvious methods are those which will diminish the increased intracellular pressure of the cancer cell, e.g. the introduction into the tumor cells of substances which act as astringents (salts of bismuth, lead, or calcium) or such as act osmotically (strong sugar solutions or isamine blue and some other dyes). [As Roosen’s recent publications have been previously and adequately dealt with in this Journal, it remains only to add that his imbibition discovery waa anticipated, by some twenty yeam, by W. Cramer. 1 F. CAVERS THE OANOER OELL 667

Fundamental Facts of the Histophysiology of Cancer Cells, E. GRYNFELTT. Quelques donn6es fondamentales de l’histophysiologie des cellules canc6reuse8, Montpellier m6d. 76: 287-300, 1933. A vague general discussion of necrohormones, “ humoral alterations,” hereditary predisposition, histological peculiarities, chemical changes, methods of diagnosis, etc., which are supposed to be of importance in the study of cancer. Many authors are mentioned, but there is no bibliography, and no experimental work is preaented. H. Q. WOODARD

Discussion of the Metabolism of the Cancer Cell, J. TURCHINI,J. BROUSSY, AND R. LAUTIB. De quelques considbrations sur le m6tabolisme de la cellule cancbreuse, Montpellier m6d. 76: 311-314, 1933. After a discussion of the well known peculiarities of the carbohydrate metab- ohm of the cancer cell, the authors suggest that any external factor which causes the partial asphyxiation of a normal cell when it is in the process of multiplication will favor its transformation into a cancer cell. H. Q. WOODARD Intracelluler Hydrion Concentration Studies. V. Colorimetric pH of Malignant Cells in Tissue Culture, R. CHAMBERSAND R. J. LUDFORD.Proc. Roy. SOC., Series B, London 110: 120-124, 1932. The authors describe the technic for the intracellular injection of indicators for the determination of the pH of the different cell constituents. They find the pH of the cytoplasm of mouse mammary carcinoma 27, mouse tar carcinoma 2146, Crocker mouse sarcoma 180, and normal mouse mammary gland, all in tissue culture, to be between 6.4 and 7.0. The nuclei of the same cells have a pH above 7.2. If the cytoplasm was injured, its pH fell to 5.6 or below, but the pH of the nucleus did not change on injury. H. Q. WOODARD Recognition of Cancer Cells in Cytodiagnosis, I. ZADEK. Die cytodiagnostischen Kennzeichen der Krebszellen, Acta Med. Scandinav. 80:78-92, 1933. Fresh cells in centrifuged exudates from the thorax or abdomen are stained in Quensel’s watery solution of methylene blue-cadmium and Sudan-cadmium (Grlibler). [See Quensel: Acta. Med. Scandinav., Supplement XXIII, 1928.1 One characteristic of the cancer cell is the extraordinary rapidity with which it stains-an average of two or three minutes only being required as compared with about ten for lining cells from the serous membranes. While this property may represent a specific feature, it is much more probable that the readiness with which the tumor cell stains is referable to the degeneration which so often overtakes it. In any case, the difference offers a valuable means of differentiation. A second characteristic is the agglomeration of cancer cells in compact, sharply outlined masses, often with jagged contours, whereas cells from a serous membrane lie in sheets that are but one cell thick and have indeterminate frayed edges. A third property distinguishing the cancer cell, though not perhaps with any great constancy, is a tendency to the formation of “ giant vacuoles,” 40-90 p in diameter. Contrary to an often expressed belief, smaller cells of the signet-ring type are not indicative of malignancy, nor is fatty or hydropic degeneration, cloudy swelling, or phagocytosis. The most characteristic of all features, and one which no other morphological variation in cell or nucleus can even approach in diagnostic value, is the nucleolus- nucleus ratio [a point upon which MacCarty has insisted for many years]. The nuclear surface in a non-malignant cell from the serous membranes is from 25 to 100 times as large as the area of the nucleolus, whereas in a cancer cell it is but from 4 to 20 times as large. 668 ABSTRAOTS

With the aid of these four criteria, the identificantion of cancer cells in fluids from the thorax or abdomen becomes a matter of no great difficulty, but it should be emphasized that sarcoma cannot thus be recogniaed. The large nucleolus appears to belong to the malignant epithelial cell of ectodermal origin. WM. H. WOGLOM

GENERAL CLINICAL OBSERVATIONS; BLOOD 8TUDIES Class&ation of Cancer and Other Newgrowths, D. A. WELBH. J. Cancer Comm. Univ. Sydney 5: 16-29, 1933. The author sets out a detailed classification of neoplasms in seven main groups -epithelial, endothelial, connective tissue, lymphoid adhematopoietic, neurogenic, melanotic, embryonia. In an addendum he suggests an eighth group, the myogenic, for tumors arising from muscular tissue. F. CAVERS Clinical Observations on Tumor Recurrences, A. BITTORF. Klinische Beobach- tungen bei Tumorreaidiven, Mtinchen. med. Wchmchr. 80: 490-491, 1933. The author reports two cases in which presumably metastatic tumors occurred many years after removal of a primary tumor in a remote region of the body. A woman radically operated upon eight years previously for carcinoma of the left breast became feverish, with symptoms of dry pleurisy. X-ray examination of the chest showed a small shadow in the right hilar region. In the skin there were small reddish nodules. Some of these were examined and showed the typical microscopic structure of breast carcinoma. A few months later the patient died with extensive carcinomatous deposits in various organa. The author adds that he has seen cases of metastasis, especially to bones, occurring at even longer intervals (up to fourteen yeam) after radical operation for cancer of the breast. The second patient, a woman of eighty, complained of weakness and loss of appetite, and increasing abdominal swelling of a few months’ duration. The liver was enlarged.and firm, and at about its middle there was a hard nodular mass. Twenty-five years previously one eye had been removed for melanosarcoma. The urine contained a large amount of melanin bodies. Against the explanation that the hepatic tumor was primary, the author argues that hepatic metastasis from primary ocular melanosarcoma is extremely common. F. CAVERE Some Factors Regulating Metastasis in Carcinoma and Their Influence on Prog- nosis, M. N. DE AND S. C. SINHA. Indian Med. Gar. 68: 371-373, 1933. After giving a summary of the generally accepted views regarding the metastatic dissemination of carcinoma, the authors describe a case of epidermoid cancer of the left scapular region in a Hindu aged thirty-five years. When first seen this was a foul, ulcerated patch of oval outline, 5 x 3 inches. There was no enlargement of the axillary or other palpable lymph nodes. The ulcer was excised and its floor curetted down to the muscles; within three months healing was complete. Eight years later the patient returned with a similar but larger (8 x 6 inch-) ulcerated growth on the same site; this had begun as a lump first observed three years previously. Again there was no sign of lymph node enlargement. The authors intended to make a skiagram of the lungs before operating again, but the patient made a hurried departure from the hospital. Sections of the tumor showed large amounts of dense fibrous tissue, with giant cells, and the authors point out that these and other products of chronic inflammation had evidently led to the formation of a barrier which prevented lymphatic extension of the cancer over B period of ten years. Two illustrations are given. F. CAVERS OENERAL CLINICAL OBSERVATIONS ; BLOOD STUDIES 669

Primary Malignant Tumors in Different Locations and of a Different Nature Found Present in the Same Individual. (Carcinoma of the Stomach and Fibromyxosarcoma of the Left Broad Ligament), P. PITOTTI.Sulla presenaa in uno stesso soggetto di tumori primitivi maligni a localizaazione multipla e di natura diversa (carcinoma dello stomaco e fibromixosarcoma del legamento largo di sin), Minerva med. 2: 619-623, 1932. The author reports a case of a sixty-eight-year-old woman who showed digestive symptoms, pallor, and loss of weight, of six months’ duration, and a more recent edema of the legs, pleural effusion, and ascites. The blood showed marked anemia of the pernicious type. X-rays disclosed a large defect in the stomach wall. Autopsy showed medullary carcinoma of the stomach with metastases to the regional nodes, chronic hypertrophic gastritis, and fibromyxosarcoma of the broad ligament with hepatic metastases. There were no metastases to the bones to explain the pernicious anemia picture. The author believes that the sarcoma may have been the result of embryonal rests activated to malignancy by the presence of the carcinoma and that the carcinoma may have represented malignant degeneration superimposed on the chronic proliferative gastritis. He reviews briefly the theories of etiology of multiple primary malignancies. JEANNETTEMUNRO Multiplicity of Tumors, G. ORosco. Tumores mdltiples en un mismo organ- ismo, Prensa m6d. argent. 18: 1095-1102, 1932. The author gives in tabular form details of seventeen cases, observed in 1067 autopsies during three years, of the occurrence in different organs of the same patient of multiple malignant tumors (three cases), of multiple benign tumors (four cases), and of a malignant and a benign tumor (ten cases). He gives in similar tabulated form reports of these and other types of multiplicity of tumors from the available literature. [The author has collected probably not more than 5 per cent of the reported cases.] F. CAVERS

Multiple Malignancy with Apparent Cure, L. H. MCKIM. Canadian M. A. J. 27: 642643, 1932. A woman sixty-eight years of age had a radical mastectomy for scirrhous carcinoma of the breast twenty-eight years ago and an excision of a rodent ulcer of the nose fifteen years ago. In January 1921 a swelling appeared over the inner side of the right knee and another in the right groin, which on removal proved to be a cellular fibrosarcoma. This tumor recurred and was again removed in August 1921. A third recurrence in October 1921 was treated with high amputation. At present the patient shows no sign of recurrence of the breast carcinoma, the rodent ulcer, or the fibrosarcoma. GRAYH. TWOMBLY Cancer and Nutrition, A. H. ROFFO.El chcer y la nutrici6n, Bol. Inst. de med. exper. para el estud. y trat. del ckncer 9: 44-58, 1932. Also in Ztschr. f. Krebsforsch. 38: 369-379, 1933. In his introduction the author deals with the question of diet in relation to malignant disease, whether induced experimentally in animals or occurring in man. He cites statements to the effect that native races are free from cancer and from various metabolic troubles, unless they adopt the ways of civilized man, when they fall a prey to these evils. [He does not mention the fact that much doubt has been thrown on these statements by more experienced observers.] He states [without citing evidence on the point1 that at any rate before the European war the inhabitants of England, Canada, Ireland, and Germany [no reason given for selecting theae particular countries] overfed themselves not only quantitatively but ABSTIUOTS also qualitatively (too much cholesterol), having four or five meals a day, “ which ought undoubtedly to provoke metabolic disorders with corresponding disturbances in cellular activity.” The author has determined the cholesterol content of various articles of food, and he gives analyses of seven diets, each consisting of four meals per day, three of the diets being deficient and the others excessive as regards the amount of cholesterol consumed. The percentage of this substance is given as 0.254 to 0.783 in the low (practically or entirely vegetarian) daily intake, and 1.26 to nearly 2.7 for “ hypercholesterolic ” rations. [This information is interesting, but it is not quite complete. Nothing is said about the occupations of those who subsist on the ‘I hypercholesterolic ’) and “ hypocholesterolic It diets analyzed, nor is any information given regarding the incidence of cancer among those living on these diets. Yet in his conclusion the author says that his diet analyses show the importance of nutrition in the development of tumors, especially with regard to the biologic soil, in which cholesterol is supposed to play an important part.] F. CAVERS Cancer in Regions Poor in Silicon, J. LERICHE. Les regions pauvres en silicium et les phenomdnes de cancbrisation, Progrhs m6d. pp. 149-150, Jan. 28, 1933. From a review of the literature the author concludes that the r81e of silicon in the metabolism, though obscure, is important; that regions in various European countries where the soil is rich in silicon have a low cancer death rate; and that silicon is of therapeutic value in the treatment of cancer. [See Sartory et al. (Bull. d. 1’Acad. d. m6d. 108: 1097, 1932. Abet. in Am. J. Cancer 17: 1077, 1933) for a discussion of such comparisons of mineral formation and cancer mortality.) H. Q. WOODARD Some Pathological Conditions seen in Central Australian Aborigines, C. H. GRAYAND J. B. CLELAND.J. Trop. Med. & Hyg. 36: 125-128, 1933. During an anthropologic survey of 150 Australian aborigines, 7 cases of benign neoplasms were found, including two of subcutaneous lipoma, two of black warts of the skin, one of multiple and one of solitary warts on the tongue. [There is no histologic report on the warts. Reference to an earlier paper by one of the authors (Cleland: J. Trop. Med. & Hyg. 31: 157, 1928) shows that among Australian aborigines there had been found three casea of cancer of the liver, two of cancer of the penis, two of gastric cancer, and one each of epithelioma of the foot and rodent ulcer of the nose.] F. CAVERS

Paraplegia and Malignant Disease in Childhood, F. J. POYNTONAND R. LIGHP WOOD. Practitioner 129: 607-613, 1932. The authors describe four cases of paraplegia resulting from cancer in childhood, and note that there is often real difficulty in distinguiehing these cancer cases in their earlier stages from tuberculous disease of the spine. In the 6rst patient, a girl of seven years, with flaccid psralyeis of the legs and loss of touch sensation below the level of the sixth dorsal segment, x-ray showed a fusiform shadow in the midthoracic region recalling the appearance of an abscess in spinal caries. How- ever, x-ray of the chest showed a dense opacity in the upper part of the right lung, while the cerebrospinal fluid showed spontaneous coagulation, xanthochromia, and increased protein. These findings excluded spinal caries and led to a diagnosis of intrathoracic sarcoma with compression paraplegia. This was confirmed at autopsy, which revealed a largo sarcomatous growth occupying the posterior mediaa- tinum and projecting into the upper part of the right hemithorax, where the maw was inseparable from the bodies of the vertebrae. In the three remaining cases, occurring in children aged respectively thirteen GENERAL CLINICAL OBSERVATIONS; BLOOD STUDIES 671 months, eight years, and three and a half years, the paraplegia was found to be due to mediastinal sarcoma, adrenal neurocytoma (Hutchinson type), and sarcoma of the neck of undetermined origin. There are four illustrations, two of them mere smudges owing to the coarseness of the paper used for reproduction. F. CAvERe

Myoblastic Tumors, R. MEYER. Myoblastentumoren (" Myoblastenmyome " Abrikossoff), Virchows Arch. f. path. Anat. 287: 55-81, 1932. Abrikossoff in 1926 (Virchows Arch. f. path. Anat. 260: 216) reported five cases of myomatous tumors which developed from voluntary muscle and, in addition to obvious striated muscles, contained unstriated ill differentiated cells described as myoblasts. These primitive cells, and also the distinct transversely striated cells, were in places arranged in a sarcomatous manner and behaved like true sarcoma cells. Since then about 30 cases have been reported, including 7 described by Abrikossoff (see Am. J. Cancer 15: 2869, 1931; 16: abst. p. 306, 1932). In these later papers Abrikossoff modified his original view that the tumors arose from latent myoblasts which had been disturbed by some injury and had developed in the subsequent muscle tissue repair, and concluded that some of them arise dysontogen- etically. For other papers on these tumors, see Am. J. Cancer 16: abst. pp. 712. 713, 1932. Meyer now reports the following additional cases: (1) a large tumor of the upper jaw in a newborn infant; (2) tumor of hazelnut size in the breast of a woman of twenty-three; (3) a small tumor of the tongue in a man of sixty-nine. He also describes regressive and regenerative proliferation of immature striated muscle cells in the scar of an abdominal operation wound, and states that the histologic appearances were similar to those seen in some of the cases diagnosed as myoblastic tumors. He concludes that the myoblastic tumors so far described form a heterogeneous and unnatural group, Only a few of them are true neoplasms; the rest are more rationally interpreted as arising by regeneration from injured muscle tissue. There are thirteen illustrations, including excellent photomicrographs. F. CAVER8 Carcinosarcoma of the Collision Type, W. NOWICKI,Carcinom und Sarkom als Kollisionsgeschwulst, Virchows Arch. f. path. Anat. 289: 564-574, 1933. A woman of forty-five had for several months noticed a slowly growing lump in the left breast, which was removed with the enlarged axillary glands. The portion of the tumor lying nearest the skin consisted of purely carcinomatous tissue, but in the deeper portion the glandular elements disappeared and the tissue was that of typical spindle-cell sarcoma. These portions were separated by a transitional zone in which the carcinomatous and sarcomatous elements were mingled. At autopsy on a man of forty-seven a tumor the size of an apple was found projecting into t,he lung, having clearly arisen in the right bronchus. The portion nearest the bronchus consisted of carcinomatous nests and strands; outside of this, the tumor consisted of spindle-cell sarcoma enclosing nests of carcinomatous cells, and in the distal portion the structure was purely sarcomatous. There are five good photomicrographs. F. CAVERS

Case of Fibrolipomatosis Associated With Fever, G. T. BURKEAND P. N. WAHI. Indian Med. Gas. 68: 396, 1933. A man of twenty-four, while under artificial pneumothorax treatment for pulmonary tuberculosis, had recurring' attacks of high fever not apparently accounted for by the tuberculous infection, since, although for a fortnight his temperature rose to 101-104° F. each evening, the morning record was normal and 672 ABsTBboTs the fever was neither preceded by rigor nor followed by sweating. From the start the patient insisted that the fever was connected with the appearance of small nodular swellings under the skin. A week later he called attention to a small nodule on the left forearm which had just appeared, and this was carefully watched. It began as a painful red indurated area, with pain on moving the limb. In a few days it had become larger and painless. Meanwhile similar nodulee had appeared elsewhere, and after a week, when no more appeared, the temperature became normal. This process was repeated a fortnight later. Altogether, during about two years, about eighty of these swellings had appeared in various parts of the body and could now be felt as small firm subcutaneous masses, movable and painless. The patient said he could foretell each attack of fever by the appearance of a new swelling. The nodules resembled neurofibromas in general appar- ance, but histologic examination showed the structure of fibrolipoma, with no trace of nervous tissue. F. CAVERN Teratomae of the Buttocks, H. NIEWIESCH.Zur Klinik der Steissteratome, Deutsche Ztschr. f. Chir. 239: 481488, 1933. Teratomas of the buttocks vary in clinical importance according to their siae and exact anatomical position. Those which extend into the pelvis in front of the sacrum often give symptoms caused by pressure on the rectum, bladder, and pelvic nerves, while those growths which are completely external to the sacrum give rise to symptoms which are dependent upon their size only. The author reports three cases of sacral teratomas all of which were operated upon successfully. One is without recurrence four and a half years after operation, but no follow-up on the other two is given. The article is well illustrated with photographs and drawings. BENJAMINR. SHORE Teratoid Tumour Successtully Removed from the Belly of an Infant, T. PEARSE WILLIAMS.Proc. Roy. SOC.Med. 25: 957-958, 1932. An infant of seven months had a mass in the right loin which had gradually increased in size over the past five months. It was removed through a right paramedian incision and convalescence was uneventful. The weight of the tumor was 21 lb;, 15 per cent of the child’s weight. No further description is given. A Pedunculated Lipoma, B. U. PUROHIT.Indian. M. Gar. 68: 460, 1933. A Hindu male of about fifty had a large ulcerating tumor in the right gluteal region, first noticed about thirty years previously. During the past two or three years it had practically prevented his walking. The mass was successfully removed and found to be a multilocular lipoma; it weighed thirty-seven ounces. There is one illustration. F. CAVERE

Congenital Lipoma, D. LEVI. Roc. Roy. SOC.Med. 26: 1008, 1933. A male infant was born with a mass on his back, the siae of an orange, below and between the scapulae. At ten months of age the tumor was growing rapidly and was then twice as large as at birth. Ten months later the mass had grown larger still, and at operation appeared to be infiltrating the dorsal muscles, while some of the fatty lobules were traced through the posterior abdominal wall to the perirenal tissue. Two subsequent operations were done. The tumor was a typical lipoma. There was a small mass, also, behind the anus. F. CAVERS

New Growth on Face, R. A. RAMSAY.hoc. Roy. 800. Med. 26: 1005, 1933. A female infant of four months showed a painless, soft, highly vascular, diffuse swelling over the right parotid gland, first notiaed two months previously. As QENERAL CLINICAL OBSERVATIONS ; BLOOD STUDIES 673 the growth extended into the parotid gland and behind the ear, it was considered inoperable. The biopsy section showed numerous blood spaces lined by flat endothelium and filled with blood, while the stroma had no appearance of malignancy and there was no interstitial hemorrhage. H. J. Seddon suggested a diagnosis of hemangioma of the parotid and treatment by implantation of radium needles, as he had had excellent results by that method. F. CAVERB

Blood Diastase in Cancer, LOUIEL. TUREEN.Arch. Path. 15: 831-842, 1933. Somogyi’s improved methods for the determination of blood diastase (Proc. SOC.Exper. Biol. 8z Med. 29: 1126, 1931-1932) permit the estimation of very low values and relatively slight variations, with a greater degree of accuracy than has been possible hitherto. The few investigators who have previously examined the blood diastase in cancer were hampered by an unsatisfactory technic, and the author has taken up the problem anew in the hope that the more refined method now available might show differences that couId not have been brought out by the older procedure. The blood of 81 persons with malignant disease at various sites, chiefly, however, about the mouth and female generative organs, was examined; in all but 5 instances a microscopic diagnosis of cancer had been made. The determination of blood diastase was found useless as an aid to diagnosis. Whether or not it will prove valuable as a prognostic test cannot be determined without further observe- tion of the cases studied. WM. H. WOQLOM Comparison of the Amount of Glutathione and Reducing Substances in Cancer Blood, R. TRUEAUTAND E. G. MINOPOULOB.Le glutathion du sang des can- c6reux. Dosages comparatifs avec les msti6res r6ductrices aprhs hydrolyse acide (sucre protbidique), Bull. de 1’asHoc. franc. p. 1’6tude du cancer 21: 717- 721, 1932. The authors determined the reduced glutathione and the reducing substances in the trichloracetic acid extract of 19 cancer bloods. They conclude that, in general, the reducing substances in cancer blood are increased above the normal, and the glutathione content is diminished. H. Q. WOODARD On the Appearance of Atowl-fast Lipase in Carcinoma Serum and Its Clinical Significance, F. BERNHARD.Uber das Auftreten atoxylfester Lipase im Serum bei dem Carcinom und ihre klinische Bedeutung, Ztschr. f. Krebsforsch. 38: 450-481, 1933. The atoxyl-fast lipase in the serum from carcinoma cases is increased to a degree comparable to that found in acute pancreatic disease. The lipase content of the serum falls to normal after surgical cure of the disease; it also, after a preliminary rise, falls to normal following successful radiation treatment. Persistently high values after treatment often indicate recurrence. A high value in chronic cystic mastitis and in prostatic hypertrophy indicates the beginning of malignant change. H. Q. WOODARD Some Observations on the Lymphocyte in Cancer, R. PHILLIPE.St. Bartholo- mew’s Hosp. Rep. 65: 231-242, 1932. The author reviews various published findings and theories concerning the relations between lymphocytes and malignancy. He briefly states some modern views concerning lymphoid tissue, and considers the lymphocyte to be an undaer- entiated cell of many potentialities. The functions of the lymphocytes are three- fold. (1) They form a reservoir of cells for the production of monocytes, hietio- cytes, plasma cells, and fibroblasts. (2) They have nutritive functions, being 674 ABSTRACTS concerned in fat transplantation and in hormone (trephone) production, (3) They have defensive functions-cellular (especially by transformation into histiocytes) and humoral (immune body production). Lymphocytic reaction to tissue transplantation is compared with that to cancer invasion, and reasons are given for not regarding the latter as of any defensive value. Certain effects of lymphocytic infiltration upon epithelium are suggested: interference with nutrition (Warburg’s work on the relationship between anoxemia, glycolysis, and malignancy) ;stimulation of reproduction (Gurwitsch’s theory of mitogenetic radiation); alteration by hormones. Certain effects of cancer cells upon lymphocytes are suggested: destructive effect of lactic acid; precancerous changes in lymph nodes, attributed to action of toxic substances produced by cancer cells. [It is difficult to see how some of the theories mentioned are related either to lymphocytes or to malignancy.] F. CAVERS Neoplasms and Ultramicroscopic Organisms, C. PFEIFFER.NBoplasies et in- framicrobes, MBd. internationde 40: 233-239, 1932. The author reviews the evidence which he believes indicates that neoplasms are produced by microorganisms. From his own studies, he believes that the organism causing malignant neoplasms in man is an ultramicroscopic form of the spirochete of syphilis.

The Function of Cancer, A. W. D’OYBRAIN,E. H. BURGMANNAND R. S. LEE. J. Cancer Res. Comm. Univ. Sydney 5: 89-92, 1933. The authors of this paper are respectively a medical graduate, a “ Th. SOC.” and a B. Litt.,” and they put forward a theory of the origin and growth of cancer based on psychological arguments. ‘I Carcinoma is the response to a libidinal need of the organism. It is an abortive attempt to form an organ for libidinal satisfaction. It amounts to what might be termed a genitalization of the part affected, It follows that a psycho-analytical investigation might throw much light on the nature and function of cancer.” “ Cancer may turn out to be a disease of civilisation and, if so, psychological investigation may point the way to the necessary changes that must be brought about before the human organism can live healthily in its modern environment.” Evidently the authors are not aware of the existence of congenital malignant tumors in the human race, of malignant tumors in native races, or of spontaneous cancers in animals. F. CAVERS

DIAGNOSIS AND TREATMENT

Osmotic Resistance of the Erythrocytes in the Diagnosis of Cancer, W. E. KUNBT- LER. Uber die Verwendungsfahigkeit der osmotischen Resistenzbestimmung von Erythrozyten bei der Diagnose bcjsartiger Geschwulste, Folia haematol. 49: 21-50, 1933. The author gives a summary of the findings of various writers who have determined the osmotic resistance of the erythrocytes in normal individuals and in patients with various diseases, including cancer. The teRt is simple, and depends upon the fact that if blood is placed in a hypotonic solution of, say, sodium chloride, the erythrocytes imbibe more of the surrounding fluid than they lose to the latter, and therefore undergo hemolysis. The weaker the solution that hemolyzes the erythrocytes, the greater is the osmotic resistance of the latter. Most writers on the subject have reported that the osmotic resistance is increased in cancer patients, especially in those showing cachexia, secondary anemia, icterus, and metastasis. DIAGNOSIS AND TREATMXNT 675

The author had made a thorough investigation of this subject. First he gives tables of results reported by writers who have dealt with reasonably large series of cases, then tables of his own findings in 70 cases of carcinoma and in a long series of cases of benign tumors, other chronic diseases, and healthy persons. Before criticiaing these, he points out that many factors are concerned in the hemolysia on which this method is based, and that previous writers on the subject have apparently not taken these into account or have been ignorant of them. It has been shown that the permeability of the plasma membrane of an erythrocyte can be changed in various ways, and that the protein content of the plasma, which also varies in different conditions, is also an important factor. In experiments with normal blood it was found that the concentration of sodium chloride solution required to produce hemolysis has a considerable range, and that concentrations only slightly lower than the minimum necessary for hemolysis of normal erythrocytes are required for that of the erythrocytes of cancer patients and for non-cancer patients with symptoms of cachexia. Kiinstler has devised a nephelometric method of determining hemolysis in place of the less accurate colorimetric methods hitherto employed. There was no increase in resistance when extracts of normal or of malignant tissue had been previously added to the blood in the tubes. A comparative investigation of the blood in cancer and in tuberculosis and other diseases causing cachexia showed that the phosphate content of the erythrocyte increased parallel with the rise in resistance and with the advance in degree of cachexia. It was also found that the resistance is raised when normoblasts or other immature blood cells are present in the blood. The author concludes that increased resistance of the erythrocytes is attributable almost if not altogether to cachexia, and that it is not due to any specific action of malignant disease on the circulating blood. Like other blood reactions, it has no practical value in the diagnosis of malignancy, since it is absent in early stages of cancer and is not present in more than about one-half of advanced cases not showing marked cachexia. The increase of resistance wafi proportional to the degree of cachexia present. F. CAVERS

Technic of Biopsy of Bone Marrow, M. E. VARELA. Consideraciones sobre las modificaciones propuestas a la thcnica de la biopsia, Semana med. 2: 826-827, 1932. The author discusses the methods of obtaining specimens of bone marrow to asRist in the diagnosis of leukemias, myelomas, etc. He has found that better results are obtained by raising a flap of about one square centimeter of skin, tre- panning a slightly smaller area of the bone cortex, and inserting a canalized trocar, than by puncture with a large needle or small trocar (aspiration method). He gives photomicrographs of specimens from a case of lymphatic leukemia; that obtained by simple puncture aspiration showed four badly preserved leukocytes in an average microscopic field, while that obtained by trepanation and trocar showed thirty-three leukocytes all well preserved. F. CAVERS

Superior Left Quadrant of the Abdomen and Its Tumors, I. ANQULOY ALVAREZ. El cuadrante superior irquierdo del abdomen y SUB tumoraciones, Vida nueva 29: 143-155, 1932. A general paper on regional diagnosis with emphasis on neoplasms. A good survey. JOHANNESP. M. VOGELAAR 676 ABSTEAOTS

Roentgen Diagnosis of Deeplying Lipoma, A. PARCELIERAND A. CHENUT. A propos du diagnostic radiologique des lipomes profonds, Gas. hebd. sci. m6d. de Bordeaux J3: 763-764, 1932. The authors refer to the method dwcribed by Reiss (Abst. in Am. J. Cancer 16: abst. p. 788, 1932) for the x-ray diagnosis of deep-seated lipomas and report a case in which they found this method valuable. A man of forty-two had seventeen years previously noticed a small swelling on the lower part of the right forearm, which had grown steadily and had apparently spread from the ventral to the dorsal side by passing through the interosseous space. X-ray showed a clear ovoid area, readily distinguished from the darker muscular masses. At one point in the light area there were small, irregular dark shadows, evidently exostosea arising from the ulna. At operation there was removed a lipoma of much greater extent than had been suspected from manual examination. The tumor had apparently arisen in, or in close relation with, the periosteum of the ulna. In the ensuing discussion, Chevalier said he had several timea noticed that lipomas, but not ot.her fluctuating tumors or fluid collections, in the limbs became hard when the limb was placed in a bag of ice, or when the tumor, if superficial, was sprayed with ethyl chloride; he thought this simple method might be used in conjunction with roentgenography. F. CAVERS

Type and Extent of Operation for Cancer, R. J. BEHAN. West Virginia M. J- 28: 25-28, 1932. In planning operation for a tumor, its location and relationship to the organs essential for life must be carefully considered. The author discusses briefly the various organs and sensea and the extent to which their sacrifice is permissible. He concludes with the statement: " The law of the surgeon should be to remove extensively all cancer tissue with a wide circumferential margin of sound tissue including the fascia1 conducting pathways with the associated lymph glands. In doing this he may sacrifice all tissue not necessary to the vital functions, and only preserve tissue when its preservation entails no risk of recurrence of the cancer."

The Danger of Incomplete Removal of Apparently Innocent Tumours, J. C. BLOODQOOD.Canad. M. A. J. 28: 600-602, 1933. To illustrate the danger of incomplete removal of apparently benign tumors, the author first describes two striking cases from his long experience. A woman was seen by him about a year after a surgeon had enucleated a small nodule, diagnosed as a ganglion, near the internal malleolus. In spite of his surprise at finding a solid and not a cystic tumor and his fear that removal had not been complete the surgeon had not suggested cauterization or postoperative radiation. Examination of the gross and microscopic features showed that a small portion of the tumor was torn off and had probably been left in the wound, and sections showed a spindle- cell sarcoma, not the more common and benign xanthomatous tumor of tendon sheathe. Deep x-ray therapy was given at intervals for more than a year, but a nodule almost the size of the original tumor remained in the scar. The author removed scar and nodule with the cautery. The nodule was a spindle-cell sarcoma, histologically identical with the original tumor; it was removed with a gone of uninfiltrated scar tissue. At the time of reporting, eight years after the last operation, there was no loss of function and no recurrence. In the second case a small subcutaneous tumor on the upper third of the forearm had been enucleated by a surgeon on the diagnosis of " fascia1 fibroma " but found on laboratory examination to be an incompletely removed spindle-cell sarcoma. Within two weeks the author excised the skin and soft parts down to the bone. Within a few months a tumor developed in the scar, but at that time DIAGNOSIS AND TREATMENT 677

further operation was refused. A year later, there waa a fungating tumor with no bone involvement, as shown by x-ray. The author removed the tumor with the cautery, saving the limb. The patient lived almost eight years after the second operation, and then showed the symptoms and x-ray picture of pulmonary metastasis, but no local recurrence. In previous publications the author has advised the irradiation of all epidermal, subcutaneous, and deeper soft-part tumors if their situation gives evidence that the most complete excision is not possible without injury to important neighboring structures. [In a recent paper (Abst. in Am. J. Cancer 18: 661, 1933) he has discussed this and cognate questions in greater detail.] TWOfurther recent cases are cited. A woman physician of forty-seven had noticed, between the periphery of the breast and the clavicle, a tiny subcutaneous nodule. It was watched for a month and grew very little; it was then removed through a small incision and found to be a carcinoma. The author considered the alternatives of very extensive local excision, with or without complete operation for breast cancer, or irradiation. Irradiation was decided upon and immediately given. In the second case a tumor in the parotid region, first noticed a few months previously, waa shelled out; section showed incomplete removal and a cellular mixed parotid tumor, and irradiation was immediately instituted. The author’s studies have convinced him that surgeons have been slow to real- iae the value of x-ray and radium irradiation preliminary to operation; also, that the entire problem of biopsy, protected by preceding and succeeding irradiation, needs detailed investigation. F. CAVERS What Can The Surgeon Expect in the Way of Guidance in the Treatment of Cancer from the Pathologist? S. BURTWOLBACH. New England J. M. 206: 1299- 1302, 1932. The answer to the question put in the title resolves itself into a discussion of the relationship of surgeon and pathologist. The pathologist, like the surgeon, must be able, alert, learned, and experienced. If he is to be of therapeutic as well as of diagnostic efficiency, he must be prepared to give immediate diagnoses during the course of operations or within a few minutes after a piece of tumor is submitted to him. “ This means that he should know beforehand all about the clinical aspect of the case and have studied the x-ray plates; that he should know as much about the external signs as the surgeon; that he should be better than the surgeon in interpreting gross evidences in excised material, that from a frozen section he should be able to recognize and name the tumor, grade its growth rate, estimate the value of radical excision, and know whether it is amenable to treatment by radiation.” Often the appearance under the microscope is a perplexing one even to the experienced pathologist, and an opinion must rest upon a careful balancing of detail. In such cases the physician is entitled to know whether or not the pathologist “ stands upon the firm ground of experience with that particular tumor or lesion.” The pathologist must remember also that what he receives from the surgeon may not be representative of the lesion, and for this the surgeon must accept some responsibility. As a whole, pathologists concern themselves too little with end-results. “ A pathology laboratory, properly run, naturally becomes a clearing house in which there is much balancing of information from clinical and laboratory wurces. The pathologist must learn the end-result of each patient from whom he has received material which he could not satisfactorily classify as to diagnosis and prognosis. Hence the pathologist learns things about tumors that most surgeons have not opportunity for; and should therefore be able to give aid in the recognition and prognosis of rare tumorR and also the commoner tumors of borderline malignancy.” 678 ABSTRAOTS

Two further points are stressed. (1) Every surgeon should to a certain extent be his own pathologist. (2) Surgical hospitals should recognise that to achieve high competency in the practice of pathology is as difficult as in any specialty and that rewards in salary and position should be so rated. The pathologist’s real opportunity for service is in the education of surgeons, which can be accomplished only by bringing the two into contact. This can never be done until long distance pathology is abolished, and every hospital has its own competent and contented pathologist.

Chemotherapy of Cancer, E. DUROUXAND A. L. CHEVALLIER.La chimiothhpie du cancer, Progrhs m6d. pp. 9-17, Jan. 7, 1933. The authors review the literature of the chemotherapy of cancer, and give their own experiences with various chemical methods of treatment. They doubt whether chemical treatment, either local or general, ever cur- cancer. They consider that local applications have a limited field of usefulness as adjuncts to radium or surgery. In the field of general chemical therapy, they think that certain lead compounds are the only agents that have been shown to have definite palliative value, and express the hope that further research may produce a lead compound more useful than any known at present. H. Q. WOODARD Results with Cordotomy for Relief of Intractable Pain Due to Carcinoma of the Pelvic Organs, F. C. GRANT. Am. J. Obst. and Gynec. 24: 620-625, 1932. Tumors in and about the genito-urinary tract, especially when malignant, cause pain through infiltration about adjacent nerves or by interference with urinary function. To relieve such pain, which is often continuous and intractable, cordotomy (section of the antero-lateral columns of the spinal cord) may be re- sorted to. Pain either unilateral or bilateral in any area below the ensiform can be permanently relieved by the operation. Cordotomy has definite advantages over other methods of relieving pain. Because pain fibers are compactly collected in the antero-lateral columns of the spinal cord, a section there produces the largest possible area of anesthesia. Pain and temperature sensations only are obliterated, without involvement of touch or position sense, and hence the usefulness of the lower limbs is not impaired. Unless the actual incision into the spinal cord is accurately placed, pain may not be completely relieved or the motor pathway may be damaged, resulting in paralysis of the legs and interference with sphincter control. The operation is therefore carried out under local anesthesia, which makes it possible to determine with accuracy the level of loss of pain sensation by sensory tests carried out in the operating room. The point of election for performing cordotomy is the fourth thoracic spinal segment, lying beneath the tip of the second and the body of the third thoracic vertebra. In deciding upon the necessity for a bilateral or unilateral cordotomy a careful description of the distribution of the pain is essential. If the malignant lesion is rapidly growing and if the pain, while still unilateral, involves midline structures, both antero-lateral tracta should be cut to assure permanent relief. A series of 25 cases of cordotomy for pain from malignant disease of the pelvis Rhows the value of this procedure. In 15 a bilateral cordotomy was performed and in 10 a unilateral section. Twenty-one patients were completely relieved and 4 were considered much improved. In 3 of these 4 a unilateral cordotomy was done, but the opposite side became involved later. Four patients died following operation. The average duration of life following cordotomy was seven months. When malignancy is sufficiently far advanced to cause pain, the decision for or against cordotomy is one of expediency. The operation will assure the patient relief of pain through the last months of life. EDWINM. DEEBY DIAGNOSIS AND TREATMENT 679

Treatment of Pain in Cancer by Optalldon, R. GUOQENAEIM.Sbdation des douleurs du cancer par l’optalidon, Schweiz. med. Wchnschr. 63: 552, 1933. The drug optalidon contains dimethylaminophenazone and caffein, and has been used as a sedative by various writers who have reported favorably on it, emphasizing the absence of undesirable side effects. In three recent cases of inoperable cancer, in which the author wished to avoid early resort to opiates, optalidon was found to afford great relief of pain, morphine not being required until a few days before death. A roentgenogram is given showing a tumor occupying the entire left hemithorax of one of these patients; even at this stage the condition was diagnosed as tuberculosis, but soon afterwards biopsy of a testicular metastasis showed the case to be one of primary lung carcinoma, and this was verified at autopsy. F. CAVERS Reasons for the Relief of Pain in Cancer by Calcium, R. J. BEAAN. Am. J. Surg. 19: 301-306, 1933. It may be assumed that the pain associated with cancers is either the result of mechanical pressure or chemical irritation. The author discusses several possible explanations for the relief of this pain following the administration of calcium. Among these are decrease in the size of the cancer cells, conversion of the irritating lactic acid into calcium lactate, reduction in the irritability of the nerves in the cancer area, changes in the conductivity of the nerves from the cancer area to the brain, and a decreased activity of the pain perception centers in the brain. No convincing proof of these hypotheses is given. BENJAMINR. SHORE What the Medical Profession Can Do to Diminish the Mortality from Cancer, ROBERTB. GREENOUQH.California & West. Med. 36: 377-382, 1932. A general discussion before the California Medical Association. Considering only cases in “ favorable ” locations, the author states that if such cases could be discovered and treated in the early and local stages, there would be a reduction of total mortality from cancer of 27 per cent. “ No miraculous discovery of the long-sought cause of cancer is necessary to obtain these results, nor any specific remedial agent. Only three things need to be done to accomplish this result. The public must be taught to recognize symptoms which are in any way suggestive of cancer, and to avoid the least delay in consulting a competent physician. The medical profession must be aroused to the vital importance of immediate and thorough examination of the patient. When the physician is himself in doubt as to the diagnosis, expert consultative service in the cancer or tumor clinic of some readily accessible general hospital must be made available to him and to his patients, without unreasonable expense.”

Classification of Tumours in Relation to Radiosensitivity, R. PATERSON.Brit. J. Radiol. 6: 218-233, 1933. The author attempts to codify in some degree the present empirical knowledge concerning the radiosensitivity of many human tumors. The absolute measure- ment of sensitivity of any tumor should be based upon the actual physical measure- ment of the lethal dose of radiation for that tumor in uiuo in its usual situation; that, however, is not practical at present, chiefly because of our lack of accurate physical data regarding distribution intensities of radiation. Relative sensitivity can be defined as the relationship between the lethal dose for any given tissue or tumor compared with that for some normal tissue such as the skin or the tumor bed. Tumors may be grouped in terms of relative sensitivity, according to whether their lethal dose is (1) definitely less than that of skin; (2) somewhere near that of skin but less than that of many normal tissues, particularly muscle or connective 680 ABSTBILCTS tiseue constituting the tumor bed; (3) greater than that of the skin and in the region of the lethal dose for most other tissues; (4) in excess of the lethal dose for normal tissues. The results of radiation treatment of squamoue epitheliomas of all types and of certain other epithelial tumors indicate that these tend to belong to group 2, while similar consideration seems to justify the placing of adenocarcinoma in group 3. The groups may be re-named as (1) radiosensitive growths; (2) moderately sensitive epitheliomas; (3) moderately resistant adenocarcinomas; (4) radioresistant growths. Group 1 tumors, in which skin-limited or external methods of radiation alone appear to be effective and sufficient, include the following subgroups: (a) seminoma testis, Wilms renal tumor, parotid tumors (in part), chorionepithelioma, desmoid tumor (abdominal wall) ; (b) thymoms, lymphosarcoma, Ewing’s tumor of bone, giant-cell tumor of bone, some other sarcomas; (c) Hodgkin’s disease; (d) rodent ulcer (untreated), transitional-cell carcinoma, basal-cell carcinoma, lympho-epithelioma. Most cases of squamous-cell carcinoma, and some cases of the last three tumors enumerated in group 1 (subgroup d) fall into group 2 (subgroup a) because they require, to produce lethal changes, a higher intensity of radiation than is necessary in group 1, the lethal dose lying in the region of that for skin, so that treatment requires methods of localised radiation. The other tumors placed by the author in group 2 and arranged in subgroups in order of suitability for radium therapy, are (b) carcinoma of the mouth and tongue, cervix, skin, and lip; (c) carcinoma of the anus, scrotum, penis, vulva, tonsil, pharynx, breast, bladder, and antrum, and metastatic carcinomatous lymph nodes; (d) carcinoma of esophagus and some of the lung. In this group the maximum intensity which may be used without destruction of normal tissue will depend upon the tolerance of the tumor bed in each type. Where the relative sensitivity is favorable, as in the breast and tongue, localised radiation methods have been devised which are highly successful; but where the tumor bed is complex, as in the esophagus, or sensitive, as in the lung, the maximum dosage which the bed will tolerate becomes much less and the pos- Ribilities of therapy greatly limited. In primary squamous epithelioma of the tongue the mucosa and the musculature are comparatively resistant and tolerate remarkably high intensitiea; hence implantation methods are easy and the results excellent. Probably the same tumor invading the nodes would respond to radiation of an equal order of magnitude, and the reason why treatment of the cervical nodes has been unsuccessful is that by no present day method is it possible to apply this necessary dose; on the one hand is the limitation imposed by the immediate proximity of overlying skin, and therefore the skin lethal dose, and on the other that due to the technical difficulty of achieving a homogeneous implantation in an area traversed by so many vital structures. The first subgroup (a) is considered in this group 2 only because there is usually no previous indication that these tumors are sensitive, and therefore they have to bekreated as if they were ordinary squamous epitheliomas. When there are reliable pathological criteria on which to pick out the lympho-epithelioma and the basal-cell or transitional-cell groups, these will pass over into the first group and be treated by x-ray; at present they are among the tumors which supply the spectacular immediate successes of inefficient radium therapy. Subgroup b includes tumors in which the tumor bed is definitely resistant and treatment therefore both easy and commonly successful. In subgroup c one finds increasing complexity of the tumor bed and with it increasing difficulty of achieving high and therefore lethal dosage for the majority of tumors. It may be that secondary malignancy in cervical nodes should be placed in subgroup d, in which these difficulties would appear almost unsurmountable. Yet it is in the treatment of the epitheliomas that radium therapy has made greatest progress in the last decade. It is this field that constitutes the radium therapist’s DMQNOSIS AND TREATmNT 681 happy hunting ground (as group 1 is the x-ray therapist’s), and it is here that he has made such inroads into a previously surgical domain. Adenocarcinoma in most sites has generally been accepted as somewhat unsatisfactory from the point of view of radiation. The sensitivity of these growths is low, and good.results are obtained only when fairly high intensities can be produced without damage to other tissues. Sometimes this is made possible by the presence of an even more resistant tumor bed, as in adenocarcinoma of the uterine body. For these tumors Heyman and others have reported excellent five-year statistics with the use of a high radiation intensity which would not be tolerated without necrosis in many other sites. At other times, results in adenocarcinoma are achieved only at the expense of equal destruction of malignant and normal tissue, which in a sense amounts merely to using radiation in place of an ordinary simple cautery. Probably such results as have been published in treatment of malignancy of the rectum either fall into this group, or, in the absence of pathologic report, are cures not of true adenocarcinoma but of epithelioma of the anus extending into the rectum. The author considers that at present the adenocarcinomas should be treated by surgery when possible, radiation methods being limited to inoperable casea, and a serious attempt being then made to achieve very high intensities within the tumor field. Group 4 is difficult to define accurately, because the inclusion of a tumor here depends no longer on knowledge of actual response to radiation, but on the facts that treatment has been generally found unsatisfactory and that there is a dearth of convincing statistics of cure-that is, it ie a group based on negative rather than positive findings. This radioresistant group includes osteogenic sarcoma, fibrosarcoma, neurofibrosarcoma, true teratome, parts of parotid tumors, melanoma, hypernephroma, chondroma, lipoma, fibroma, and fibroids. Most of these, in- cidentally, are of connective-tissue origin, and many of them are slow growing and not unduly prone to metastasis. In this group, attempts at massive radiation will do more damage to the normal tissues of the tumor bed than to the cells of the tumor itself. Surgical measures should not only take precedence, but should not be combined with either intensive postoperative (“ prophylactic ”> radiation or with implantation of radium needles into the operative field, as is so frequently done. However, after operation, or where surgical measures are frankly contra- indicated by the situation, there is available another method of treatment, which has been called “ growth restraint,” in which, by means of small doses of radiation repeated at intervals of from a week to a month, there is produced a gradual process of endarteritis obliterans; in this way the blood supply to the tumor is cut down or completely stopped, or, in some tumors, a gradual change is effected in the actual nature of the growth so that it becomes more benign. Such a process will cause reduction in growth rate or even complete cessation and a static condition. This, though not a cure in the ordinary sense of the word, may be a very valuable palliative procedure. The author points out that his attempt to classify tumors is based on their histologic nature, which is described by Ewing as the intrinsic factor relating to sensitivity. The same writer had, however, also called attention to extrinsic factors or external influences which may cause either decrease or increase in relative sensitivity. The former may or may not render a tumor actually less sensitive, but they lessen the margin between the lethal dose for the tumor and the limit- ing dose of normal tissue; these factors are poor nutrition, poor blood supply, syphilis, previous surgery, cachexia, anemia, sepsis, and previous radiation. The most important and best known of the extrinsic factors influencing sensitivity favorably is the time factor. For any tumor growing in any particular bed there is, apparently, an optimum duration of treatment giving the greatest margin between lethal dose to tumor and lethal dose to tumor bed, that is, which gives the 682 ABSTRACTS best relative sensitivity. In mouth tumors Regaud has shown that this time factor lies in the region of seven to ten days. For other tumors much remains to be done in determining what is really the optimum spacing and duration of treatment. None of the many attempts to induce or increase radiation sensitivity (by intravenous injections of glucose, lead, etc.) have come into general usage, presumably because the results have not been sufficiently striking. The author indicates three of the lines along which fruitful research may take place in the immediate future. The first of these is the determination by the pathologist of accurate criteria on which tumors can be grouped, until ultimately we have an exact pathologic classification of tumors in relation to sensitivity. The second is the determination by the physicist of the exact quantity of radiation which is delivered to and absorbed by the cell. The r unit in x-ray has gone some way toward solving this problem, but is still a far from completely effective unit for such a purpose, and there is not as yet a suitable unit in routine practice for radium therapy. The third determination is for the clinical radiologist and concerns the exact lethal dose for each type of tumor thus classified for him, and the development of methods of delivering such a dose without producing permanent damage to normal tissues. F. CAVERB Relation between the Radiosensitivity of Malignant Tumors and Their Tissue of Origin, J. BORAK.Die Besiehungen swischen der Strahlenempfindlichkeit maligner Tumoren und ihrer Muttergewebe, Strahlentherapie 44: 601-654, 1932. The sensitivity of a tumor is best determined by comparing its behavior under radiation with that of connective tissue. If it disappears after a dose which does not injure connective tissue, it is sensitive; if it fails to regress after a dose which causes necrosis in connective tissue, it is resistant. The degree of sensitivity of a tumor is not determined by its rapid growth rate nor by a large number of mitoses, for often a tumor showing one or both of these characteristics is resistant. The sensitivity of the tissue of origin is a safer criterion. The tumor may have the same or a greater degree of sensitiveness than this, but is never more resistant. Whether malignant or benign, if it arises from a sensitive tissue it will be sensit,ive, regardless of its state of differentiation. So also when its origin is in a resistant tissue it will be resistant. The proper dose of radiation is therefore the one which will destroy the tissue from which it has been derived. Normal tissues are highly susceptible when their cells undergo transformation (germinal epithelium, lymphatic tissue, hair follicles, epidermis, pavement epithelium). When these transformed cells are killed, regeneration proceeds from the tissue of origin (autocellular type). If the latter is destroyed, no regeneration is possible. In other tissues (lymph nodes, etc.) regeneration occurs by the migration of cells from surrounding unradiated areas (allocellular type). The destruction of the tissue of origin may often be followed by repair. Tumors arising from the first type can be successfully treated; this is not always true of the second type. Constitutionally sensitive tumors are those which arise from sensitive normal tissues (the first type mentioned above) Their sensitiveness is estimated by their quantitative reactions to radiation. Extrinsic factors also are important in determining susceptibility. Among these are injuries to the adjacent tissues caused by disease, especially syphilis and tuberculosis, by mechanical injuries, and by changes in the vascular supply. Metastases which lose contact with the primary growth are often less sensitive. Obviously sensitivity is only one element in successful radiotherapy; early diagnosis and radical treatment are essential. Tumors arising from resistant tiesues are constitutionally resistant and cannot be treated according to the principle just outlined. They do not regress completely even though the originating tissue undergoes necrosis. In this group are adeno- DIAGNOSIS AND TREATMENT 683

carcinomas of the thyroid, breast, liver, pancreas, kidneys, prostate, and intestinal tract. Metastases from these are usually more sensitive than the primary tumor. Carcinomas of the simplex type may occur in this group and are also amenable to radiation. Histological study of the tumor is important in order to determine the primary origin and maturity of the cells. Only the absolutely immature forms are sensitive. Surgery and radiotherapy are alike in that both aim to destroy the source, but while the former injures adjacent tissues, the latter tries to spare them. Often both methods must be combined. The most resistant elements in a tumor give the measure of sensitivity, and radiotherapy should be directed against them. But with resistant tumors radiation must be adjusted so that no lasting injury will develop in the vital tissues. Constitutionally resistant tumors should be given the maximum dose; constitutionally sensitive tumors should receive the optimum dose. CHARLESPACKARD

Results of Radiotherapy in Our Anticancer Center, A. JIANOAND I. JOVIN. RBsultats de la radiothhrapie notre centre anticancbreux, Rev. d. chir. Bucaresti 35: 419-421, 1932. Archives of the Anticancer Center at Strasbourg, A. GUNSETT. Archives du Centre anticancbreux de Strasbourg, Strasbourg mCd. 92: 357-379, 1932. The report by Jiano and Jovin deals with far too small a number of cases (none traced for as long as five years) to justify an abstract. Gunsett’s report also does not appear to require abstracting, for a very different reason. Practically all of the extensive material presented has been fully dealt with by him in numerous reports published during the preceding two years (see Am. J. Cancer 15: 357,398,1148, 1885, 1931; 16: abst. pp. 1435, 1441, 1472, 1932; 17: 508, 1933). F. CAVERB Report on Treatment by Radium at Guy’s Hospital During 1930 and 1931, F. J. STEWARD.Guy’s Hosp. Rep. 83: 159, 1933. Cases of Malignant Disease Treated with Radium in the General Surgical Wards During the Years 1930 and 1931, F. J. STEWARDAND A. SIMPSON-SMITH. Guy’s Hosp. Rep. 83: 160-165, 1933. Cases Treated with Radium in the Gynaecologicd Department, J. B. BLAIKLEY. Guy’s Hosp. Rep. 83: 166-167, 1933. The total number of patients reported is 561, of whom 187 were admitted as in-patients and 147 as out-patients in 1930, the corresponding numbers for 1931 being 127 and 100. These reports are of too recent date to allow of conclusions regarding radium treatment of the patients included. A gratifying feature is the fact that an unusually large proportion of the treated patients have been followed-up. The third report is better presented than the others, the results being summarized in a table. F. CAVERS History and Work of the Cancer Research Committee of St. Bartholomew’s Hospital, R. G. CANTIAND W. M. LEVITT. St. Bartholomew’s Hosp. Rep. 65: 139-150, 1932. This report, though containing very little that is of importance with regard to five-year results of radiotherapy, is an interesting narrative of the evolution of a radiotherapeutic center from small beginnings. The largest number (324) of caes in any single site group is in the upper air passage group, and the results in some of its constituent subgroups have been dealt with in detail in a longer report by Harmer (Abst. in Am. J. Cancer 16: abst. p. 1082, 1932). F. CAVERS 684 ABSTRAOTS

Recent Progress in the Use of Radium, H. S. SOUTTAR.Clin. J. 62: 265-269,1933. Radium “seed ” treatment is being used by Souttar for carcinomas of the buccal cavity and of the breast. F. CAVERS

Radon Administration, N. T. BULL. M. J. Australia 2: 234-236, 1932. The author reports briefly on the radon treatment of fifteen cases of cancer during nine months at a hospital in Victoria, Australia, and concludes that in hospitals with a limited supply of radium, the Commonwealth Radium Laboratory, by supplying radon, serves a very real need. F. CAVERS End-Results of the Treatment of Malignant Diseases at the Cleveland Chic, G, CRILE. Surg. Gynec. and Obst. 56: 417, 1933. Crile and his associates at the Cleveland Clinic have seen 8679 casea of malignant tumors of various portions of the body. Of these, 2756 were treated by operation only, 1399 by operation and radiation, and 1931 by radiation alone; 2593 were not suitable for treatment. Of the patients seen prior to 1928, 4059 have been traced. Of these, 1182 have survived for three years or more, and 737 for five years or more. The end-resulta for various locations, regardleea of the type of treatment, are given and may be tabulated as follows:

Ceeeeseen Three Five Total before 1928 year year Location cases andtraced cur- OUT08 skin ...... 786 216 100 62 Buccal Surfaces and Jaws...... 618 300 94 63 Larynx ...... 162 - 14 9 Thyroid...... 292 185 66 37 Breast...... 1666 919 437 307 Stomach...... 726 - 13 7 Large Inteatine and Rectum...... 841 - 89 48 Kidney ...... 143 16 7 Bladder ...... 389 47 30 Prostate ...... 336 24 9 Cervix uteri...... 169 98 Fundus ...... 676)246 Bone (exclusive of jaws)...... 176 16 10

BENJAMINR. SEORE

Report of the Cured Cancer Clinics Held on April 5 and 6, 1932, at the Masea- chueetts General, Collie P. Huntington Memorial and pllmer Memorial Hospitals, the Free Hospital for Women, and the State Cancer Hospital at Pondville, ROEBRTB. GREENOUGH,WILLIAM P. GRAVES,CEANNING C. SIMMONS,DANIEL F. JONES,ERNEST M. DALANDAND HARRYF. FRIEDMAN. New England J. M. 206: 1294-1299, 1932. The material shown at the cured cancer clinics reported in this article included 58 cases from the Massachusetts General Hospital, 29 cases from the Collis P. Huntington Memorial Hospital, 24 casea from the Palmer Memorial Hospital, 12 cases from the Free Hospital for Women, 46 cases from the Pondville Hospital, and 9 cases from the Boston Dispensary. All the cases from the Massachusetts General and Huntington Hospitals and the Free Hospital for women represented five-year cures. The Palmer Memorial Hospital and Pondville Hospital had THE SKIN ti85 been open too short a time for the accepted five-year period to have elapsed in the majority of cases. Seven of the cases from the Palmer Memorial represented five-year cures, and 3 of the 9 cases from the Boston Dispensary. The results of treatment of cancer of various regions at these clinics are presented in summary in Table I, supplemented, where figures from these hospitals were unavailable, by reports from other well known clinics.

TABL~I: Curability of Cancer (Cases living five yeam without dieewe are classed as cured)

Primary All Operative Early Cases CasW CW33 Situation (per cent) (per cent) (per cent) Skin...... 06 - 96 LiD...... 60 68 88 Tongue and Mouth...... 6 30 38 Stomach...... 4 24 24 Colon...... 10 19 49 Reatum ...... 23 66 a+ Breast...... 31 30 02 ovary...... 20 29 40 Funduauteri...... 72 70 88 Cervix (radium)...... 20 66 76 Vulva ...... 10 - 30 Bone aarcoma...... - 10 - Penia ...... 26 50 Testicle...... 4 16 30 Bladder ...... - 26 Proatate., ...... 0 0 0 Kidney ...... lrss than 20 - -

The authora present, for the various locations, suggestive symptoms, methods of examination, procedures to be avoided, and results with surgery and radium, where this WM applicable. THE SKIN Sunlight and Cancer of the Skln, A. H. ROFFO.El sol y el chncer, Bol. Inst. de med. exper. para el estud. y trat. del c4ncer 9:230-318, 1932. Also in Prensa med. argent. 19: 1239, 1318, 1932; 20: 54, 115, 166, 1933. This is by far the most comprehensive article that has been published on the subject of cancer and potentially cancerous lesions of the skin in relation to exposure to solar irradiation. The author’s observations agree entirely with those of Molesworth in Australia (see Am. J. Cancer 18: 664, 1933) concerning the heavy incidence of cancers and “ precanceroses ” of the skin in countries in which the sunlight is abundant and bright. It is rather difficult to ascertain from this paper just how many cases of cancer and of “ precancer ” (keratosis) of the skin the author has actually observed at Buenos Aires. Early in the paper he says: ‘‘ The carcinogenic sensibility of the skin in regions which remain uncovered-face and hands-manifests itself in a striking manner, as is reflected in the following figures for patients who attended the Institute in the year 1931.” [No other year, or period of years, is mentioned in the article.] The figures given immediately after the sentence quoted are as 686 ABSTRAOTS follows (percentages): skin of the face, 95.51; dorsum of the hand 3.07; regions covered by clothing, 1.54. Next comes a table showing the number of facial carcinomas classified according to site: nose, 302 (61.4 per cent), cheek, 93 (18 per cent), forehead, 38 (7.7 per cent), ear, 39 (7.9 per cent), temporal region, 20 (4 per cent). This gives a total of 492 cases. Of these, 70.9 per cent occurred in men and 29.1 per cent in women, a difference which the author attributes chiefly to the fact that women frequently protect their faces with ointments and powders. A few pages further on, in a table entitled “ anatomociinical summary of the patients observed,” and with columns showing occupation, age, nationality, macroscopic appearance of lesions, histology, and duration of the process, the author includes 136 cases (raised in the sentence after the table to 138, and again reduced in the following sentence to 135). Only 80 of these cases have an entry (always ‘‘ carcinoma ’I) under the heading “ histology.” Yet in the succeeding analyses the 135 cases are referred to as ‘‘ keratotic carcinomas.” Roffo’s analysis shows that no less than 97.8 per cent of these 135 persons carried on work in strong sunlight; 82.78 per cent were farm and field workers, 3.62 per cent masons and brioklayers. Only 5 patients (3.62 per cent) were less than forty years of age. The numbers and (in brackets) percentages in the next decades were as follows: 41-50 years, 17 (12.31); 51-80 years, 32 (23.18); 61-70 years, 41 (29.71); 71-80 years, 31 (22.31); 80 to 90 years, 12 (8.69). The table showing the incidence according to nationality is, of course, useless, in the absence of corresponding information concerning the total number of persons employed as farm laborers, etc., in the whole country or the region served by the author’s institute. The ratio between the sexes (55 per cent males, 45 per cent females) is very different from that given earlier in the paper. Nowhere does the author state whether or not the 135 (or 136) cases analyzed according to age, macroscopic and histologic findings, etc., formed part of the 492 stated earlier to have been seen during the year 1931. Tables, graphs, and diagrams are also presented based on determinations of the percentage quantities of cholesterol found in rat tumours and in the animal’s body apart from the tumor, and in the serum of normal rats and of tumor-bearing rats; in the skin of normal persons, of patients with various non-neoplastic lesions, of those with non-cutaneous cancer, and of those with cutaneous cancer; in the normal and the affected skin areas in patients with “ keratotic carcinoma;” and in the normal skin in men as compared with that of women, children, and even fetuses down to the first three months. Still other tables and graphs show determinations of cholesterol in the skin of rats before and after exposure to sunlight for different time periods, before and after ultra-violet radiation, before and after having been kept in darkness for different periods; also, determinations of the carbon, hydrogen and oxygen content of cholesterol after exposures to ultra-violet radiation, etc. The data presented in this paper represent an enormous amount of labor. The paper is profusely illustrated, there being nine colored plates and more than seventy photographs and photomicrographs. F. CAVERI Precancerous Lesions of the Skin, A. H. CONRAD. J. Missouri M. A. 30: 21,1933. In a lantern slide demonstration the author emphasized the importance of trauma and irritation as a predisposing cause of skin cancer. The opinion is expressed that “ sunlight ” cancer from actinic rays will be found to be a separate species of cancer. It is also pointed out that varicose ulcers are seldom the site of cancerous lesions, in spite of years of stimulation in many cases. W. BAYARDLONQ THE SKIN 687

Cutaneous Papillomas among Patent Fuel Workers in relation to Malignant Disease, C. C. R. DOWNING. J. Indust. Hygiene 14: 255-279, 1932. Since 1906 the occurrence of papillomas and epitheliomas due to pitch, tar, or tarry compounds has been recognized in England as specific to the trade of patent fuel workers. These lesions occur on any part of the body, but most commonly on the face, hands, and scrotum. Pitch appears to be the one irritating substance responsible for the lesions. The earliest effect upon the skin is an erythema, which is followed by a chronic dermatitis. The surface of the inflamed skin becomes dry and scaly and studded with little papules. There is intense irritation, and the subsequent scratching opens up the follicles, which are soon filled with pitch dust. Keratoses are formed which vary in size from a pin-head to a split pea or larger, and are of a brown color. Prosser White describes the skin at this time as “ shag- reen.” In the early stages, a well defined red areola may be seen around the hair follicles, especially on the anterior surface of the thighs and on the forearms. In many workers continuous pitch dust irritation causes a marked conjuncti- vitis, extreme photophobia, and lacrimation. Often an intense burning pain over the parts of the body exposed to sun and wind is experienced at the end of the day’s work. Papillomas and epitheliomas develop from the irritating papules and keratoses on the skin. Two types of papillomas are seen: a pedunculated “ dry ” wart with a small base and a flat, sessile wart with a broad base and a smooth top. The former are usually rubbed off when the men bathe and dry themselves with coarse towels. The latter are usually very tiny and painless until they grow or ulcerate. Growth is often very rapid, recurrence is common following cauterization, and, if unexcised, the lesions may become epitheliomatous. Trauma may initiate malignancy. Scrota1 growths tend to metastasize rapidly and are especially difficult to treat. Histologically the pitch papilloma, either sessile or pedunculated, is marked by excessive keratinization and otherwise resembles the common wart. Pitch epitheliomas are typical prickle-cell carcinomas. A detailed description and analysis of 73 cases examined and treated by the author is given. The greatest incidence was found to occur between forty and sixty years of age. Those who had spent more than ten years in the industry were most affected. There is a direct relationship between the intensity of exposure to the irritating substances and the incidence of the lesions. [See, for similar conclusions from experimental work, Curtis, Dunning, and Bullock: Am. J. Cancer 17: 894, 1933.1 Local destructive measures were used in treatment. There were no deaths from epitheliomas. Preventive periodic health examinations among these workers are recommended by the author. W. BAYARDLONQ R81e of Physical Therapy in the Treatment of Precancerous and Cancerous Dermatoses, J. J. ELLER.J. A. M.A. 100: 385-388, 1933. The author lists ten physical therapeutic agents which are commonly used by the dermatologist, either alone or in combinations, for the treatment of precancerous and cancerous dermatoses. The lesions commonly considered in these two groups are listed. Each type of lesion mentioned is then summarized and the treatment advocated by the author is mentioned. The author advises the treatment of basal-cell epithelioma with doses of three to four skin units of unfiltered roentgen rays after electrocoagulation of the lesion under novocaine anesthesia. Similar mixed treatment is advised for the more malignant types of carcinoma, with larger or more prolonged doses of x-ray. No bibliography is given. 688 ABSTRAOTS

[The author has covered much the same ground in Archives of Physical Ther- apy, X-ray, Rsdium 14: 95, 1933, N. Y. State J. M. 30: 1344, 1930 (Abst. in Am. J. Cancer IS: 1670, 1931), and Brit. J. Dermat. & Syph. 42: 263, 1930 (Abet. in Am. J. Cancer 15: 385, 19311.1 W. BAYABDLONQ Treatment of Rodent Ulcer, N. 5. FINZI. Brit. M. J. 2: 137-139, 1933. Treatment of Rodent Ulcer, H. DONOVANAND E. B. ASH. Ibid. 2: 314, 1933. Treatment of Rodent Ulcer, R. T. BRAIN. Ibid. 2: 359, 1933. Finsi points out that although an early basal-cell carcinoma can be excised, the proportion of recurrences is large unless the excision goes very wide of the growth, Moreover if the growth haa been excised and recurs, subsequent irradiation is more di5cult and less certain than when it is applied at the beginning. Carbon dioxide snow has occasionally cured a case, but it produces considerable scarring, while other caustic methods, excepting diathermy, have even less to recommend them. The author prefers radium to x-ray treatment, but it must not be used unfiltered or only slightly screened. The minimum filtration should be 0.3 mm. of platinum, but 0.5 mm. is better even for early cases, while for advanced cases 1 or even 2 mm. may have to be used. In early cases Finsi advocates a mild erythema dose of filtered radium gamma rays to the whole of the affected area, repeating this dose after six weeks if any evidence of growth remains. Occasionally a third curative dose is necessary. He follows this by two prophylactic doses at intervals of six weeks and fourteen weeks after the last curative dose. He thinks it does not matter whether radium or radon is used, and that mesothorium would be equally effective. He prefers tubes to plaques, because they can be better adapted to the various cases. For small lesions he uses a tube of 50 mg. radium, with filter of 0.5 platinum; the tube has an active length of 15 mrn. and diameter of 4 mm., and is covered with rubber to cut down secondary radiations from the platinum. The time of exposure in a patient forty to fifty years old is sixty-five to seventy minutes; in older patients this is slightly increased, and in younger ones diminished, because rodent ulcer becomes less and less radiosensitive with age. “ Anyone whose statistics do not show more than 90 per cent success in all cases, early and late, and something of the order of 99 per cent in early cases, would do well to consider carefully what he is doing, and revise his methods.” Donovan and Ash consider that Finzi has dismissed the surgical treatment of rodent ulcer rather summarily. They state that at the Birmingham Skin Hospital they see about 50 cases annually, and in many of them have obtained very satisfactory results by excision or diathermy. A large percentage of these lesions have a diameter of about half an inch, and these are especially amenable to surgev. Some of their patients have been given radiotherapy; they obtained better results with screened than with unscreened radium. They believe the matter may be summed up by hying that patients who can be trusted to attend hospital should be treated by radium, and those who cannot should have an immediate “ once and for all ” treatment, i.e. surgery or diathermy. Brain states that one of his patients was seen with recurrence after having previously had, in competent hands, three of these “ once and for all ” treatments. When a rodent ulcer recurs after operation, its progress is generally characterized by more rapid growth and marked resistance to radiotherapy. ‘‘ It ie certain that some cases of early rodent ulcer will relapse under any form of treatment, and experience of one’s own failures makes one tolerant of those of other people.” F. (7hVERS THE SKIN 689

Treatment of Cancer of the Skin by Roentgen Ray and by Radium, ROBERTL. KBLLY. Urol. and Cutan. Rev. 36: 419-423, 1932. This is a general discussion of the treatment of basal-cell and squamous-cell cancer with x-rays and radium. It contains a review of the opinions of a large number of men experienced in this field but no original observations. A good bibliography is appended. GRAYH. TWOMBLY

Five-Year Results of Radium Therapy of Skin and Lip Carcinoma, L. ARZTAND H. FIJHS. Zur Radiumtherapie des Haut- und Lippenkrebses mit besonderer Berticksichtigung der Dauererfolge, Wien. klin. Wchnschr. 46: 706-704, 1933. The authors deal here only with cases of skin and lip cancer treated by them between 1912 and March 1, 1928, that is, cases in which at least five years have elapsed since the last radium treatment given. During that period they treated 642 patients, of whom 175 were lost sight of before the expiration of five years. This leaves 467 cases followed for five years or more. Of the 431 skin cases, 368 were treated by radium alone, 63 by combined surgery and radium; the corresponding figures for lip cancer are 36, 18, and 18. The figures for five-year cures reveal a remarkable coincidence: the percentage is precisely the same (75 per cent) in the cases treated by radium alone (289 out of 386) as in those treated by combined operation and radium (61 out of 81). An analysis of the five-year results according to site shows that for skin cancer the eyelids gave better results than the average (101 cases out of 120, or 84 per cent, with radium alone, and 19 out of 21, or 90 per cent, with combined treatment), while the poorest results were obtained in cancer of the ear (none cured out of 14 cases with radium, one out of 3 with combined treatment). The authors explain the disturbing fact that more than one third of the patients treated were not traced for five years as being due largely to the absence, owing to economic etringency, of a follow-up section in the Vienna Radium Station. De- spite this drawback, the Vienna figures are slightly better than those reported from larger institutes with a good follow-up department, such as the Stockholm Radiumhemmet. F. CAVERS Postoperative Treatment after Excision of Roentgen Carcinoma, K. GUTIQ. Zur Nachbehandlung des exstirpierten Rtintgenkarzinoms, Strahlentherapie 47: 390-392, 1933. In 1909 a male attendant in a radiologic institute showed severe ulcerated hyperkeratoses, which had appeared after ten years of handling x-ray appliances. He left this work, but ten years later, in 1919, the left little finger was amputated, and in 1926 a portion of the right ring finger, on account of x-ray carcinoma. Early in 1932 new lesions on the back of the right hand were diagnosed by biopsy as carcinoma, but the patient, though now a qualified physician, procrastinated until, a few months later, there was a deep ulcer. This was extirpated surgically, but the wound was slow in healing, despite applications of various kinds. Finally, rapid and complete healing followed applications of an ointment containing boracic acid and adrenalin. Three illustrations are given. F. CAVERB Treatment of Skin Cancers with Carbon Dioxide Snow, A. A. EPSTEIN. Uber Behandlung von Hautcarcinom mit KohlenRaureschnee, Arch. f. klin. Chir. 175: 344-350, 1933. Freezing of superficial skin cancere with carbon dioxide mow has been prac- tised by Epstein in 115 cases since 1929. Histologic study of 61 growths showed 49 basal, 5 squamous without pearls, and 7 squamous growths with pearls. Ex- tension to the underlying fascia, bones, or cartilage is an absolute contraindication 690 ABSTRACTS to this form of treatment. Cures of from six months to three years have been secured in 87.5 per cent of 96 patients followed, and in the majority of cases in which recurrence was observed this took place in the.first year after treatment. There are no illustrations. BENJAMINR. SRORB Epithelioma of Rodent Type in a Native of Bougainville Territory of New Guinea, C. M. DELAND,L. B. BULLAND J. B. CLELAND. M. J. Australia 1: 712-713, 1933. A man of about thirty, a native of New Guinea, had a painless ulcer of the left temporal region, which he said had been present for only three months, almost certainly a false statement since the lesion extended from the point of the ear to the left orbit, had begun to invade the latter, and was inoperable. Histologic examination showed the structure of basal-cell carcinoma. An intereeting feature was the presence in many of the epithelial and stromal cells of melanin granules. Diffusely scattered groups of plasma cells and lymphocytes were present, SU~- gesting that the growth was somewhat more active than usual in rodent ulcer, or that the extensive ulceration of the surface was responsible for the round-cell reaction. The occurrence of such a growth in a dark-skinned race is interesting in view of the suggestions that have been made that these tumors are more frequent in persons exposed to strong sudight and unprotected by adequate pigment. Three illustrations are given. F. CAVERS Rodent Ulcer Occurring in Man and Wife, S. GORDON.Canadian M. A. J. 29: 181, 1933. A man had a rodent ulcer of six years’ standing, which had destroyed the left lower eyelid. The tumor was excised and found to be non-keratinizing. The wife of this patient had a small, yellowish, scaling area on her upper lip, and was convinced that she had contracted it from her husband. For years she had wiped the crusts from his eyelid with her handkerchief. Her lesion was of the same type as her husband’s. Both patients were of blood group I (Jansky), and the author considers the possibilities of coincidence, direct grafting of the tumor, and implantation of a virus. “ Against the first is the fact that both are relatively young. Againet the second is the fact that no history of any injury to the involved area could be obtained. As for the third possibility no comment can be justifiably made.” There are two good photomicrographs. F. CAVERS Nevocarcinoma of the Parieto-temporal Region in a Child of Twelve, MILIAN,L. PBRINAND BRUNEL. Naevo-;arcinome de la region paribto-temporale cher un enfant de 12 ans, Bull. SOC.frang. de dermat. et syph. 39: 1327-1330, 1932. In a boy of twelve there developed, after trauma to a congenital coffee-colored nevus under the hair, an elevated bluish red plaque with coffee-colored edge. A retroauricular node appeared with smaller nodes in a chain below. There was pallor; the liver and spleen were slightly enlarged. Biopsy was performed, followed by immediate massive electrocoagulation of the tumor. The pathological examination showed pigmented carcinoma. The author brings out the danger of biopsy without immediate destruction of the tumor. No follow-up is given. JEANNETTEMUNRO Case of Melanocarcinoma, Illustrating the Danger of Inadequate Early Treatment of Pigmented Nevi, J. L. CARRERAAND J. L. MONSERRAT.A prop6sito de un caso de melanocarcinoma; el peligro de las intervenciones intempestivas en el tratamiento de 10s nevi pigmentarios, Prensa med. Argent. 18: 1253-1262, 1932. A man of twenty-one had from early childhood had s pigmented wart on the THE SKIN 691 outer aspect of the left forearm. After injury to the wart with a nail, it had within a few days begun to grow rapidly, and a swelling appeared in the axilla. For more than a year the patient had been treated by a surgeon and a physician, who had fomented and cauterized the lesions repeatedly. On admission to the hospital the primary tumor of the forearm was a large bleeding ulcerated mass, there were large inguinal nodes resembling the axillary nodes and the primary tumor in their blackish color and their structure, and there were metastases in the liver and lungs; the patient died a few days after admission. The author states that doctors, and a good many surgeons, either adopt a noli me tangere attitude towards pigmented nevi and tumors or else fail to realise that mild measures of surgical treatment will not suffice. He points out that up to the present neither x-ray nor radium has been of much avail, and that the best hope appears to lie in drastic removal of the tumor with a wide zone of healthy tissue, regardless of cosmetic considerations. F. CAVERH

Cancerous Degeneration in a Wound Produced by Repeated Blistering. Treat- ment by Diathefmy and Radium. Cure, PAR~H.Dbgbnbrescence cancbreuse d’une plaie volontairement provoqube par un cauthre. Traitement par la diathermo-coagulation et le radium. Gubrison, Arch. SOC.de sc. mbd. et biol. de Montpellier 13: 168-170, 1932. A woman of sixty-nine was found to have a large foul-smelling ulcerated tumor 10 cm. in diameter on the left arm. When about forty-five she had extensive vaginal hemorrhages which led her to believe she was suffering from some internal malady. She conceived the idea of counteracting this by applying to her arm a small piece of blistering paper, the size of a postage stamp, removing the soiled piece every night, and replacing it by a new one. This practice she kept up for twenty-three years. At the end of that time the small wound thus produced began to grow rapidly in size and to have a bad odor. The patient then consulted a physician, who treated the lesion with antiseptics and vaccines, but the wound continued to grow larger and more foul, with pain of increasing intensity, which radiated to the forearm and hand. A year later the author was consulted. He made a biopsy, and the pathologist reported actively growing and infiltrating squamous-cell carcinoma. At one sitting the projecting and discharging portions of the tumor were destroyed by diathermy. This was followed by an application of radium tubes in a paste mould arranged to give at 3 cm. skin distance a dosage of 80 mg. radium element for five hours. The wound became clean, and scarring rapidly progressed from periphery to center. At the time of reporting, a month after the radium treatment, there was no sign of recurrence. Analysis of the paste covering of the blister paper showed that it was a strong preparation of cantharides, and the author suggests that after twenty-three years of daily application this substance, normally harmless, had exerted a carcinogenic action comparable with that of tar, mineral oils, etc. F. CAVERS

Cutaneous Carcinoma, with Sarcomatoid Features, Developing in the Ulcerated Scar of a Bum, E. GRYNFELTTAND A. AIMES. Epithblioma malpighien sarcomatoIde dbveloppb sur une cicatrice ulcbrbe de brlllure ancienne, Bull. de 1’Assoc. franp. p. l’btude du cancer 21 : 670-692, 1932. Thirteen years before being seen by the authors, a man of thirty-seven had, during an epileptic fit, fallen into a vat of boiling whey. His upper extremities were severely scalded. When he was seen by the authors, an enormous scar occupied the whole of the right arm and forearm. The elbow and wrist were fixed in a position of strong flexion, and the fingers were scarcely movable, owing 692 ABSTRACTS to the contraction of cicatricial bands. Many places on the scarred area were highly vascularized, others ulcerated, and on the back of the elbow was a large cauliflower-like mass the size of a mandarin, the surface of which was ulcerated, bleeding, and infected. This mass was excised, and, as histologic examination showed it to be a malignant growth, the limb was amputated. Eight months later the patient was in good health. The author made a very full histologic investigation of the tumor, making serial sections from different portions and at different depths of the mass. The findings are reported in great detail and are illustrated by twelve excellent photomicrographs. The first sections examined presented the appearance of a poly- morphic sarcoma consisting chiefly of large, irregular cells, but further study showed the presence of areas with the characteristic features of " prickle cell " or 'I mal- pighian " (squamous-cell) carcinoma, with colloid areas staining deeply with mucicarmine. Transitional areas occurred between the squamous-cell and the quasi-sarcomatous types of structure, and the authors conclude that the tumor is most accurately described as a sarcomatoid epithelioma, that is, a malignant epithelial tumor resembling a sarcoma in the form of its cells and their relation to the connective-tissue stroma, especially in the deeplying portions of the tumor mass. A picture of the patient and numerous photomicrographs illustrate the report. F. CAVERS Cutaneous Carcinomatosie Secondarg to Cancer of the Pancreas, G. RADAELI. Sopra un caso di carcinoma obsoleto del pancreas con inconsueta generalizza- zione metastatica, con speciale riguardo alla presenea di metastasi cutanee, Arch. ital. di dermat. 8: 464482, 1932. The author describes a case which came to autopsy and in which the outstanding feature was extensive metastatic dissemination in the skin of practically the entire body surface from a primary carcinoma of the pancreas. From the somewhat scanty literature, mainly Italian, to which references are made, the author concludes that cutaneous metastasis from pancreatic cancer is of rare occurrence; he found only eight previous reports of this condition. His account is interesting in other ways, however. It would appear that the primary carcinoma of the pancreas had grown very slowly and to a limited extent in that organ, and had undergone spontaneous regression owing to sclerosing fibrosis, but before this process was completed tumor cells had passed into the thoracic duct and thence entered the general blood circulation and been carried into the skin by the blood stream. Nowhere was there found evidence of lymph-borne metastatic cancer cells. Evidently the patient had died before the cancer cells had found a lodg- ment elsewhere than in the skin. The author describes, also, a case of choroidal melanosarcoma with cutaneous metastases, in order to illustrate the fact that blood-borne malignant cells may produce metastases exclusively in the superficial tissues. Seven illustrations are given. F. CAVERS

Generalized Cutaneous MOtaStaSeS Five Yeam after Operation for Breast Neo- plasm, LOUSTE,CAILLAU AND MEZARD. Ghblisation specitdement cutanbe d'un neoplasme du sein opere il y a cinq ans, Bull. SOC.frang. de dermat. et syph. 40: 97-100, 1933. A woman sixty-nine years of age had the left breast removed because of cancer and remained apparently cured for four years. Extensive lymph node involvement was then observed, and skin metastases appeared over the entire trunk, limited, however, to the most superficial lymphatic spaces; the blood capillaries not containing any cancer cells. THE SKIN 693

The metastatic process in this case resembled that of acute miliary carcinoma- tosis except that it was localized to the lymphatics of the papillae of the skin with no demonstrable invasion of the viscera or serous cavities. WM.MENDELSOEN Lupus Erythematosus with Carcinoma, GEORGEB. ANDREWS. Arch. Derm. & Syph. 26: 550-553, 1932. A report, with rather extensive discussion, of a case of lupus erythematosus treated by roentgen rays, with the subsequent development of cancer, proved by biopsy. It was suggested that any chronic irritation in lupus erythematosus may lead to carcinoma and also that practically all lupus lesions of long standing have been subject to irritation of some sort, in the course of treatment. A case in which carcinoma appeared after repeated exposure to sunlight is cited. Lupus Erythematosus with Sarcoid T~mours,E. GRAEAM-LITTLE.Proc. Roy. SOC.Med. 26: 1002, 1933. A case is reported of extensive and typical lupus erythematosus of the scalp, resulting in cicatricial alopecia. The unique feature was the presence of vivid red areas of infiltration on the right eyebrow, cheek, and particularly the neck below the chin, and of similar but paler lesions on the right arm. These sarcoids were of the two types described by Darier: that in which the skin moves over the nodule, and that in which the subcutaneous infiltration is definitely attached to the skin and forms a mass continuous with it. Sections failed to show the tuber- culoid structure, stressed by Darier. A. H. M. Gray said there were several interesting points in this case. If he had seen only the lesions under the jaw, he would have regarded these as the infiltrative type of lupus erythematosus, as compared with the typical form on the scalp. He raised the question whether the lesions on the arm were examples of Darier-Roussy sarcoid, and did not agree that they were the nodular sarcoid of Darier, as the latter was probably a form of Bazin’s disease. He did not think it was generally agreed that the Darier-Roussy sarcoid was tuberculous. F. CAVERS Mixed Tumour of the Face, Not Associated with the Parotid Gland, P. N. RAY. Indian Med. Gaz. 68: 373-375, 1933. A Bengali woman of eighteen had a small, rounded painless cystic tumor just in front of the left ear, first noticed three years previously. It contained pale yellow fluid without epithelial cells or cholesterol crystals, and was easily excised together with the fibrous capsule which surrounded its deep aspect but was not adherent to the deep fascia or connected with the parotid gland. The epithelial cells of the tumor, nowhere continuous with the epidermis, were arranged in columns, masses, or in alveolar formation. The author discusses the origin of mixed tumors of the parotid region, and agrees with Benedict and Meigs (Surg. Gynec. & Obst. 51: 626, 1930. Abst. in Am. J. Cancer 15: 1705, 1931), that encapsulated extraglandular tumors like that described probably arise from misplaced embryonal portions of the gland tissue. There are four photomicrographs, and a useful bibliography is appended. F. CAVERS

33 694 ABSTRACTS

Kaposi’s Cutaneous Sarcomatoeis, G. BERTACCINI.La sarcomatosi cutanea di Ksposi, Rsssegna clin., therap. e sc. aff. 10: 247-253, 1932. This is a general review of the theories as to the nature of Kaposi’s sarcoma. No new data are presented, A short bibliography is included. C. D. HAAGENSEN

Lichenoid Sarcoid (Boeck), J. L. MORSE. New York State J. Med. 33: 686-690, 1933. In diagnosing lichenoid cases of Boeck’s sarcoid, careful biopsy and histological study are of chief importance. The author reports a case in a woman fifty-three years of age. Biopsy showed that the tubercles were made up of epithelioid cells, with giant cells more numerous in the lesions of the forearm than in those of the neck. There was little evidence of any local tissue reaction. Gold-sodium thiosulphate given intravenously cleared up the lesions entirely. Roentgenologic Changes in Bones and Lungs in Boeck’a Sarcoid, J. NIELBEN. Die r6ntgenologiske forandringer i knogler og lunger ved Boeck’s sarcoid, Hospitalstidende 75 (Densk radiologisk Selskabs Forh.) 1-7, 1932. In many cases of Boeok’s sarcoid there are found roentgenologic evidences of changes in the bones and lungs. In the bones the changes occur chiefly in the phalanges of the fingers and toes, less commonly in the metacarpals and metatar- sals. Areas of cyst-like rarefaction have been described in the bones of the wrist and in the nasal bone, usually coincidentally with the sarcoid process in the skin, but sometimes before the latter is observed. There are three types of bony change: two diffuse and one circumscribed. The large vesicular difluse type is characterized by a slight diffuse swelling of the bone with thinning of the compact tissue, which usually forms a paper-like shell. The medullary cavity is obliterated. The bone appears cystic with rarefactions of varying size. This condition may progress; it may show a tendency to healing, or may assume the circumscribed form, which is in most cases stationary. In the circumscribed type, round or typically heart-shaped, punched-out transparent areas are seen in the heads of the phalanges. Usually there is a marked differentiation between the well preserved compact tissue and the medulla. In a third type, the small cystic diffuse type, a whole phalanx is transformed into a fine network without differentiation between compact and medullary tissue. This seems to be the most chronic type. In the large cystic form fractures may occur with extensive bone resorption. Aa regards treatment, neither roentgen therapy nor ultraviolet irradiation has given encouraging results. Of 24 cases of Boeck’s sarcoid seen at the Finsen Institute, 7 showed bone changes. Schauman (Acta Radiologica 7: 358-364, 1926) and Gans (Dermat. Ztachr. 33: 64-80, 1921) have given the best pathologic description of these changes. They consider them due to sarcoid tissue with epithelioid cells (as in skin), which displaces the spongy tissue, causing it to disappear. The disease seems to extend through the Haversian canals to the subcutis. Tumor of the soft tissue seems due chiefly to development of sarooid thue in the eubcutis either by continuity from the bone or independently (hematogenous metastasis). Roentgenologically intact phalanges may show microscopically extensive diffuse sarcoid tissue. Kuenitsky and Bittorf (Miinchen. med. Wchnschr. 62: 1349-1353, 1915) were the first to describe lung changes in Boeck’s sarcoid. They found opacity and increased density in the median and lower lung areas on both sides. In 35 patients with skin aarcoid, x-ray examination of the lungs showed changes in 19. THM SKIN 695

There were no symptoms referable to these pulmonary changes. The process is very chronic; it is of a productive, proliferative nature with absence of exudative and destructive processes and with a slight tendency to healing by calcification. Mediastinal and hilus changes are most common. There are large tumor-like shadows in the glandular regions with or without radiating infiltrating proceases to the central portions of the lung, often resembling sarcomatosis or Hodgkin’s lesions, so that even the expert is confused. The peribronchial localization of the changes is of aid in differentiating this condition from tuberculosis, as is the lack of destructive processes and cavitation. Nearly all the roentgenograms resemble tuberculosis, in some respects. [For those who are interested in further details of this subject there is a well illustrated paper by Doub and Menagh in the American Journal of Roentgenology (21: 149-155, 1929); also an excellent monograph, La Maladie de Boeck, by A. Kissmeyer, Copenhagen, 1932, in which bone and other lesions are well described (reviewed in Am. J. Cancer 16: 927, 1932.1 Operative Treatment of Hernangiornas, R. DEMEL. Operative Behandlung von Htimangiomen, Wien. med. Wchnschr. 83 : 618, 1933. In a series of cases [number not stated] several were encountered in which severe hemorrhage occurred during operation. In one patient, eighteen years of age, with a large cavernous hemangioma of the right side of the face, the author had just begun operation by cutting a mucous flap at the right corner of the mouth, when there set in hemorrhage which proved fatal within half an hour. The author makes passing mention of solid carbon dioxide, x-rays, and radium 88 palliative agents. He believes, however, that radical surgery may be made safer by preliminary injection of the tumor with hypertonic (15 per cent) glucose solution, repeated injections of which change the growth into a more or less solid mass. Another method is to inject 20 per cent of x-ray opaque material (abrodil) into one of the vessels of the tumor, in order to ascertain roentgenographically whether the intratumoral vessels are connected with outside ones; in one case an angioma of the forehead was found by this means to be connected with intracranial vessels. F. CAVERS

Hietologic Characters of Solitary Congenital Xanthoma, J. M. JORQEAND D. BRACHETTO-BRIAN.La estructura histologica del xantoma solitario y con- genito, Prensa med. argent. 18: 1129-1144, 1932. The authors describe 4 case6 of solitary congenital xanthoma, 3 of which were observed in children a few days old and the fourth in a woman of fifty-three years. In one of the children the tumor occupied the upper and in two the lower gingival border. The tumor in the woman was in the umbilical region and had been noticed since childhood. It was painless and had grown to an enormous size. In each case the tumor was excised, with good recovery. All four tumors were made up of the characteristic xanthomatous or foam cells, in a stroma containing dilated blood and lymph vessels. With silver impregnation the cytoplasm of the xanthomatous cells showed more or less abundant chromaffin bodies, which the authors believe to be lipochrome granules. The stroma was finely reticular, and in sections treated with ammoniacal silver carbonate the individual xanthomatous cells were seen to be surrounded by a fine fibrillar capsule derived from the reticular stroma. These points are well illustrated in the photomicrographs given. F. CAVERS 696 ABSTRAOTS

Xanthoma Diabeticom; An Early Case, R. B. MORELANDAND V. J. DARDINBKI. J. A. M. A. 100: 491-494, 1933. A man of twenty-four complained of an erythematous eruption on his penis of three weeks’ duration. Ten days before he was seen he developed a different type of eruption on the extensor surfaces of his arms and legs and on his buttocks. It consisted of more than a hundred discrete raised papules of a faint yellowish tint. The dermatitis about the penis suggested diabetes. The urine was found to contain sugar and the blood sugar was 312 mg. per 100 C.C. A biopsy was taken of one of the yellowish papules and showed hyperkeratosis, subepithelial fibrosis, moderate perivascular mononuclear infiltration, and an occasional foam cell. Three photomicrographs showing the appearance of this lesion are reproduced. The diabetes was easily controlled with dietary treatment and the xanthomatous papules disappeared in about a month and a half. There is a short review of the literature, with references. GRAYH. TWOMBLY

THE EYE AND EAR

Sarcoma Statistics, E. v. HIPPEL. Fortsetaung meiner Sarkom-Statistik, Arch. f. Ophthal. 129: 552-568, 1933. The author bases this paper on a series of 118 cases of sarcoma (mostly melanotic) of the uveal tract, operated upon in the eye clinic of Gottingen Uni- versity. He divides weal sarcoma into three stages: (I) latent, (11) glaucomatous, (111) perforated. In stage I the lesion is usually symptomless and as a rule is detected only on examination of the eyes either as a routine measure in sight correction or for other lesions; in stage I1 the prognosis is fairly good; in stage I11 it is practically always hopeless. The cases constituting the author’s series are tabulated on this basis, showing for each stage the total number of patients, the number alive and apparently cured after various intervals, the number dead from metastasis and from other diseases, etc. In both stages I and I1 two-thirds of the metastases occur in the first five years after operation. In the entire series metastases were observed in just under 40 per cent. In several cases, mostly belonging to stage 11, metastases were very late in appearing; in two cases the intervals after operation were twenty-three and twenty-six years. F. CAVERS

Sarcoma of the Choroid: History of Six Cases, with Early Operation, HERBERT MOULTONAND E. C. MOULTON.J. A. M. A. 99: 460-463,1932. Six cases of sarcoma of the choroid are reported, all of which were seen and operated on in an early stage before involvement of the outer coats of the eye had occurred. They are presented in summary in the accompanying table. .

Csee Age at Num- Oper- Status after Operation Type of Sarcoma br ation 1 44 Living and well today, after 28 years Small spindle cell 258 Well 15 years, death from apoplexy Leukosarcoma ; small spindle cell 3 53 Living and well today, 16 years later Small epindle cell 4 52 Metastasis and death 4 yeare and 8 months later Small spindle cell 5 50 Metastasis and death 2 years later Large round cell 6 42 Generalized sarcomatoeis and death 19 years later Large round cell THE EYE AND THE EAR 697

As will be seen, there were three cures and three deaths from metastasis. All of the patients who lived had tumors of the small spindle-cell type, one of which was a leukosarcoma. In two of the fatal cases the tumors were of the round- cell type, one was a small spindle-cell sarcoma. The authors arrive at the following conclusions: 1. Metastasis may occur after the earliest enucleations. 2. It may occur as late as nineteen years after enucleation. 3. It may occur with any type of cell, but the round cell is most malignant. In the discussion following this report Dr. Mary K. Asbury cited a series of 7 cases of choroidal sarcoma with enucleation in an early stage which she had previously reported and had retraced. Two patients were not heard from, 3 had died in less than five years after operation, and 2 were well, five and fourteen years after enucleation. On the other hand, 2 patients in whom the disease had reached the inflammatory stage were well after more than five years, and one with orbital extension of the tumor was well after eight years. Dr. Laura Lane had collected from the literature in a twenty-five year period, 356 cases of sarcoma of the choroid, for 176 of which she had practically complete records. While she agreed with the authors’ first conclusion, she did not find that the round-cell tumor was of greater malignancy than the spindle-cell growth. The authors’ case reports are illustrated by photomicrographs. Six Cases of Metastatic Carcinoma of the Choroid, H. B. STALLARD. Proc. Roy. SOC.Med. 26: 1042-1048, 1933. Six cases of metastatic carcinoma of the choroid are reported, representing an incidence of 1 in 140,000 cases seen in the outpatient clinics of an eye hospital. In 3 cases the primary tumor was in the breast; in two of these the interval between removal of the mammary growth and the discovery of the ocular metastasis was two and a half years; in the third case the interval was seventeen years. In two cases the primary tumor was in the lungs, and in these the metastatic growth in the eye was the first evidence of trouble. [These two cases have been reported previously. See Am. J. Cancer 17: 1018, 1933.1 No reliable history was obtained in the sixth case, in which there was a primary tumor in the bladder and prostate. The patient was in prison during the course of the disease and died shortly after his release, the affected eye being removed at autopsy. In three cases the right eye was affected and in three the left. The average length of life after the discovery of the metastasis was four and a half months. The case reports include details of the history and of the macroscopic and histologic appearances. There are seven illustrations. F. CAVERS Ophthalmological Curiosities : Pterygium and Carcinoma, E. CAMPOS. Curiosi- dades em ophtalmologia pterigio e carcinoma, Brasil-med. 45: 1094-1095, 1931. A woman forty-five years of age had a pterygium of the right eye, extending almost to the pupillary area, but differing in no way from ordinary pterygium. A similar lesion on the left eye spread in comet fashion, having for its head a small carcinoma which occupied one quadrant of the cornea. The tumor was firmly implanted in the limbus, but was very easily detached from the corneal surface. Total ablation’ was done, including a small portion of the pterygium close to the tumor. Ten days later, the pterygium of the other eye was operated upon. The cornea of the left eye (where the tumor was found) became perfectly transparent, whereas in the other eye there persisted, as usual, a small opacity in the portion occupied by the pterygium. These tumors are superficial and careful cauterization of the site of implantation in the limbus prevents recurrence in a considerable number of cases. The author mentions two other cases of small epibulbar carcinomata originating outside of the limbus, one operated upon in January 1925, the other soon afterwards, without recurrence at the time of his report. 698 ABSTRAOTS

Cyste of the Retina with Cholesterin Crystab in or behind the Retina, H. NEAME. Proc. Roy. Soc. Med. 26: 1037, 1933. Neame reports the case of a woman of twenty-five who said that the sight of the left eye had failed gradually during the previous four or five yearn. The right vision was 6/6, with good direct but very little consensual reaction of the pupil. Left vision was limited to perception of shadows. The left pupil was larger than the right, with very little direct but good consensual reaction. The left fundus showed numerous brilliant iridescent flat crystals, widely distributed in the posterior part of the eye, deep to the retinal vessels. In the far temporal periphery two contiguous rounded tumors projected into the vitreous; these did not undergo floating movement after movement of the eyeball.

Cyst of Left Retina. Detachment of Right Retina (Cured), R. 5. SCOTT. Proc. Roy. SOC.Med. 26: 1037,1933. Scott’s patient, a woman of fifty-three, had recently lost the upper portion of the visual field of the right eye, which had until then had better vision than the left. The right fundue showed a large retinal detachment, cured by endothermic cauterization. In the left eye there was a large globular translucent swelling, evidently a true retinal cyst, in the temporal periphery of the retina. The author, fearing eventual rupture of the enlarging cyst, suggested early operation by endothermic cauterization and external puncture. In discussing this report, Neame suggested that the outer wall of the cyst should be dealt with rather than the inner wall. In all sections of such cysts that he had seen the outer was the thinner wall and was stretched more than the inner. In order to give the retina the best chance of avoiding rupture at a later date, therefore, the better plan would be to make a hole in the outer wall or to remove it. F. CAVERE

Case of Retinoblastoma Apparently Cured by Roentgen Therapy, FLEIBCHER. Demonstration meinee durch Rontgenbestrahlung geheilten Gliomfalles, Ztschr. f. Augenheilk. $0: 202-203, 1933. The author presented a boy of eight years to whom he had first given x-ray treatment for retinal glioma four years previously. The treatment had caused cataract, which had been operated upon. Such of the glioma mames a8 had not disappeared had given rise to retinochoroid C cars. Up to the time of reporting the author had found only six other cases of complete x-ray cure of retinoblastoma. In the ensuing discussion, Wessely stated that he had treated a girl of nine years for retinoblastoma which had appeared five years after successful enucleation of the opposite eye for a similar growth. Seefelder reported a case of spontaneous cure of a retinoblastoma, and one of x-ray aure. F. CAVERB

Glioma Retinae, H. F. MOORE. Proc. Roy. SOC.Med. 26: 1036, 1933. The author showed a boy who at five years of age had one eye enucleated for glioma. The other eye, in which growth was also present, was treated by radon seeding, and the patient was observed at intervals of six weeks during the inter- vening three and a half years. There are now extensive changes in the choroid, perhaps due to too much radium having been used, but the patient ‘attends school and his vieion is 6/18. The mother refused to have the second eye removed, because the boy’s brother had previously died after having both eyes removed for glioma. F. CAVERS THE EYE AND THE EAR 699

Epithelioma of the Lacrimal Caruncle, M. M. AMAT. Epitelioma de la caruncula lagrimal, Gac. med. espafl. 7: 19-20, 1932. This is an immediate post-treatment report of a small, typical basal-cell epithelioma of the inner canthus of the right eye of two years’ duration, treated by operative removal and postoperative surface application of radium. JOHNE. WIRTA

Mixed Tumor of the Lacrimal Gland, Report of Case, C. S. SYKESAND HARRISS WILLIAMS. Texas State J. Med. 27: 850-852, 1932. Tumors of the lacrimal gland are comparatively rare. Lane in a comprehensive review of the subject (Am. J. Ophth. 5: 425, 1922) stated that only 229 cases had been reported. The most common type is the mixed tumor. The author’s patient was a negro woman aged twenty-nine. The tumor was removed and on microscopic study showed areas of cartilage, epithelial cells, and mucoid connective tissue. The areas of epithelial tissue were arranged in tubular and acinar formation. There were no gross signs of malignancy, but because recurrences are not unusual with such tumors postoperative radium therapy was given. The report was presented a few months after operation. At that time the eye approsched the normal in appearance; vision w& 20170.

Teratogenesis of Certain Embryoma of the Temporal Conjunctival Sac, C. GALLENGA.Bemerkungen zur Teratogenese einiger Embryome der tem- poralen Bindehauttasche, Klin. Monatsbl. f. Augenheilk. 90: 433-441, 1933. The author explains the origin of teratomata of the conjunctival sac as being the result of delayed closure, during embryonic development, of the clefts of the soft parts and bones of the orbit, with consequent inclusion of mesenchymal and ectodermal elements. This would place the origin of such growths in an early period of embryonic development. Conjunctival teratoma may contain muscle fibers, cartilage, and bone tissue, and, if ectodermal inclusions are present, true skin tissue with glands and hair follicles.

Large Cyst of the Orbit. Case Report, J. W. CRAWFORDAND E. KELLERT. New England J. Med. 206: 1041-1042, 1932. A woman sixty-six years of age had noticed a slight swelling medial to her right eye eight years previously. The mass grew slowly until it measured 10 cm. in diameter. The eyeball was displaced laterally but not greatly deformed. Vision was gone. A cyst filled with thin cloudy fluid was removed. The wall was fibrous and in places contained thin sheets of bone. Origin from a dermoid cyst is suggested. GRAYH. TWOMBLY

Large Angioma of the Orbit, H. VILLARDAND C. DEJEAN. Volumheux angiome de l’orbite, Arch. d’opht. 49: 638-643, 1932. A young woman eighteen years of age had a very large angioma of the orbit causing a marked degree of exophthalmos; the eye was pushed outward and downward to such an extent that it appeared as if ‘‘ attached to a pedicle.” The tumor in its posterior position surrounded the optic nerve, so that it could not be removed without loss of vision. The histological structure of the angioma was unusual in that it was of a mixed type-both cavernous and telangiectatic. Two Cases of Aural Cholsateatoma, W. STEWART.J. Laryng. & Otol. 47: 333- 334, 1932. The author presents two cases which he regards as supporting the view that cholesteatoma is a primary condition and suppuration, where it coexists, is secondary. THE ORAL CAVITY, UPPER RESPIRATORY TRACT, AND NECK

Surgery and Pathology of Cancer of the Head and Neck, E. S. MEYERBAND J. V. DUEIG. J. Cancer Ree. Comm. Univ. Sydney 5: 30-88, 1933. This paper is based upon 73 cases treated during six years at the Brisbane Hospital, Queensland. Brief case histories are given throughout, with histologic descriptions of the tumors and notes on the methods of treatment and the results so far obtained. The cases include cancers of the tongue (ll), lip (8), pharynx and larynx (6), jaws and inside of the cheek (6), floor of the mouth (7), ear, parotid, and face (lo), tonsil and palate (6), and neck (19). Meyers concludes the general section of the report by stating that every case of cancer of the regions studied constitutes an individual problem, which is never of the simple order too often suggested by a survey of the history of the surgical treatment of cancer. “ We believe that such treatment, in which we naturally include radiological methods, can be greatly improved if account is taken of every factor likely to influence the method of approach, the line of attack, the actual technique and the prognosis-if, that is, the problem is rightly seen for the very complicated thing it really is, even in apparently simple cases.” In the second part of the paper, whioh is illustrated by 21 photomicrographs, Duhig says he has found the classification of Broders very valuable in prognosis. The tumor was squamouscell carcinoma in 68 cases ; basal-cell carcinoma, endothelioma, and lympho-epithelioma in one each; lymphosarcoma in two cases. Of the squamous-cell tumors, 25 were classed as grade 1 (Broders), 18 as grade 2, 12 as grade 3, 13 as grade 4. F. CAVERS Clinical Observations, SCHMIEGELOW.Kliniske Iagttagelser, Hospitalstidende 75: 92-100, 1932. The author presents several clinical cases, including 2 cases of sarcoma of the tonsil with good results after six and seven years from roentgen therapy and combined surgery and irradiation respectively; one case of primary carcinoma of the left frontal sinus in which life was prolonged by surgical and x-ray therapy; a case of benign cystic tumor of the nasal sinus which was mistaken for carcinoma. He has found that tumors of the nose and pharynx respond favorably to electrocoagulation. In one case in which the patient was well twenty-one months after operation he attributed the good result to the fact that electrocoagulation has been very thorough, penetrating deeper than the hasal mucosa and causing a bone sequestration several months later. In some cases of cancer of the vocal cords electrocoagulation will suffice, although radical surgical removal is to be preferred. One patient with carcinoma of the tongue was well a year and a half after electrocoagulation. Relative Value of Radiotherapy in the Treatment of Cancers of the Upper Air- Paseages, W. D. HARMER.St. Bartholomew’s Hosp. Rep. 65: 17-101, 1932. This is the full text of the author’s Semon Lecture, which had previously been published in abbreviated form (Lancet 2: 1057-1063, 1931. Abst. in Am. J. Cancer 16: abst. p. 1082, 1932). It has also been published as a book (John Murray, London, six shillings net). F. CAVERS ORAL OAVITY, UPPER RESPIRATORY TRACT, AND NECK 701

Lesions of the Oral Cavity and of the Jaws and the Region of t,he Jaws Including the Temporal Fossa, Orbital Cavity, and Sinuses, JOSEPHCOLT BLOODGOOD. Internat. J. Orthodontia 18: 491, 633, 740, 874, 993, 1109, 1218, 1316, 1932. A series of articles reprinted, with some few additions to bring the material to date, from Lewis’ Practice of Surgery. Pathological Study of Malignant Tumors of the Mouth, J. HOFHAUSER.uber die bosartigen Geschwtilste der Mundhohle auf Grund patho-histologischer Untersuchungen, Arch. f. klin. Chir. 174: 371-377, 1933. Also in Orvosi hetil. 76: 1017-1019, 1932. In a group of 393 lesions of the lips, mouth, and pharynx studied histologically there were 99 benign and 166 malignant tumors, and 128 inflammatory lesions. The clinical diagnosis of malignancy was uncertain in only 29 of 137 histologically proved malignant growths, but when ulceration had taken place the correct clinical diagnosis was made in only 66 per cent of the cases. In those cases in which there was no doubt about the clinical diagnosis of malignancy and in which an operation was performed, there was extension to the surrounding muscles and lymphatics in 82 per cent. Several tables are included to show the location and histologic types of the various tumors. BENJAMINR. SHORE

Treatment of Oral Cancer, J. D. MORGAN.Amer. Med. 38: 81-84, 1932. A brief outline of the treatment of oral cancer with particular reference to the various types of irradiation and the problems of time factor, filtration, and dosage. WILLIAMJ. HOFFMAN

Cancer of the Lip, R. STEWART-HARRISON.Das Lippenkarrinom, Strahlen- therapie, 46: 401-434, 1933. Abstr., Zur Behandlung des Lippenkrebses, Schweir. med. Wchnschr. 63: 159-162, 1933. From 1919 to 1931 42 cases of carcinoma of the lip have been treated in the surgical and radiologic institutions at the University of Zurich. Fifteen of 20 patients treated by radiation alone and 8 of 17 surgically treated patients remain well for from one to thirteen years. It is concluded from this study that for primary tumors of the lips radiation treatment is the method of choice. Radical dissection of the cervical lymph nodes is indicated only in those cases in which cure of the primary growth appears probable. In this series there were 32 such cases and radical neck dissections were performed in 20. Histologic study showed carcinomatous involvement of the lymph nodes in 31.3 per cent of the cases. The author concludes that radical neck dissections may safely be post- poned in cases in which the lymph nodes are not enlarged to palpation if such patients can be followed closely. In cases with enlarged or definitely carcinomatous lymph nodes radical operations on the neck should be performed as soon as possible. Postoperative radiation should be given in all cases in which metastases are demonstrated after histologic study of the lymph nodes. BENJAMINR. SHORE Surgery for Cancer of the Face and Lip, DONALDV. TRUEBLOOD.Western J. Burg. 40: 401-404, 1932. The cure of cancer depends on early diagnosis and complete eradication of the disease. Procrastination or timid conservatism can rob the patient of his only chance of cure. Cancer of the face and lip are usually noticed early and the physician consulted. Adequate treatment can be given by electrocoagulation. radiation, and surgery if the physician is properly trained in the use of these agents. Because there are many more good surgeons than there are well trained radiologists, the treatment of lesions of the face and lip most widely available is surgical. 702 ABSTRAOTS

For lesions of the skin of the face Trueblood prefers wide excision by endotherm; for early cancer of the lip he employs a V-shaped excision, or the removal of the whole lip if it is widely involved. Where’there ia evidence of node involvement, he practises a radical resection of the nodes of the neck. WILLIAMJ. HOFFMAN

Radiation Treatment of Cancer of the Lip, P. C. FENWICKAND C. F. HINEB. New Zealand M. J. 32: 53-65, 1933. The authors state that aince 1924 they have treated about 200 cases of disease of the lip (leukoplakia, chronic ulcer, wart, fissure, etc.). Biopsy WBB not done in the earlier cases, and no statement is made regarding either the number of cases diagnosed BB carcinoma since the authors began to make it a.routine procedure to take sections, or the results obtained in the carcinoma cases. The report, therefore, would be devoid of general interest, but for the inclusion of replies received from radiotherapeutists in various countries to inquiries concerning the technic employed by them. These replies form an interesting symposium. F. CAVERS Pseudohemangiomatous Cysts of the Mucous Membrane of the Lip, D. EISEN- KLAM. Pseudo-Hglmangiome der Lippenschleimhaut, Wien. klin. Wchnschr. 46: 690-691, 1933. The author says he has during the past three years seen about twenty patients with small cystic tumors of the lips, mostly the lower lip, which on excision and histologic examination proved to be blood-containing cysts of the mucous membrane, and not true hemangiomas. He describes the histology of one of these cysts and, for the sake of comparison, that of a sweat-gland cyst of the lower eyelid, the wall of which showed almost exactly the same structure. There are two photomicrographs. F. CAVERS Glandular Cheilitis (Disease of Volkmann-Baelz). (Adenomata of the Lower Lip. A Precancerous state), TOURAINEAND SOLENTE.Cheilite glandulaire (maladie de Volkmann-Baelz). (Adhomes de Is levre inf6rieure. Etat pr&cenc6reux), Bull. SOC.frang. d. dermat. et syph. 40: 89-92, 1933. Glandular cheilitis is an affection of the lower lip involving the accessory mucoid glands that are contained in its mucous membrane. Hyperplasia of these glands with the formation of small adenomata constitutes what is known a8 simple glandular cheilitis. Sometimes secondary infection occurs and the lip becomes swollen and crusted, with occasional fistula formation. This condition is called cheilitis glanddaria apostematosa. In 4 of 18 cases studied by the authors there was a change from the benign adenoma to carcinoma. Consequently the authors consider this condition as one of the many manifestations of the precancerous state, though it is not necessarily associated with a syphilitio infection. A male patient sixty-two years old is described who had the infected type of glandular cheilitis. After the secondary infection had cleared up, a biopsy of what appeared to be a benign adenoma revealed a squamous-cell epithelioma. WM. MENDELSOHN Epithelioma of the Mucosa of the Cheek Treated by Excision and Autoplasty, AUCH~AND CHABTAIONET.Sur un cas d’6pith6lioma de la face muqueuse de la joue trait6 par ex6rdse et autoplastie cervicale, J. m6d. de Bordeaux 109: 71fl-720, 1932. A man of forty-seven had contracted syphilis twenty-three years previously and been given intensive antiluetic treatment on account of the appearance of ORAL CAVITY, UPPER RESPIRATORY TRACT, AND NECK 703

patches of buccal leukoplakia. These had disappeared for a time but had recently recurred and given rise to a large ulcerated mass which occupied the buccal surface of the left cheek and was adherent to the external skin. The ulcer had irregular edges and hard underlying infiltration, and there was extensive submandibular adenopathy. An incision was made from the point of the chin to the posterior end of the clavicular insertion of the sternomastoid, and the affected nodes were dissected out, while the tumor was removed with a margin of healthy tissue by a circular incision starting from the chin and comprising the whole thickness of the cheek wall. The defect was repaired by autoplasty with tissue from the upper part of the neck. Good scarring, with a fair cosmetic result took place within a month. Histologically the tumor was a squamous-cell carcinoma. F. CAVERS Cancer of the Tongue, J. ARCE. Cheer de la lengua, Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 532-533, 1932. Arce presents four cases of squamous carcinoma of the tongue. In three cases the right border of the tongue was involved. Excised cervical nodes in these three cases did not contain metastases. Two of the three patients were treated with radium in platinum needles and were alive twelve and six years without recurrences, while the third was treated by electrocoagulation plus radium and was alive one year after treatment without recurrence. In the fourth case the carcinoma involved the base of the tongue and there was a metastasis in a node in the left side of the neck. In this case the tongue was treated with radium in platinum needles. The patient was alive four years later without recurrence. JOHNE. WIRTH

Cancer of the Tongue, D. GIORDANO.Cancri della lingua, Morgagni 74: 635- 643, 1932. Giordano presents one case of cancer of the tongue in which interstitial radiation treatment accomplished only temporary palliation, and proceeds to a general discussion of the diagnosis and treatment of tongue cancer. He is emphatically opposed to taking a biopsy, believing that the diagnosis should be made as best it can by clinical means, and wide excision carried out in cases where a suspicion of a neoplasm remains. Giordano has never seen a case of cancer of the tongue cured with the quantity of radium (80 milligrams) owned by the City Hospital of Venice. He believes that physical agents such as radium and diathermy have no place in the treatment of lingual cancer. In every operable case the primary tumor should be excised intrsorally, and the submaxillary and upper cervical lymph nodes on the affected side dissected out, preferably at a second operation. C. D. HAAGENSEN Cancer of the Tongue Following Trauma, K. ULLMANN.Ueber einen Fall von traumatischem Zungenepitheliom, Wien. klin. Wchnschr. 46: 250-251, 1933. A man of forty had a painful ulcerated area on the tongue corresponding in poeition to a molar tooth which had recently been extracted because of loosening of the filling. Biopsy of the ulcer showed cornified squamous-cell carcinoma, with purely superficial extension and no sign of downward penetration. Six radium needles were inserted, giving a total dosage of 1135 mg. hours, and at the time of reporting, two months after treatment, there was apparently complete healing. In discussing the etiology the author points out that the patient showed no signs of leukoplakia or erosions elsewhere in the mouth, had never used tobacco or aloohol, denied syphilitic infection and showed a negative Wassermann reaction. ThuR the usual etiologic factors in lingual cancer were not present. The irritation due to the loosened tooth filling had lasted for a very short time. F. CAVERS 704 ABSTRAOTS

Mistaken Clinical Diagnosis of Cancer in Cases of Hypertrophy of the Lateral Papillae of the Tongue, ALBERT SIMONS.Die M8glichkeit irrttimlicher klinischer Krebsdiagnose bei Hypertrophie des Bog. Randorganes der Zunge, Ztschr. f. Hals-, Nasen- u. Ohrenheilk. 32: 490-492, 1933. Hypertrophy of the lateral papillae of the tongue, especially with associated inflammation, may closely simulate malignant neoplasms. The author reports such a ca8e with a photograph of the gross lesion and a photomicrograph, and stresses the fact that histologic study of biopsy specimens must be made in all suspicious cases. [Lacassagne has discussed the possibility of such an error (Arch. de 1’Inst. du radium de 1’Univ. de Paris 2: 587, 1932. Abst in Am. J. Cancer 16: abst. p. 1078, 1932). See also MacFee, W. F.: Ann. Surg. 93: 481, 1931 (abst. in Am. J. Cancer 15: 2907, 1931).] BENJAMINR. SHORE

Case of Neurinoma of the Tongue, F. CIANTINI. Su di un caso di neurinoma della lingua, Policlinico (sez. chir.) 39: 413-422, 1932. In a child aged eight an intrinsic tumor of the tongue developed and grew so rapidly that after four months speech was interfered with. The right half of the tongue was d8usely involved by the tumor, which could also be palpated through the neck as a swelling in the suprahyoid region. The lingual mucosa was incised, and an encapsulated tumor without obvious connection with any nerve was shelled out of the musculature. There had been no recurrence after four months. Ciantini classifies the tumor as a neurinoma. In one of the two photomicrographs which he presents good palisading is seen. He unfortunately neglects to state whether or not the patient or members of her family showed any of the stig- mata of von Recklinghausen’s disease. A short bibliography is included. C. D. HAAQENSEN Hypertrophy of the Lingual Tonsil, P. MOLQAARD.Hypertropi af tungeton- sillen, Hospitalstidende 75: 99-103, 1932. Hypertrophy of the lingual tonsil is relatively common, giving rise to symptoms usually interpreted as hysteria. Malignant tumors in this region are rare, however. Cancer arises almost always from the epiglottis, or true lingual carcinoma may extend backward from the tonsils or palatal arch. Sarcoma is more common. [See account of a similar source of error in the diagnasis of tongue cancer, by Lacassagne, abst. in Am. J. Cancer 16: 1078, 1932.1 Dosage in Roentgen Treatment of Malignant Tumors of the Upper Jaw, It. MITTERMAIER.Zur Frage der Dosierung der Rthtgenbestrshlung bei malig- nen Oberkiefertumoren, Ztschr. f. Hals-, Nasen- u. Ohrenh. 31: 247-255, 1932. In his treatment of 40 cases of malignant disease of the upper jaw, including the paranasal sinuses, the author has tried various forms of roentgen therapy, either alone or combined with operation. These have included the saturation method of giving a high initial dose followed by smaller doses at intervals of several days, and three variations of fractionated dosage: (a) equal small doses at intervals of several days, (6) equal small daily doses, (c) the Coutard protracted method, with a daily dosage of 300 r given for a longer time and a total delivery to one field of not more than 5000 to 6000 r or, if several fields are irradiated, up to about 4000 r per field. Four cases are selected for detailed consideration. First come two cases of sarcoma-lymphosarcoma and polymorphous-cell sarcoma-treated by fractional method a. In the first case the total dosage to a single large field, given in five sittings at intervals of two or three days, was 1.5 skin erythemaa; the tumor entirely disappeared. In the second case the total dosage, given in seven sittings to ORAL CAVITY, UPPER RESPIRATORY TRACT, AND NECK 705 three fields at intervals of four or five days, was 3.6 skin erythemas; x-ray examination two months later showed a small recurrence in the ethmoid region, which the author believes could have been prevented by timely coagulation of the tumor bed. Two cases of squamous-cell carcinoma are described by way of contrast to the two foregoing examples of radiosensitive tumors. In the first of these cases there was practically no sign of regression after using method a, with a total dosage of 3.5 skin erythemas, but after changing to method b (14 applications within seventeen days of a 10 per cent skin dose to each of three fields, totalling 4.2 erythemas) there remained only a small neoplastic residue, which was removed by electrocoagulation. In the second case a modified Coutard method was also used (11 applications within fourteen days of a 10 per cent skin dose to each of three fields; total dosage 3.3 erythemas) ; the tumor showed complete regression, but further similar doses were given at intervals of several days by way of prophylaxis. The author prefers to use first the method of fractionation with intervals of several days. If the cancer is radiosensitive, it is frequently cured by this method. If not, he then uses the method of daily or almost daily small doses. His experience with these less sensitive types of upper jaw and paranasal sinus cancers has shown that this treatment, though it may result in appreciable regression of the tumor and convert it from inoperability to operability, is rarely sufficient in itself to result in cure, though the prognosis is improved by subsequent electrocoagulation of any recognizable remaining portion of tumor, or of the tumor bed when this is possible. Coutard’s method has not been tried out in a sufficient number of these cases to allow of conclusions as to its relative value, and the same is true of the saturation methods. Four illustrations are given. F. CAVERS Tumors Originating in the Dental Tissues in Young Children, H. EULER. Vom Zahnsystem ausgehende Geschwulste des friihesten Kindesalters, Deutsche zahniirztl. Wchnschr. 36: 206-213; 228-234, 1933. In discussing tumors of the dental tissues in young children, the author includes only children in the first two years of life. If somewhat older children were included, follicular cysts would be among the most common of such tumors, as these cysts not infrequently arise from the milk teeth; no record was found of their occurrence, however, in children two years of age or younger. Perthes collected 7 cases of so-called ‘I congenital epulis ” in children under two; no further cases of this type have been reported, and the author’s review of Perthes’ cases leads him to doubt the diagnosis. A review of the literature shows only one case of histologically proved adamantinoma in a child under two. This was in an infant of six months (Coote, 1861). Other cases are reported in which this diagnosis was made clinically but not proved histologically. The author reports one case in a child of thirteen months, successfully operated upon, in which the diagnosis of adamantinoma was made from the histological findings. Only one case of odontoma with detailed histological description has been reported in the literature as occurring in a child under two years of age, that of Mummery and Pitt (1926), whose patient was five and a half months old. Even in this case there is some question as to whether the tumor should not be classified as an adamantinoma. The author reports one case, with histological description, of an odontoma in a child nineteen months of age. In this case there was a marked clinical resemblance in the early stages to the case of adamantinoma which he reports, but the histological difference between the two was definite. The nature of the stroma was of first importance in differentiation. From his results in his 2 cases, Euler concludes that surgical removal in the early stages of such growths in young children is definitely indicated and usually successful. ABSTRACTS

Infected Dental Cyst of the Mandible, J. STAZ. Brit. Dental J. 55: 152-155,1933. A woman of sixty, who had been edentulous for about five years, had during the past month had severe pain in the right lip and chin, corresponding to the distribution of the right mental nerve, followed by anesthesia of the same region. Palpation of a small swelling of the gum in the region of.the lower right premolars revealed the presence of an underlying hard mass resembling a root fragment. Intra-oral and extra-oral x-ray films showed a small root, connected with a large cavity in the bone which had invaded the entire thickness of the body of the mandible. This cyst was excised with the anterior half of the inferior nerve, which was firmly attached to it. The histologic appearance of the cyst suggested that it had arisen from the epithelial elements in the periodontal membrane. There are five illustrations. F. CAVERS Case of Adamantinoma, M. SAMPAIO.Considerapdes em torno de um caso de adamantinoma, Bol. SOC.d. med. e cir., SPo Paulo 15: 418427, 1931-32. A thirty-seven-year-old man suffered for three years from a tumor on the right side of the lower jaw. It increased gradually in size, had a smooth surface, and was not painful upon pressure. Biopsy showed it to be an adamantinoma. It was removed successfully and the patient was still in good condition more than one and a half years afterwards. A general discussion of adamentinoma follows the case report. JOHANNESP. M. VOQELAAR Von Recklinghausen’s Disease with Local Tumour of the Palate, G. T. HANKEY. Proc. Roy. SOC.Med. 26: 959-961, 1933. A woman of forty-four had a soft tumor of the hard palate, the size of a walnut, which had first been noticed ten years previously. The author diagnosed the tumor as a fibrolipoma and removed it in order to fit the patient with full dentures. At the end of the operation the lower part of the forearm became exposed, and the author noticed a small tumor which aroused his suspicions. Further examination revealed similar tumors on the arms and thorax. The diagnosis was obviously von Recklinghausen’s diseaee, and this was confirmed by the pathologist’s report that the palatal tumor WBE a neurofibroma with several nerves embedded in its base, The patient’s father, sister, and a paternal aunt were all covered with similar turnours.” In discussion F. P. Weber remarked that, so far as he knew, the palate was a very rare site for a neurofibroma. He believes it more usual to meet with a case of von Recklinghausen’s disease without, than with, a family history; that is, isolated cases of the disease greatly exceed the number of family groups, though not the total number of familial cases if each affected member of a family is counted BE a separate case. Two illustrations are given. F. CAVERS

Angioma of the Nasal Septum, VIRQINIUSDABNEY. Trans. Am. Laryng. Assoc. 53: 202-206, 1931. Interesting features of the case here reported are the absence of hemorrhage during examination and on removal of the growth; disappearance, after operation, of asthma which had previously been severe; and failure of the tumor to recur in a period of four years.

Malignant Disease of the ~ypopharplu,YON EICKEN. J. Laryng. & Otol. 47: 229-234, 1932. Also in Proc. Roy. SOC.Med. 25: 436-439, 1932. Hypopharyngeal tumors may be divided into two groups: (1) those arising from the lateral walls of the lgrynx, the outer surface of the epiglottis, the pharyngo- epiglottic fold and the plica aryepiglottica; (2) those having their origin from the sinus pyriformis and the lowest parte of the hypopharynx. ORAL CAVITY, UPPER RESPIRATORY TRACT, AND NECK 707

Because of the unfavorable results of surgery, especially in the second group, von Eicken has employed radium with promising results. The area of the tumor and the posterior wall of the pharynx are exposed by an incision along the border of the sternomastoid muscle. When necessary, the omohyoid is cut through, as are also, after ligature, the common facial vein and the external carotid artery. Care is taken to avoid opening the pharynx. Three or four radium carriers, each containing 10 mg. of radium, are distributed in the region of the tumor, the great vessels being protected by sheets of soft rubber. The wound is completely closed and the radium carriers are left in position for three or four days, i.e., until a dose of 3,000 or 4,000 mg. hours has been delivered. The carriers are removed, and the wound is again closed. The radium carriers are provided with a metallic filter and a rubber coating 2 mm. thick which serves as a secondary filter. The author has treated 11 patients by this method, of whom 2 are now free from symptoms, with complete disappearance of the tumor. In 5 other cases the tumor has decreased but symptoms are still present. In 4 advanced cases with lymph node metastasis no benefit was obtained. [The interval since treatment is not stated.] The author has had no experience with the Coutard method of fractional x-ray radiation, but believes that it, too, holds out promise for a more hopeful outlook in the therapy of cancer of the hypopharynx. In the discussion Trotter reported 8 cases treated surgically, with freedom from recurrence varying from three and a half to twenty years, with an average of eight years. J. B. Hunter emphasized the fact that until the exposure and examination of the primary growth it is impossible in the majority of cases to say whether surgical removal or radium is indicated. The most important point in reaching a decision is the lower limit of the growth. The postcricoid growths have a tendency to spread downward and frequently the growth extends beyond the cervical esophagus and is inoperable. Douglas Harmer stated that he and his colleagues had treated 106 patients with carcinoma of the.hypopharynx with different forms of radiotherapy, and of these, 70 died within a year. Only 11 were now alive, 5 without disease. These unfavorable results he attributed in part to the fact that nearly all his cases were hope- lessly inoperable, and in part to inadequate dosage. He advocated intensive surface irradiation, supplemented by a sufficiently high tissue dose. Stanford Cad8 advocated x-ray irradiation either alone or as a preliminary to interstitial radium in all inoperable cases. In operable cases, treatment depends on the localization, extent, and type of the disease. Epilaryngeal growths should be treated by radium in preference to surgery; postcricoid growths by surgery when possible; pyriform fossa growths by radium in split doses with massive quantities of radium. In all cases preliminary x-ray therapy is indicated. Numerous illustrative case presentations follow. Large Fibrolipoma of Hypopharynx, R. GIOACCHINI.Voluminoso fibrolipoma pendulo dell’ipofaringe, Valsalva 8: 895-903, 1932. A man of sixty-five complained of difficulty in swallowing, speaking, and breathing, first noticed a few months earlier. On laryngoscopic examination and manipulation a firm tumor, somewhat larger than a hazelnut, was found in the hypopharynx, attached by a stalk to the left glosso-epiglottic fold. It was easily removed with a galvanic loop. Histologically it consisted of solid fibrous and lipomatous tissue, the latter predominating. The author discusses some previously reported cases of fibromatous and lipomatous tumors of the pharynx and larynx, which are of rare occurrence, and gives five illustrations and a short bibliography. F. CAVERS ABSTRAOTS

Roentgen Diagnosis During the Course of Roentgen Therapy of Carcinomas of the Larynx and Hypopharynx, H. COUTARDAND F. BACLES~E.Am. J. Roentgenol. 28: 293-312, 1932. Roentgen examination of the larynx and pharynx is important because it may disclose malignant tumors long before such lesions (except when located on one of the cords) cause symptoms, It is also a useful procedure in the study of particularly difficult cases such as carcinomas of the ventricle of Morgagni, of the pre- epiglottic thyrohyoid space, at the base of the pharyngo-laryngeal groove, of the mucosa of the posterior portion of the cricoid, of the postero-inferior wall of the pharynx, and of the esophageal opening. Roentgen studies are necessary to determine whether or not a tumor is suitable for roentgen therapy. The extent 6f the lesion, particularly its lower border, its invasion of cartilage, whether it is fungating or infiltrating, and its point of origin can be determined by means of a roentgenogram. It is thus possible to decide whether to treat the case by roentgen therapy alone or in combination with surgery. During roentgen therapy the changes in the carcinoma and its involution can be easily followed by roentgenography. An excess of the daily dosage of radiation is manifested by small local edemas either in the tumor itself or in the submucous cellular tissue. After roentgen therapy such study permits a determination of whether the lesion has disappeared, and whether the cartilages are invaded and are actually necrotic. The differential diagnosis between a recurrence and a late necrosis, according to Coutard and Baclesse, is better made from a roentgenographic film than from clinical examination. The roentgenographic changes may be due to the projection of a very dense shadow onto a normally clear transparent space, without the distortion of the normal segments and spaces. This is the simplest diagnostic point to indicate the presence of a fungating tumor. Distortion of the normal segments and spaces may constitute another factor, as seen in the case of an infiltrating tumor or a simple epithelioma which has attained considerable size. These changes are excellently shown by forty-eight radiographs and diagrams illustrating sixteen case summaries. WILLIAMJ. HOFFMAN

Present State of Surgery of the Larplu, CA~ADE~~US.L’Btat actuel de la chirurgie du larynx, Rev. de laryng. 53: 835-867, 1932. The rivalry between conservative operations and radical mutilating operations for the cure of cancer of the larynx still continues. The solution of this question rests on the four following points: early diagnosis, selection of cases, perfection of surgical technic, and improvement in the construction of an artificial mechanical larynx. Early diagnosis permits a conservative procedure with preservation of the voice and little fear of recurrence. Proper selection of cases takes account of the extent of the disease, its localization, and the presence or absence of regional gland involvement. The ideal case for conservative surgery is a tumor well localized to one vocal cord, without involvement of the anterior commissure and without fixation of the cord. A case of this type is well suited to treatment by thyrotomy. Application of thyrotomy to cases more advanced in character has unjustly cast discredit upon the operation. Perfection of surgical technic has permitted the performance of a wide thyrotomy with partial resection of one side of the cartilage. This iR suitable for lesions somewhat more advanced than that just described and which have produced limitation of motion of the cord. How- ever, if the lesion involves the anterior portion of the opposite cord as well, a conservative operation is still possible if associated with the use of radium in situ. If, on the other hand, a lesion at the anterior angle extends to involve the mucosa and is not limited to the cord, a laryngectomy is advisable. If the cancer has extended posteriorly, the prognosis is grave. Invasion of the arytenoid, ventricu- ORAL QAVITY, UPPER RESPIRATORY TRACT, AND NECK 709

lar bands, base of the epiglottis or subglottic regions requires hemilaryngectomy or even total laryngectomy if prompt recurrence is to be avoided. In marked contrast to the favorable results achieved in cases of intrinsic cancer of the larynx are the poor results in extrinsic cancer. If surgery is to be successful in this latter group, it must include not only a total laryngectomy but a more or less wide resection of the pharynx. With a few exceptions, these cases are inoperable when first seen and in only a very small group is surgery advisable. When surgery is decided upon, the family should be acquainted with its mortality and the uncertainty of its permanent benefit. The author discusses the details of technic in hemilaryngectomy and total laryngectomy, as well as the merits of local and general anesthesia for these operations. He makes the surprising statement that nearly every one of his patients learns to speak with a pharyngeal voice and some of them become quite expert, so that they can be understood by the average person. The mechanism involves the expulsion of air from the esophagus upward into the pharynx. The author also describes the latest model of his artificial larynx and enumerates its many advantages. Because of the comparatively poor results obtained in the treatment of cancer of the larynx by external radiation and the interference with subsequent surgical procedures, Casadessus does not believe one is justified in advising its use in operable cases. The field of radiotherapy, he believes, should be restricted to the palliative treatment of inoperable growths. WILLIAMJ. HOFFMAN

Comparative Results of the Surgical and the Protracted Radiation Treatment of Carcinoma of the Larynx, V. HINSBERGAND S. EPSTEIN. Resultate der Behandlung des Kehlkopfkarzinoms durch Operation einerseits und durch Langzeitbestrahlung andererseits, Med. Klin. 29: 177-180, 1933. Of 214 cases of intrinsic and extrinsic carcinoma of the larynx which Hinsberg has seen in the past thirty years 70, or 33 per cent, were inoperable, and only 38, or one-sixth of the entire number, were considered to be early and favorable cases for operation. Laryngoscopic examination in patients with symptoms referable to the vocal cords and larynx should detect malignant growths in a much earlier stage, and it is by the education of the medical profession in this respect that better results in the treatment of laryngeal carcinomas are to be realized. Hinsberg has performed 38 laryngofissures with local excision of the tumors, and 35 unilateral and 61 total extirpations of the larynx for carcinoma. The operative mortality following local removal of vocal cord tumors is low, and a cure is to be expected in about 80 per cent of the cases. The operative mortality following complete laryngectomy for intrinsic carcinoma is about 8 per cent, and for extrinsic growths, 25 per cent. Lasting cures can be expected in from 15 to 20 per cent of the intrinsic growths. The author has no cures in those cases in which the pyriform sinus has been involved. Only 9 cases of carcinoma of the larynx have been treated by radiation therapy, and these only within the past six months, so that a comparison with surgery is hardly justifiable. However, Hinsberg concludes that the operative treatment ie preferable in all mechanically operable growths when the physical condition of the patient warrants it, and that radiation therapy should be reserved for inoperable tumors, and especially those which involve the pyriform sinus. Epstein describes the technic of the radiation therapy of laryngeal carcinomas which is modelled after that of Coutard. BENJAMINR. SHORE 710 ABSTRAUTS

Branchlnl Fibrochondroma with Pre-Auricular Fistula, M. JACOD. Fibrochon- drome branchial pr6-auriculaire fistulis6, Lyon m6d. 151: 613-815, 1933. A young woman twenty years of age, whose mother and grandmother both had congenital pre-auricular fistulae, had a small swelling in the pre-auricular region. At the age of twelve this nodule enlarged, became painful, and finally opened spontaneously, forming 4 small fistula. The fistula closed, but abscess formation and fistulization occurred twice subsequently, the last time when the patient was seventeen years of age. Under local treatment, the inflammatory symptoms subsided. It was then found that at the site of the fistula the skin was indurated and adherent to a cartilaginous tumor. This was dissected and proved to be fibrochondroma of branchial origin.

THE THYROID AND PARATHYROID GLANDS

Results of Roentgen Therapy in Two Cases of Malignant Thyroid Gland Tumora, G. STEINER. Strahlenerfolg bei zwei FElllen maligner Schilddrtlsentumoren, Strahlentherapie 45: 796-800, 1932. The author points out that, whereas malignant tumors of the thyroid were not even mentioned in German textbooks of radiotherapy of ten years ago, Barthels in his recent monograph on strums maligns (Ergeb. d. Chir. 24: 162, 1931) states that 19 per cent of cases treated by x-ray alone have been cured. Steiner reports two cases. A woman of sixty-seven had a large, firm thyroid tumor which had broken out of its capsule and sent a process into the left supraclavicular fossa; radiography showed a cyst-like shadow in the poeterior mediastinum behind the right hilar region. The case was considered inoperable. The author irradiated five fields (three cervical, two mediastinal), using 150 kv. and giving a total dosage of 1736 r; this was followed, seven weeks later, by a dosage of 3000 r to the cervical fields. For seven months the tumor diminished in she, though the mediastinal shadow remained unchanged, as did also the tumor process extending to the left supraclavicular foasa. The latter region was then given a dosage of 2600 r. The main tumor became smaller still, but no further change had occurred up to the time of reporting, though the patient was feeling better, being free from the pain and the difficulty in breathing and swallowing complained of before treatment. The second patient, a woman of fifty-six, had a rapidly growing thyroid tumor, which she had painted freely with iodine. In thia cam a biopsy was made, and the diagnosis was spindle-cell sarcoma. The symptoms included pain and difficulty in breathing, facial cyanosis, tachycardia, emaciation, and tremor. Radiog- raphy showed a large mass in the right upper mediastinum and several smaller ones in the lungs, presumably metastases. Practically the same x-ray treatment was given as in the first case, and within four months all the symptoms had disappeared, with reduction in size of the primary tumor and the intrathoracic masses. [In both cases the follow up has been short, only a few months.] Three good roentgenograms are given. F. CAVERS

Case of Small Alveolar Large-Cell Adenocarcinoma (Langhans) of the Thyroid Gland, E. M. EBERTB. Canadian M. A. J. 28: 650-652, 1933. A woman of forty-three, complaining of enlargement of the neck, nervousness, palpitation, and loss of weight, said she had noticed the swelling on the right side of the neck four years previously and that iodine, prescribed by the family physician, had apparently aggravated the symptoms. She showed the usual signs of thyrotoxicosis. The encapsulated tumor was resected, and recovery WBB uneventful. THE THYROID AND PARATHYROID QLANDS 711

On gross section the tumor in general resembled normal thyroid tissue, but there were several circumscribed areas of lighter color and more solid structure. Histologically these nodules were found to consist of large, closely packed cells arranged in alveoli. The cells were mostly polyhedral, with small vesicular nuclei; they resembled adrenal or liver cells in appearance, and contained no glycogen or fat, and no mitotic figures. None of the usual signs of infiltration were observed; the engrafted tumor had evidently in its advance directly replaced the contiguous adenomatous thyroid tissue. After operation deep x-ray treatments were given at intervals over eighteen months, and at the time of reporting, more than two years after operation, the patient had remained free from symptoms referable to the thyroid. There are three photomicrographs. F. CAVERS

Tumors of the Parathyroid Gland: Report of Two Cases, F. W. RANKINAND J. T. PBIEBTLEY.Am. J. Surg. 20: 298-314, 1933. In the diagnosis of hyperparathyroidism the roentgenological evidence of the osteitis fibrosa cystica type of bony involvement is of greatest single importance. This, together with chemical studies of the blood and the history of the illness, usually suffices to render the diagnosis certain. The history is usually one of prolonged skeletal pain, weakness often confining the patient to his bed, and perhaps one or more fractured bones. The calcium content of the blood serum is either normal or elevated and is associated with increased excretion of calcium, giving a negative calcium balance, while the phosphorus content is either normal or decreased and is associated with an excess excretion of phosphorus, giving a negative balance for this element, also. In addition, certain secondary findings are commonly present, the most prominent of which are weakness, generalized myotonia, anemia, loss of weight, and gastrointestinal disturbances. Nephro- lithiasis is a rather common associated finding. Palpation of an enlargement in the thyroid region is of help, but is not necessary for the typical clinical picture. The roentgenological findings are perhaps the most pathognomonic of any data, namely, the generalized osteoporosis, cystic lesions and deformities. These are best observed in the skull. Two cases of parathyroid tumor are reported. The first patient was operated upon over four years ago and is alive and well with no clinical signs of disease. The roentgenograms showed some increased density of bones. In the second patient, although the calcium-phosphorus values were normal, the value of the blood phosphatase was increased, namely 61.7 units. The parathyroid tumor was located with some difficulty, but was eventually found lying between the trachea and esophagus. Immediately following operation, the patient was in good general condition and the blood calcium fell until on the fourth day it had reached 4.6 mg. per 100 C.C. of blood. At that time definite evidence of tetany developed, despite previous administration of calcium. This symptom, however, was averted by the use of parathormone. Concomitant with the drop in serum calcium, the value of serum phosphatase fell to 22 units. Nausea and vomiting, with abdominal cramps, distention and diarrhea, developed. The calcium balance again became negative and tetany occurred, to be relieved only by intravenous injections of parathormone and the giving of calcium lactate by mouth. The patient failed gradually and died on the seventy-eighth postoperative day. At necropsy three parathyroid bodies were found, all slightly larger than normal and histologically hypertrophied. A very small amount of thyroid tissue remained in the operative site and microscopically this showed marked degeneration, almost suggestive of myxedematous changes. All the bones gave evidence of marked decalcification, and could be easily cut with a knife. The authors emphasize the importance of careful examination of both sides of the thyroid gland at the time of operation. Parathyroid tumors are frequently 712 ABSTRAOTS bilateral, and it may be possible to remove a tumor from one side only, preferably the larger of the two, leaving an adequate amount of functioning tissue. WILLIAM5. MACCOMB

Parathyroid Tumour with General Symptoms, but No Bony Deformities, J. F. VENABLES. Guy's Ho8p. Rep. 83: 194-199, 1933. -4 woman of fifty-two complained of extreme weakness and aching'pains in the legs, which increased until she had become almost bedridden, loss of appetite, and loss of weight. During the past eighteen months her hair had increased rapidly in thickness, and she had noticed slight discomfort in the right side of the neck. No bony deformity was detected; bone tenderness on deep preseure was general, but especially marked over the lumbar vertebrae, right tibia, both femora, and the sternum; the blood urea was normal, and the blood count within normal limits. The possibility of gastric carcinoma was considered, and a roentgenogram of the left hip joint, showing a large rarefied area in the upper third of the femur was at first considered suggestive of a metastasis. The x-ray appearance of the stomach, however, was far more suggestive of gastritis than of neoplasm. The whole skeleton was then x-rayed. Generalized rarefaction and mottling were found in the cranial bones, and generalieed decalcification in practically the entire skeleton. The blood calcium was 15.8 mg. per 100 C.C. (compared with a normal maximum of 10 mg.) Although the right thyroid lobe showed fullness, no definite tumor could be palpated, but a diagnosis of parathyroid tumor was made. At operation two nodules were felt in the right thyroid lobe and considered to be thyroid adenomas, but as no obvious parathyroid tumor was found after dissection of both lobes and thorough digital exploration of the upper mediastinum and behind the trachea and larynx, the two nodules were removed. One was a thyroid adenoma; the other, completely embedded in thyroid tissue, proved to be an eosinophil parathyroid tumor. Five days after operation the blood calcium wae 12.2 mg. per 100 c.c., after which it fell to normal. A year after operation the patient had no pain and could walk long distances; complete achlorhydria was still present; and the blood pressure, which rose from 150 mm. before operation to 220 a few weeks after, still remained over 220. The author believes this to be one of the earliest cases of hyperthyroidism yet recognized. There are four illustrations. F. CAVERS

Case of Parathyroid Tumow, G. KEYNESAND H. TAYLOR.Brit. J. Surg. 21: 20- 28, 1933. The authors find that upwards of fifty cases of hyperparathyroidism treated operatively have been reported in European and American journals. In reading the reports it has occurred to them that attention has perhaps been focused too much on the changes in the skeleton and too little on the condition of the patient as a whole. They consider it worth while, therefore, to present a fuller account of a single case than is usually done, since the patient presented a very complete picture of the disease, with some unusual features as well. The patient was a youth of eighteen, whose initial symptoms were acute abdominal pain, with persistent vomiting, frequency of micturition, and considerable wasting. Other symptoms developed, including those pointing to hyperparathyroidism, with characteristic bone lesions, and an increase in serum calcium was observed, which was held to establish the diagnosis, although no tumor could be detected. At operation a cystic tumor measuring 3.5 x 2.5 cm. was found lying behind the lower pole of the left thyroid lobe and was easily removed. The serum calcium figures fell abruptly after operation, and the symptoms THE THYMUS GLAND 713 rapidly abated. The premonitory signs of tetany soon disappeared, and the various affected bones were found to be undergoing recalcification. There are twelve good illustrations. F. CAVERR THE THYMUS GLAND

Case of Thymoma Arising in HassaU’s Corpuscles, L. CORNIL,J. OLMERAND J. ALLIEZ. Considbrations anatomiques sur le thymoblastome hassalien, Bull. Assoc. franc. p. 1’6tude du cancer 21 : 693-699, 1932. A woman of thirty-one had severe dyspnea, for which immediate tracheotomy was performed. She had had a similar attack a year previously, which had been diagnosed and treated palliatively as asthma. During the interval she had noticed slight dysphonia and some difficulty in swallowing solid food. There was marked cyanosis of the face and upper part of the chest, with cape-like collateral circulation. Chest examination confirmed the suspicion of mediastinal trouble, there being symptoms of perihilar condensation and of left pleural effusion, besides 1’Espine’s sign, while the left cervical nodes were enlarged and hard, the supraclavicular group forming a mass as large as an orange. X-ray confirmed the clinical findings and showed a large mass in the posterior mediastinum. The patient was slightly feverish; the blood Wassermann reaction was negative, and a blood count was normal. Despite the absence of pruritus and eosinophilia, the condition was diagnosed as Hodgkin’s disease, but removal and examination of an enlarged supraclavicular node negatived this and revealed the following histologic features. Apart from a thin peripheral layer, the normal structure of the node had practically disappeared. Thc capsule was the seat of considerable sclerosis, from which there extended inward partitions dividing the node into numerous lobules of varied form and size and consisting of masses of cells which were mostly of uniform shape and size and showed numerous mitoses. Scattered among these cells there were in nearly every lobule several masses showing the typical features of .Hassall’e corpuscles. The patient was given x-ray treatment, after which she left the hospital with her symptoms considerably relieved. She died a few months later in an attack of dyspnea, and although autopsy was not permitted the authors consider that the histologic features of the lymph node examined by them justify the conclusion that this was a metastasis from a thymoblastoma of reticular type arising from Hassall’s corpuscles. In their discussion the authors select for special reference the writings of Ewing (Surg., Gynec. & Obst. 22: 461, 1916; Neoplastic Diseases, ed. 3, 1928, pp. 966-977) and of Margolis (Am. J. Cancer 15: 2106-2142, 1931), though they complain that the latter fails to discuss the conclusion of Dustin, based chiefly on morphologic and experimental studies on Batrachia, that the small thymic cells are not derived from the mesenchyme but from the entodermal thymic reticulum. [As pointed out by Margolis op. cit. p. 2107), final conclusions regarding the actual origin of the small thymic cells are not as yet warranted, hence “ it would seem reasonable that a definitive classification of thymic tumors is equally unjustified.” The subject has been more recently discussed in a valuable paper by Crosby (Am. J. Cancer 16: 461-486, 1932).] F. CAVERS 714 ABsmuTs

THE BREAST Bleeding from the Nipple, C. WOLPERS.Die blutende Mamma, Arch. f. klin. Chir. 174: 447-474, 1933. Bleeding from the nipple in women occurs with cancer of the breast but it is not pathognomonic of this disease, being observed in cases of chronic cystic mastitis and papillary cystadenomas of the ducts. In all cases of chronic cystic mastitis the secretion contained in the ducts is increased in amount due to the desquamation of the lining epithelial cells. At times, because of vascular thrombosis in the wall of the cyst or direct trauma to the blood vessels, this secretion may become blood-tinged. Two such cases in which malignancy wa~eliminated by histologic study of the breast are reported. Hemorrhages or alight bleeding are observed in the relatively vascular duct papillomas before menstruation or following slight trauma. In 414 cases of carcinoma of the breast bleeding from the nipple was observed in only 5, or about 1 per cent. It is to be expected in the more highly differentiated adenocarcinomas and those of the medullary type which show a particular tendency towards necrosis. Bleeding from the nipple in men is due either to a cystadenoma of the ducts or to carcinoma and has not been observed in an histologically proved case of chronic cystic mastitis. Case histories of 22 patients with bleeding from the nipple are appended. There are no illustrations. BHINJAMINR. SHORE

Radical Operations for Cancer of the Breast, C. EQQERS.Ann. Surg. 96: 1098- 1102, 1932. (Transactions Am. Surg. Assoc. 1932.) The author remarks that ever since the radical operation for cancer of the breast was proposed by Halated and Willy Meyer, attempts have been made to improve the results by variation of the technic, or by preoperative or postoperative radiation or both. Yet the operative results at present, as far as can be judged, are not much better than they originally were. The best reports come from clinics where radical surgefy is combined with postoperative radiation. At the Lenox Hill Hospital the radical operation for cancer of the breast is as follows: (1) Removal of the breast with an adequate skin margin well beyond the tumor. (2) Thorough undermining of the skin margins to insure extensive removal of the subcutaneous tissue with the breast and to aid in closing. (3) Excision of the entire pectoralis major and minor. (4) Removal of the entire axillary contents including the lymph nodes in front of the scapula and those situated high in the axilla above the vessels. (5) Thorough clean dissection of the chest wall. (6) Skin graft if indicated. The incision is varied according to the position of the tumor. The functional results are satisfactory; there is edema of the arm occasionally, but very rarely is this disabling. Local recurrences with this technic are very rare, axillary recurrences almost unknown, and chest-wall. growths rare. Yet in spite of these favorable local results, the death rate from late cancer of the breast is high at this hospital as at other institutions. The patients die from metastases. Carcinoma is usually believed to be spread by way of the lymphatics, but tumor cells may enter the blood stream directly. The author is of the opinion that distant isolated metastases, such as bone metastasis in breast cancer, are more probably due to dissemination by the blood stream. The radical operation of to-day aims at the removal of all those tissues that may be directly invaded by the tumor, as well as all the lymphatic vessels leading away from it, that are accessible. Only in the direction of the axilla does it include lymphatics that drain THE BBEAST 715 the breast; if the tumor is so situated that the lymphatic drainage is into the mediastinurn, this is not guarded against nor is the spread of cancer cells by the blood stream. Rough handling of the tumor or involved lymph nodes either before or during operation may easily favor the dissemination of cancer cells and should be carefully avoided. If at the operation the breast is forcibly drawn over to the opposite side during the axillary dissection, this may result in the dissemination of cancer cells. It is for this reason that the author has made it a practice to excise the tumor or do an ablation as the first step in the radical operation. In doubtful cases, and in cases where the growth is clinically carcinoma but single and easily removable, an excision is done with a good margin of normal tissue, and the report on the frozen section awaited before proceeding with the radical operation. In more extensive carcinoma, a rapid ablation without much handling is done as the first step of the radical procedure. Complete excision of the tumor with surrounding normal tissue is the only form of biopsy justifiable in breast cancer in the author’s opinion. The only other way of controlling metastases is by radiation therapy, either preoperative or postoperative or both. Combined treatment by surgery and radium implantations also deserves attention. [There is one fact which the author has neglected to stress, and that is the spread of tumor cells by mechanical wiping of the wound with gauze compresses. It is still too common a practice for assistants to wipe out the wound with gauze during an operation, exerting considerable pressure. Removal of blood is necessary in order to catch small bleeding vessels, but wiping should be avoided, and the assistants taught to sponge up the blood by light pressure rather than to wipe the wound, which can easily squeeze cancer cells through the deeper lymphatics into the mediastinal drainage system, or distribute them over the skin flaps, thus giving rise to implantations which later may be noted as recurrences. A still worse practice is to use gauze pads to wipe out the fat and drag out the nodes in the axilla. The dissection here should be entirely with a sharp knife; no traction or pressure should be exerted on the axillary contents, as Dr. Eggers states, but this defect of technic, with occasional disastrous results to patients, is still too commonly seen. The advantages which are alleged to accrue from the use of the cautery or the high-frequency cutting knife may be due to the fact that such sponging of tissues carrying lymphatics filled with cancer cells is not necessary, owing to the hemostasis produced by the cautery instruments. Such clean scalpel dissection may take considerably more time than that required to drag out the fat of the axilla with the fingers or a pair of blunt scissors, or a game sponge, but there is practically never any question of haste in an operation on carcinoma of the breast. Haisted, whose mortality was very low, was a most leisurely operator, often taking three hours or more to complete his mastectomies. There is also a regrettable tendency, still only too frequent, to save too much of the skin in order to escape the necessity of grafting to cover the wound. It is true that such grafted areas do not stand postoperative radiation as well as skin flaps, but in the present status of postoperative radiation, no guarantee can be given that such treatment is necessarily capable of destroying all the tumor cells left in the tissues, despite the excellent statistics which have been brought forward by the German clinics, indicating a distinct benefit by such measures. A surgeon is still bound in duty to his patient to do as complete an operation as is mechanically possible, and not to slight his operation technically in the hope that the radiologist will complete a cure. Ed.] 716 ILBSTRACTS

Partial Mastectomy for Cancer, R. MANNINI.Considerazioni sulle mammellet- tomie parziali per cancro, Policlinico (sez. prat.) 39: 721-727, 1932. The author believes that partial mastectomy may be substituted for radical mastectomy in cases of breast cancer where the disease is “ limited l1 in extent. He advances no data of his own to support this medieval thesis. C. D. HAMENSEN Irradiation Therapy in Cancer of the Breast, G. E. PFAHLER.Canadian M. A. J. 28: 602-604, 1933. The author considers that, despite the advances made in the irradiation treatment of breast cancer, such treatment is still in the stage of investigation, and should for the present be reserved for patients who cannot or will not be operated upon or who are under observation in the larger clinics, where they have the advantage of both surgical and radiological resources. Owing to the demonstrated value of irradiation in inoperable and recurrent cases, radiotherapeutists are gradually being called upon to treat earlier cases and at times even the operable group. The author confines his discussion to postoperative treatment and recurrent cases, for the reason that in such cases the diagnosis has been definitely established and there can be no question about the nature of the disease. Probably about one-third of operated cases show recurrence within the first year. In the author’s series of 1022 cases previously reported elsewhere (Am. J. Roentgenol. 27: 497, 1932. Abst. in Am. J. Cancer 16: abst. p. 1370, 1932), 64 per cent of the recurrences developed within the first year and 42 per cent within the first six months. Postoperative irradiation should therefore be instituted as soon as it is safe to move the patient to the x-ray equipment, which is usually within two weeks after operation. “ Judged by past records, the surgeon should not assume the responsibility of not recommending postoperative irradiation, excepting in those cases in which the disease is absolutely limited to the breast tissue and when he is quite sure all of it has been removed. Past records also show that it is extremely difficult to pass such judgment.” The sections on technic and results are repeated from the author’s longer paper, cited above. F. CAVERS

Radium in Cancer of the Breast, F. 5. BATCHELOR.New Zealand M. J. 31: 31 1- 315, 1932. Some Notes on Radiotherapy in Cancer of the Breast, C. DE MONCHAUX.Ibid. 31 : 383-392, 1932. Report on Irradiation Therapy of Breast Cancer, J. MURDOCHAND S. SIMON. Rapport sur le traitement radiologique des cancers du sein, Cancer, Bruxelles 9: 175-192, 1932. Also in Scalpel 85: 1257, 1284, 1317, 1932. Neither of these three papera contains anything new. Those by Batchelor and de Monchaux deal with too small a series, followed by too short a follow-up, to be of statistical value. Murdoch, though presenting no new facts or case reports, gives a valuable summary of much of the recent literature on irradiation of breast cancer, covering practically every aspect of this extensive field and presenting most of the collected data in clearly tabulated form. In a final section dealing with the comparative results of purely surgical treatment and of irradiation alone or combined with surgery, he selects the English surgical statistics collected by Lane-Claypon for comparison with the recent publications by Pfahler. The former writer gives for operated cases an average of 33.9 per cent three-year cures and of 25.5 per cent five-year cures. For operable cases Pfahler’s figures are 62.5 per cent three-year cures and 52.5 per cent five-year cures; while for all cases (operable, irradiated THB BREAST 717 with or without surgical intervention, and inoperable and recurrent cases) his figures are 50 per cent three-year cures and 38 per cent five-year cures. The author concludes that combined surgery and irradiation is manifestly superior to purely surgical treatment, the chance of survival of irradiated patients being about double that of patients treated by surgery alone. He believes preoperative and postoperative irradiation to be preferable to postoperative irradiation alone. The report ends with a passage cited from Pfahler in which that author points out that in radiotherapy, as in surgery, apparatus and technic are of minor importance in comparison with the skill and judgment of the person using them. F. CAVER~ Palliation in Advanced Mammary Carcinoma, W. P. NICOLSON. Am. J. Surg. 20: 815-632, 1933. It is far easier to determine the procedure to be carried out in an early case of mammary carcinoma than in an advanced one. In the latter case a too zealously guarded professional reputation, or statistical data, or surgical timidity may cause the adoption of a watchful-waiting policy when, as a matter of fact, the patient might be rendered more comfortable. Some relative or friend should be advised that there is no hope of cure as a precaution against bringing surgery into dis- repute. In general, increase in the comfort of the patient dictates the choice of various palliative procedures. Lessening of pain or the prevention or reduction of slough are the usual goals. Case histories are given to illustrate the treatment used in some of the advanced cases and the article is illustrated by photographs of selected patients. BENJAMINR SHORE Early Cancer of the Breast, S~JOURNET.Cancer du sein au d6but, Bull. et m6m. SOC. de chirurgiens de Paris 24: 528, 1932. Brief report of a case showing early clinical signs of breast cancer, verified histologically after operation. F. CAVERS Unusual Complication in a Case of Mammary Cancer; Well Eleven Years, F. E. ADAIR. Ann. Surg. 96: 302-303, 1932. A woman, fifty-three years of age, was treated at the Memorial Hospital (New York City) for mammary cancer. In August and September 1920, two series of low-voltage x-ray treatments were given ; the tumor diminished in size, and in February 1921 a radical amputation was done. A skin graft was performed three weeks later and no postoperative x-ray treatments were given. Histological examination of the breast removed showed a cellular plexiform carcinoma with no involvement of the lymph nodes. The patient remained under observation and showed no signs of recurrence in eleven years. At the end of that period, in February 1932, an acute osteomyelitis of the third and fourth ribs developed. This was incised for drainage, and &aphylococcus aureus and albzre identified. There had been no injury to cause the osteomyelitis; no irradiation had been given for over eleven years, and that which had been given earlier was mild in comparison with modern treatments. It is difficult to conceive of any infection from a skin graft done eleven years previously breaking out after such a long interval. Carcinoma of the Breast with Unusual Metastasis, R. A. KILDUFFE,H. S. DAVID- SON AND D. B. ALLMAN.J. M. SOC.New Jersey 29: 701-704, 1932. A forty-seven-year-old woman had a tumor of the right breast first noticed fifteen months previously. Over the left tibia was a bluish, mottled lump of two months’ duration which she ascribed to striking her shin some two or three months before its appearance. Sections from the scirrhous breast tumor were typical for adenocarcinoma, while those from the tibia1 region showed a mass of inflam- 718 ABSTIUGTS matory tissue containing scattered groups of carcinoma cells with frequent alveolar arrangement. In spite of x-radiation the tibia1 tumor recurred in three months. The leg was amputated above the knee, and the specimen revealed a subcutaneous tumor spreading along the fascia1 planes to the periosteum, the latter not being invaded however. The histologic picture of proliferating alveolar carcinoma and round-cell inflammation wm only slightly modified by irradiation reaction. NELSONB. SACKETT Carcinoma in an Aberrant Axillary Nodule of Mammary Gland, T. BIANCIIERI. Carcinoma di un nodo aberrante ascellare di ghiandola mammaria, Pathologica 24: 401-405, 1932. A woman aged fifty-seven developed an axillary tumor, without any evidence of a primary tumor in the corresponding breast. Dissection of the axilla showed a single large, round tumor which proved to be scirrhous carcinoma in mammary tissue, and also several enlarged lymph nodes which contained metastases. Two years later the patient died with mediastinal and pulmonary metastases. At no time in her illness did either breast show any evidence of carcinoma. Three microscopical drawings and a short bibliography are included. C. D. HAAQENSEN Bilateral Carcinoma of the Breasts Associated on One Side with Tuberculosis, CARLO PAN^. Carcinoma bilaterale dells mammella associato da un lato a tubercolosi, Policlinico (ses. chir.) 39: 155-186, 1932. In a woman of sixty-seven bilateral mastectomy was done for carcinoma. In the right breast a nodule of scirrhous carcinoma was found. In the left breast a superficial area beneath the nipple showed undoubted tuberculosis. Deeper in the breast, typical tubular carcinoma was found. Pan& believes that the tuberculosis perhaps favored the development of the carcinoma in the left breast. Because the tumom in the two breasts differed in their histologic character, he believes that they were of separate and independent origin. Four photomicrographs and a brief bibliography are included. C. D. HAAQENSEN

Gelatinous Carcinoma of the Breast, N. ENZER.Am. J. Clin. Path. 2: 457462, 1932. A tumor of four years’ duration involved the whole left breast, with infection and ulceration of the skin, metastases in the axilla, and a nodule in the right breast. A simple mastectomy was performed, and the patient eurvived at least eight months before she was lost sight of. Mucicarmine stained the gelatinous areas and some of the intracellular globules. This, together with the absence or scarcity of stroma in these areas, and the non- staining of the intraduatal secretion, supports the author’s view of the epithelial origin of the colloid material. N. B. SACKETT Treatment of Fibrocystic Disease (Reclue) of the Breast by the Injection of Ovarian Extract (Folliculin), R. LEEWEE. Esseis de traitement de la mam- mite scl6ro-kystique de Reclus par la folliculine, Lyon chir. 30: 54-55, 1933. The author points out that when fibrocystia diseeee of the breast, often accompanied by a slight yellow or brownish discharge, haa been diagnosed by a surgeon, the latter is faced by a dilemma as to treatment. If the disease is extedve, total ablation involves mutilation out of proportion to the ueually benign nature of the malady, while if both breasta are involved, bilateral ablation seems to carry to INTRATHORAOIO TUMORS 719 excess the prophylaxis of malignancy which arises in a very low percentage of cases. Yet no reliable non-operative prophylactic or curative treatment seems to have been so far devised. On the assumption that ovarian folliculin controls the growth of the female genital tract and the breast, the author concludes that Reclus’ disease is a dystrophy of ovarian origin, and he has given injections of ovarian folliculin extract to four patients whom he has now followed for four years. He does not claim complete cure, for in all the cases the lesions have diminished but not disappeared; he believes that earlier use of this remedy might arrest the development of the disease. F. CAVDRS

Subcutaneous Angiomas of the Breast, J. G. MENVILLEAND J. C. BLOODQOOD. Ann. Surg. 97: 401413, 1933. Eight benign and one malignant angiomas have been observed in 3000 breast cases collected in the surgical pathological laboratory of the Johns Hopkins Hospi- tal. There were six hemangiomas of the cavernous and one of the capillary type, and one lymphangioma. All angiomas of the epidermis overlying the breast have been excluded as lesions of the skin rather than of the breast itself. Short abstracts of these cases are given, and several photomicrographs are included. BENJAMINR. SHORE Sarcoma of the Female Breast, VITTORIOSPEZIALE. Contributo alla conoscenza del sarcoma della mammella muliebre, Morgagni 74: 827-835, 1932. Speziale’s patient was a woman aged thirty-seven. Nine months previously, while still nursing her fifteen months’ old baby, she had noticed a tumor of the left breast. It grew rapidly to form a large superficially ulcerated mass. Radical mastectomy was done. The further course of the disease is not recorded. The tumor was classified by the author as a “small, round-cell, alveolar sarcoma.” There were metastases to the axillary nodes. Five photomicrographs do not aid in informing the reader exactly what the tumor was. C. D. HAAGENBEN INTRATHORACIC TUMORS Primary Carcinoma of the Lung, TETSUOSUZUKI. Uber den primaren Lungen- krebs, Gann. 27: 1-68, 145-193, 1933. During the years 1887-1932 there were observed in the Pathological Institute of Tokyo Imperial University 97 primary malignant growths of the lung among 1608 malignant tumors encountered at autopsy. When these were grouped in five-year periods it was found that there was an apparent increase in the incidence of primary pulmonary tumors. The author autopsied 32 of the cases during the period of 1925-1932. Thirty-one of the tumors were carcinoma and one proved to be sarcoma. According to Suzuki, the influenza epidemic of 1918 had no bearing upon the incidence of pulmonary carcinoma, since the actual increase began before 1918. Nor does he consider poisonous gases which were used during the world war as a factor in the increase of pulmonary carcinoma among Japanese, as they were not actively engaged in the war zone. While it is true that the number of motor cars has increased in the metropolitan areas during recent years, the number is relatively small in comparison with metropolitan cities of America and Europe and automobile gases are therefore probably not responsible. Nor are street-dust and tar to be blamed, since the gradual increase was already noticed before the improvement of the city streets. It is interesting to note that about 40 per cent of the case8 of pulmonary 720 ABSTRACTS carcinoma occurred in excessive smokers, but the increase of tobacco *smoking among Japanese is of questionable significance. Males predominated over females in the ratio of 3 to 1. The age of maximum frequenoy was between sixty and seventy. The youngest patient was eighteen and the oldest eighty-one years old. Men were most affected in the sixth, and women in the seventh decade. Occupation appeared to have no relation to the increase in lung tumors since the disease was equally distributed among patients with varied occupations. The author states that 13 per cent of the cases studied showed existence of an hereditary tendency to develop primary lung carcinoma. Primary carcinoma of the lung appears more often in the right than in the left lung, especially the right upper lobe. In the left lung it is found more frequently in the upper than in the lower lobe. A bronchial origin was definitely indicated in 10 cases. Squamous-cell carcinoma predominated, followed by glandular carcinoma, basal-cell carcinoma, and polymorphous-cell carcinoma. Tuberculosis is commonly associated with the carcinoma. Metastases from lung carcinoma were found in 30 of the 31 cases, or 97 per cent. The regional lymph nodes were most frequently involved. Visceral metastases occurred most frequently in the lungs, followed by the liver, kidneys, suprarenal glands, and bones. Occasionally metastases were found in the brain. The author points out that roentgenograms and bronchoscopic examinations are important in the diagnosis of malignant tumors of the lung. Clinical diagnosis was correct in 80 per cent of the cases. A factor in the increasing incidence of primary pulmonary carcinoma is easily attributable to a rising standard of diagnosis. Suzuki studied the end-results in a series which included 55 patients with malignant tumors of the lung and found that the patients survived from three months to fifty-three months after the first symptoms were observed, an average of eleven months. The location and size of the primary pulmonary tumors and the histology of these tumors are described in detail and well illustrated in sketches and photomicrographs. In the second part of his paper Suzuki gives special attention to the etiological relationship between primary lung carcinoma and pulmonary tuberculosis. Of the 31 primary carcinomas of the lung which the author himself autopsied, 8 were coexistent with chronic, aotive lung tuberculosis, and 7 were associated either with cured pulmonary tuberculosis or showed slight signs of tuberculosis. In these 15 cases the carcinoma and the tuberculosis were closely related, as evidenced not only by their appearance in the same lobe, but also in that they were more or less bound together. In 5 other cases a morphological relation between carcinoma and tuberculosis was difficult to prove, as they were not in the same locality. The author points out that in these cases there was an inflammatory process, since the lobe involved by the carcinoma showed pleural thickenings. He concludes that between lung tuberculosis and lung cancer some relationship exists. K. SUGIURA Metastatic Pulmonarg Carcinoma, ROBERTC. PENDERQRASS.Am. J. Surg. 17: 422-426, 1932. The author emphasizes the importance of the diagnosis of carcinomatous metastases to the lungs in preventing futile surgery, in indicating the possibility of palliative radiation, and in determining prognosis. He points out the un- reliability of symptoms and physical signs and the necessity for x-ray examination. Chest metastases may be divided into three groups: (1) those in the tracheobronchial lymph nodes; (2) those in the parenchyma of the lung, which may be INTRATHORAOIC TUMORS 721 further classified as nodular, miliary, infiltrative, and massive; (3) those in the pleura. The latter cause thickening and pleural effusion, which is often bloody and reaccumulates rapidly after removal. In the treatment of metastatic lesions in the lungs frequent tapping, in cases of effusion, with possible replacement of the fluid by air is recommended. In cases without effusion x-ray therapy to relieve pain and cough and prolong life is indicated. Several good roentgenograms of the chest illustrating the various forms of parenchymatous metastases are reproduced, and five short case reports given. GRAYH. TWOMBLY

Radiosensitivity of Bronchial Carcinoma, G. HERRNHEIER.Die Strahlenemp- findlichkeit des Bronchialkarrinoms, Strahlentherapie 45 : 269-280, 1932. The author reports two cases treated by x-rays. In the second case the radiographic diagnosis of bronchial cancer was confirmed at autopsy. The patients were men aged thirty-six and fifty-three. In the first case three fields were irradiated, the total dosage to each field being 3100 r; in the second case, each of four fields received a total of 1400 r. In both cases radiography after treatment showed considerable clearing up of the disease, and the patients put on weight and showed great symptomatic improvement. At the time of reporting, the first patient was in apparently good health, eight months after x-ray treatment was begun. The second patient showed more marked improvement as judged radiographically but less as regards symptoms. He died exactly a year after the first x-ray application, the autopsy report being bronchial carcinoma with numerous metastases in the liver and other organs. The author discusses the question of radiosensitivity of bronchopulmonary carcinoma, with references to the literature, mainly German, the sole extra- German publication cited being that of Stern (Am. J. Roentgenol. 14: 8, 1925), who is mentioned as one of the first writers to claim that at least temporary alleviation of.this disease was obtainable by radiotherapy. [In this connection, see abstracts in Am. J. Cancer 15: 1737 (Manges), 1738 (Funk), 1931; 16, abst. p. 1114 (Tyler), 1932; 17,522 (Vinson), 522 (Allen and Smith), 524 (Manges), 1933.1 The author concludes that lung cancers are as a rule slightly sensitive to x-rays, and not almost entirely refractory, as various writers have stated. He believes that better results may be obtained with higher voltage than that used by him (180 kv.), and also with heavier dosage. Five excellent roentgenograms illustrate this paper. F. CAVERS

Three Cases Showing Symptoms and Radiographic Appearances Suggestive of Pulmonary Neoplasm, ONTIVEROS.Tres casos de neoplasia de pulmh, Rev. med. de Barcelona 19: 162-164, 1933. The interest of this article lies chiefly in the discussion it provoked. The four speakers taking part in this expressed grave doubts whether the clinical and radiographic findings justified the author’s diagnosis of bronchopulmonary tumor in any of the cases reported. D. Rodiilo said he had recently seen a patient with syphilitic antecedents and roentgen findings closely resembling those shown by the author; the shadow cleared up under specific treatment. Morales mentioned a case, similar to those described, in which the lesion proved to be pulmonary gangrene. Serrano considered that fluoroscopy of the thorax, with the patient in several successive positions, was of much greater value than a single roentgenogram and that diagnosis was facilitated by antecedent artificial pneumothorax. Cuatrecasas, after remarking that an absolutely definitive diagnosis in such cases was usually made only at autopsy, expressed the opinion that one of the reported cases was probably pachypleuritis, while the diagnosis of the other two was doubtful; one he believed might have been chronic pneumonia, 722 ABSTRAOTIJ

[The sole justification for the abstracting of reports of such inadequately investigated cases, with definite diagnoses of neoplasm, is that it may serve as a warning to other similar offenders, whose name is legion.] F. CAVERS

Case of Primary Bronchial Carcinoma, A. A. RAIMONDIAm J. P. USLEN(IHI. Sobre un caso de tumor primitivo de bronquio, Prensa m6d. argent. 19: 1095- 1108, 1932. The authors publish a detailed and well illustrated report of a case of bronchial cancer which they had the opportunity of studying throughout the course of the disease from its early stage, when correct diagnosis was quite impossible. A man of fifty-six was found, on routine medical examination, to be in excellent health except for chronic bronchitis with mucopurulent sputum, in which no bacteria were discovered. X-ray examination showed a slight enlargement of the branches of the bronchial tree, diagnosed as bronchiectasis secondary to the bronchitis, and slight thickening of the right pleura. Five months later the man complained of pain in the right side; the cough had become worse and the expec- toration more profuse, and several slight hemoptyses had occurred. The sputum was still free from bacteria, and the blood Wassermann reaction was negative. X-rays now showed dense hilar shadows and numerous small peribronchial nodules. The authors at this time suspected neoplasm. Nine months later the bronchial symptoms had become much worse, with intense pain in the right hemithorax, loss of weight (six kilos), and general weakness. X-ray now showed intensification and increase of the hilar and nodular shadows. Subsequent examinations at shorter intervals showed spread of the disease process, which had now been recognized as a neoplasm occupying the right upper lobe. Bronchography after lipiodol filling showed almost complete blockage of the right upper bronchus and its branches, while clinical symptoms and palpation pointed to hepatic metastasis. The patient, who had remained at work in the meantime, was now admitted to hospital, but died a few days later. At autopsy metastatic nodules were found in the liver, kidneys, and adrenals. The primary tumor was of bronchial origin. There are nine roentgenograms and eight photomicrographs, all of good quality. F. CAVERS

Nontubercdoue Lung Diseases; a Report of Three Cases; Coccidiosis, Actino- mycosis, Carcinoma, HARRYB. WILLIAMS. Med. Bull. Vet. Admin. 8: 435- 441, 1932. Three cases are described illustrating the necessity of making a thorough clinical and bacteriological study of doubtful cases of lung and spinal diseases and the fallacy of making a diagnosis of tuberculosis which is not supported by proper evidence. One of these was a primary carcinoma of the bronchial mucous glands with metastases in the lungs, trachea, tracheobronchial lymph nodes, second lumbar vertebra, and left ilium.

Basal-Cell Carcinoma of the Trachea, BECK. Basalzellenkarzinom der Trachea, Folia oto-laryngol., pt. 2, 35: 257-258, 1932. A man fifty-six yeam of age had a cough, with occasional bloody sputum, and dyspnea for three months. A tumor was found in the left side of the trachea which was microscopically a basal-cell carcinoma. The tumor was removed and four radium treatments of five to six hours each were given with 100 mg. radium- bromide introduced into the trachea by means of a cannula. The symptoms were relieved and there had been no recurrence four months after operation. Squamous and basal-cell carcinomas of the trachea are of rare occurrence, as these epithelial types do not normally occur in the mucous membrane of the respiratory passages. INTRATHORACIC TI J MOltS 723

Costopulmonary Sarcoma and Trauma, G. BECCHINI. Sarcoma costo-polmonare e trauma, Riforma med. 48: 676-679, 1932. Two case reports are presented. (1) A child aged eight fell and struck his flank against a stone. Seven months later he began to cough and complain of pain in the lower chest on the same side. A rounded subcutaneous tumor developed OR the chest wall in the mid-axillary line at the level of the fifth to the seventh ribs. Roentgenograms showed an opacity of the lower chest, and exploratory aspiration of the tumor obtained a few cells from which the author made a diagnosis of “ round-cell sarcoma.” Radiotherapy was begun and the tumor regressed almost completely within a month. A year later there was recurrence in the opposite side of the chest. This proved to be radioresistant, and the child died two years after the onset of his illness. (2) A child aged six and one-half years was struck in the left axillary region by a bicycle. Fifteen months later a painful subcutaneous tumor developed in this region accompanied by a cough and fever. Roentgenograms showed a mass almost filling the left chest. Roentgen therapy was begun but it8 result is not stated. The author diagnoses both of these cases as ‘‘ sarcoma of the chest,” and believes that both were traumatic in origin. Two roentgenograms are reproduced and a short bibliography is given. [In neither of these cases is the nature of the disease proved histologically in a satisfactory manner, nor is there any valid evidence of traumatic origin.] C. D. HAAQENSEN Voluminous Fibromyxoma of the Endocardium, V. GRILLO. Su di un voluminoso fibromixoma dell’endocardio, Pathologica 24: 405-408, 1932. At autopsy of a man aged seventy-seven, dying with gangrene of the leg, an egg-shaped tumor measuring 5 x 4 x 3 cm. was found projecting into the right auricle. It was firm in consistence, and its surface was irregularly nodular. Histologically it proved to be a fibromyxoma. Good pictures of the gross and microscopic specimens, as well as a brief bibliography, are included. C. D. HAAGENSEN

Congenital Epidemoid Cyst of the Heart, A. DE CH~TEL.Kongenitale Epiderm- oid-Cyste des Herzens, Frankfurt. Ztschr. f. Path. 44: 426-429, 1933. An epidermoid cyst of the heart was found in a new born infant in whom there were also present a meningo-encephalocele of the occipital region and incomplete development of the nasal septum. The cyst lay in the interauricular septum and was multilocular, the thick walls of the loculi being lined by squamous-cell epithelium with horny pearls. The obvious histogenetic theories are enumerated. There is one illustration. F. CAVERS Pseudo-cystic Mediastinal Tumor. Acute Terminal Leukemia, C. LAUBRY,G. MARCHALAND L. MALLET. Tumeur mediastinale psendo-kystique. Leucbmie aigue terminale, Sang 6: 899-905, 1932. In a man thirty-two years of age, with mediastinal pressure symptoms, roentgen examination showed a round shadow of irregular outline in the upper part of the mediastinum to the right. The appearance and regularity of the outline suggested a cyst. The possibility of a mediastinal lymphosarcoma, however, led to the use of deep radiotherapy, with the result that the tumor gradually disappeared and pressure symptoms were entirely relieved. Two months after completion of the radiotherapy, the blood count showed a leukemia, with a total white cell count of 24,400, lymphocytes 82 per cent. The spleen was enlarged. There was no recurrence of the mediastinal tumor. Radiotherapy over the spleen 724 ABSTBAOTS failed to control the leukemia; hemorrhagic symptoms developed, and the patient died a little more than a month after the onset of the leukemia. As there was no autopsy, it is impossible to determine the exact natur6 of the mediastinal tumor.

Tumor of the Manubrlum Sterni, Josg M. JORGEAND ALBERTOGALINDEX. Tumor del manubrio esternal, Bol. y trab. de la SOC.d. cir. de Buenos Aires 16: 930-932, 1932. A short preoperative discussion of a tumor limited to the space between the two tables of the manubrium sterni, for which a radical operation was planned. No diagnosis was made. JOHNE. WIRTH

THE ABDOMINAL WALL Fibromas of the Abdominal Wall, ADOLFODUJOVICH. Fibromas de la pared abdominal, Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 1392-1404, 1932. Three cases are presented of abdominal wall tumors in women who had borne children. The tumors were located in the anterior rectus sheath or in the oblique muscles. One photomicrograph typical of the three is given, and nineteen cases previously presented by local authors are tabulated. [From the descriptions and photomicrograph we would class the three cases as ordinary desmoid tumors.] JOENE. WIRTH Case of Non-Speciflc Granuloma of the Abdominal Wall, U. SANTOBONI.Sopra un caso di granuloma aspecifico della parete addominale, Minerva med. 2: 535-543, 1932. A man of thirty-two, in excellent health, had a hard, non-tender, slowly growing abdominal tumor. At operation the tumor was found to infiltrate a large part of the right rectus and to be adherent to the omentum and the intestine. Histologi- cally it appeared to be the result of a slowly progressing inflammatory process with excessive scar tissue formation. There were no tubercle bacilli, giant cells, or tubercles, no parasites, and nothing suggestive of a syphilitic process or a foreign body. The author hypothecates some slight intestinal injury with resultant mild infection. Surgical removal was followed by a complete cure. The histology is shown in photomicrographs. JEANNETTEMUNRO

THE DIGESTIVE TRACT

Carcinoma of the Oesophagus, WILLIAML. WATSON. Surg. Gynec. & Obst. 56: 884-897, 1933. Esophageal growths are usually classified according to their relation to the various anatomical constrictions of the esophagus. Of 245 esophageal neoplasms in his Memorial Hospital series, Watson found over half (53.8 per cent) in the lower third. Histological clawification of 267 cases disclosed 243 squamous-cell lesions, 19 adenocarcinomata, and 5 of the transitional-cell type. The adenocarcinomata were all located in the lower third of the esophagus. Histological grading was possible in 227 of the specimens. Fifteen were of Grade I, 148 of Grade 11, 39 of Grade 111, 19 were adenocarcinomata, and 6 were transitional-cell carcinomata. Thus, 83 per cent of the cases fell in Groups I1 and 111. Only 18 per cent could be designated microscopically as rrrdiosensitive. Cancer of the esophagus is much more frequent in the male sex. Watson’s THE DIGESTIVE TRACT 725

material showed a male preponderance of nearly six to one (84.3 per cent males, 15.7 per cent females). The diagnosis of carcinoma of the esophagus is easy. The routine diagnostic procedures include history, phyRical examination, Wassermann test, fluoroscopy and radiography of esophagus and lungs, esophagoscopy, and biopsy. Treatment by surgery is practically limited to the lesions of the upper and lower ends of the esophagus. Intra-esophageal irradiation by radium capsules in tan- dem, interstitial irradiation by insertion of gold seeds of radon, and dilatation of carcinomatous strictures of the esophagus have all been given a trial at the Memo- rial Hospital and have been abandoned. The present treatment employs x-rays through four skin portals, cross-firing through the lesion. A skin dose of 2000 T to each port is well tolerated, but the mortality is practically 100 per cent. Some palliation is possible if gastrostomy is performed early. The cause of death in 48 per cent of cases is bronchopneumonia; a similar percentage of patients reveal no evidence of metastases at autopsy. Where death occurs from bronchopneumonia, it is probably frequently a result of spreading infe ction from the ulcerating esophageal cancer. This article is well illustrated and a bibliography of 57 references is appended. WILLIAMJ. HOFFMAN

Carcinoma of the Esophagus with Special Consideration of Treatment by the Plummer Method of Dilatation, E. DEHNE. Das Oesophaguscarcinom mit besonderer Berticksichtigung der Dilatationsbehandlung am Leitfaden von H. S. Plummer, Deutsche Ztschr. f. Chir. 239: 453-461, 1933. Palliative relief of dysphagia in patients with carcinoma of the esophagus may be obtained by careful dilatation with bougies which are guided through the dis- eased area by a thread which has been previously swallowed. The author has treated 19 patients in this manner without a death attributable to the dilatation, and in 18 the results have been satisfactory. The technic used is that introduced by Plummer and Vinson at the Mayo clinic and is described in detail. BENJAMINR. SHORE

Ulcerated Carcinoma of the Esophagus, A. A. CETR~NQOLOAND E. MINDLIN. Sobre un caso de possible chcer de es6fago ulcerado, Arch. argent. de enferm. d. ap. digest y de la nutrici6n 7: 262-267, 1931-32. This is mainly a discussion of the proper interpretation of two x-ray pictures of a probable cancer of the esophagus in a man of fifty-three. No autopsy was done. JOHANNESP. M. VOQELAAR Cancer of the Stomach, R. P. ROWLANDS.Brit. M. J. 1: 905-907, 1933. After referring to recent reports by Ralfour (Collected Papers of the Mayo Clinic, 1931, p. 80), Finsterer (Wien. klin. Wchnschr. 42: 1125, 1157, 1929), and Gatewood (Surg. Gynec. & Obst. 56: 442, 1933, abstracted below) on the results of operation for gastric carcinoma, the author describes three cases which he operated upon with good results. In the first he performed partial gastrectomy on a woman of forty-one, who is well at the time of reporting, seventeen years after operation. In the second patient, a woman of sixty-four, primary jejunostomy was first done, followed four weeks later by resection of about half of the stomach. This patient is well eleven years after operation. The third patient, a woman of fifty-six, was operated upon for carcinoma of the splenic flexure of the colon, and eight years later about two-thirds of the stomach was resected for gastric cancer. The patient is well nearly six years after the gastric operation. The author briefly discusses the differentiation of carcinoma from chronic 34 ABSTRACTS gastritis, simple ulcer, syphilis, cancer of the pancreas, and empyema of the gallbladder; also the indications for operation in gastric cancer. He concludes that surgeons are probably too pessimistic about cancer of the stomach. It should be more widely known that a fair proportion of cases can be cured by early operation. Relatively few cases are ever sent to the surgeon, and less than one third of these come in time for radical operation with hope of success. Diagnosis can and should be made much earlier than it is at present, even if exploration is necessary to decide this in doubtful cases. Despite the deplorable procrastination still obtaining, nearly 20 per cent of the patients who survive operation, at a risk of about 10 to 15 per cent mortality, remain well for ten years. Much better results will surely follow earlier resection. F. CAVERS Prognosis in Gastric Carcinoma Treated by Resection, GATEWOOD.Surg. Gynec. & Obst. 56: 442-444, 1933. Four hundred and seventeen patients with carcinoma of the stomach were discharged from the Presbyterian Hospital in Chicago during the ten-year period from January 1, 1920, to December 31, 1929. Almost exactly one half, or 208, of these were either inoperable at the time they were seen or refused operation. Of the 209 patients operated upon, 30 per cent had only exploratory laparotomies because of the extent of the growths. Fifty-eight resections were done. Forty- six per cent of those patients who survived the radical operation lived over three years, and 39.5 per cent have survived over five years. This gives 17 five-year cures out of 417 cases seen. BENJAMINR. SHORE Adenocarcinoma of the Stomach Simulating a Benign Polyp, A. LOB. Adeno- Karzinom des Magens unter dem Bilde eines gutartigen Magenpolypen, Deutsche Ztschr. f. Chir. 239: 232-233, 1933. In a thirty-one-year-old man with digestive disturbances, roentgenography showed a mass about the size of a plum, on the greater curvature of the stomach. At operation a pedunculated, apparently benign polyp was removed. Histologic study showed the growth to be an adenocarcinoma, and a resection of the tumor- bearing portion of the stomach was done one month later. A roentgenogram and low-power photomicrograph are included. BENJAMINR. SHORE

Sarcoma of the Stomach, R. BLABI. Sul sarcoma dello stomaco, Pathologica 24: 249-254, 1932. A man of forty-one suffered from anorexia and attacks of epigastric pain which bore no relation to meals. Operation showed a soft, fist-sized tumor arising from the fundus and projecting into the lumen of the stomach. Resection was done, but was followed by death in three months. The tumor was a round-cell sarcoma. Two poor photomicrographs are presented. A review of previously reported cases of sarcoma of the stomach and a considerable bibliography are included. C. D. HAAGENSEN

Sarcoma of the Stomach. Gastrectomy. Postoperative Results, S. A. MARINO. Sarcoma de est6mago. Gastrectomia. Resultados post-operatorios, Arch. argent. d. enferm. d. ap. digest. y de la nutricion 7: 595-597, 1931-32. A forty-eight-year-old man was admitted to the hospital with the diagnosis of cancer of the stomach. A tumor, the size of an orange, occupying the posterior wall of the duodenal antrum was removed. The regional nodes were not enlarged. Pathological investigation showed the tumor to be a fusicellular sarcoma. The patient is in full health nine years after the operation and can eat any sort of food. Two x-ray pictures show how efficiently the stomach and the duodenum function. JOHANNEBP. M. VOQELAAR THE DIGESTIVE TRACT 727

Mposarcoma of the Stomach, C. R. EDWARDSAND R. B. WRIGHT. Am. J. Surg. 19: 442-445, 1933. The authors report a case of myosarcoma of the stomach observed in a sixty- eight-year-old patient. At operation the tumor was found to originate by a pedicle from the greater curvature of the stomach and to be completely free posteriorly. The growth was removed and the patient made a good recovery, only to return five months later with a large metastatic nodule in the liver and a smaller one in the operative scar. The tumor from the stomach measured 37 x 23 x 16 cm. and weighed 6180 grams. Histologic examination showed the growth to be composed of large spindle cells with the cytoplasm of one cell passing imperceptibly into that of an adjacent cell, There were no mitoses. The article is illustrated with a photograph of the gross specimen and photomicrographs. BENJAMINR. SHORE Gastro-omental Reticulo-endothelioma, U. FOGLIANI.Reticulo endotelioma gastromentale, Pathologica 24: 463-408, 1932. A man aged fifty-seven died with a large abdominal tumor of one year’s duration. Autopsy showed a neoplasm involving the great omentum and the stomach. The omentum was greatly thickened and retracted. The wall of the stomach was thickened throughout except in the cardiac region. There were metastatic nodules in the wall of the diaphragm. Fogliani classified the tumor histologically as a reticulo-endothelioma.” Five unsatisfactory photomicrographs are presented. C. D. HAAGENSEN Contribution to the Knowledge of Benign Gastric Tumors, G. SCAGLIOSI.Con- tributo alla conoscenza dei tumori gastrici benigni, Riv. osp. 22: 1-20, 1932. The author gives a long bibliography and a review of the literature. He cites a case of a man of sixty-one who had not during life had any symptoms to suggest gastric pathology, but at autopsy was found to have a benign pedunculated gastric tumor, microscopically a myoma, on the lesser curvature in the region of the cardia. There was a concomitant carcinoma of the pancreas. JEANNETTEMUNRO Gastric Lipomas and Mixed Tumors Containing Adipose Tissue, P. BEZZA. I lipomi ed i tumori misti con tessuto adiposo dello stomaco, Pathologica 24: 376-380, 1932. Four benign tumors of the stomach found at autopsy are described. They were as follows: 1. In a woman aged sixty-five a pedunculated tumor the size of an apple was found projecting into the lumen of the stomach from its anterior wall. It was a lipoma covered with normal mucosa. 2. In a woman of eighty-one an almond-sized tumor projected into the stomach cavity from the anterior gastric wall near the pylorus. Histologically it was a lipoma situated in the submucosa. 3. In a woman aged seventy-five a bean-sized submucous tumor was found on the posterior gastric wall near the cardia. It proved to be a lipoma. 4. In a man of eighty an almond-sized submucous tumor was found near the pylorus. Histologically it was partly angioma and partly lipoma. The author collected reports of 27 previously described lipomas of the stomach. He believes that these tumors arise from islands of fat sometimes found in the submucosa of old people. An extensive bibliography and good photographs of the gross and microscopic specimens are included. C. D. HAAGEN~EN ABSTRACTS

Multiple Tumors of the Stomach Diagnosed by Gaatrophotography, R. TESS~R. Ein mit Hilfe der Gastrophotographie diagnostizierter Fall von multiplen Magentumoren, Med. Klin. 29: 222-223, 1933. The author reports the case of a seventy-one-year-old woman in whom multiple submucous tumors of the stomach were observed by intragastric photography. The patient has remained well for three years, and the exact nature of the gastric tumors is still unknown. It is most probable that they were tumor-like areas of hypertrophied gastric mucosa. Excellent reproductions of the photographs are included. BENJAMINR. SHORE False Tumors of the Stomach, SAVIQNAC.A propos d'un cas de fausse tumeur gastrique, Arch. d. mal. de l'app. digestif. 22: 771-774, 1932. Two cases are described, one in detail and the other briefly. A woman who was about to be operated upon for what had been diagnosed as a stenosing pyloric carcinoma consulted the author the day before that fixed for operation. The diagnosis seemed to him to be doubtful, though there had been progressive loss of weight, blood in the stool, and a radiological report of pyloric stenosis. On careful examination he satisfied himself that the epigastric tumor was the abdominal aorta, that there was no radiographic abnormality, and that the case was one of early Basedow's disease with arterial hypertension, a slight degree of athe- roma, dyspepsia, and constipation. Rest, a liberal diet, and aperients were advised, and a year later the patient was quite well except for the slight goiter. As a contrast to the case just described the author relates that of a patient sent to him by her physician with a diagnosis of gastric tumor, which proved to be an aneurysm of the abdominal aorta. Yet this patient died " some years later I' with carcinoma of the stomach. Evidently early carcinoma was present when the patient was first seen, though no evidence of this was detected on examination. F. CAVERS Contribution to the Knowledge and to the Surgical Treatment of Carcinoma of the Smalf Intestine, L. Sussr. Contributo alla conoscenza e alla cura chirurgica del carcinoma dell' intestino tenue, Policlinico (sez. chir.) 39: 405-412, 1932. Sussi's patient was a man aged fifty-eight who was operated upon for subacute intestinal obstruction. A carcinoma at the junction of jejunum and ileum was found. A portion of the transverse colon was adherent to and involved by the tumor. A successful resection of 175 cm. of small bowel and 10 cm. of colon was done. The subsequent history of the patient is not given. Two poor photographs and a short bibliography accompany the report. C. D. HAAQENSEN

Lymphosarcoma of Small Intestine in a Boy of Five Years, DUPERI~AND MAU- PETIT. Lymphosarcome du j6juno-il6on chez un gargon de 5 ans, J. m6d. de Bordeaux 109: 960-961, 1932. A five-year-old boy was admitted to the hospital on account of abdominal swelling and general ill health. About two weeks previously he had shown soft swelling of the feet, and two days before admission he had diarrhea and vomiting. The family physician, suspecting ascites, had tapped the abdomen. Apart from the ascites, there was a large tumor in the right upper quadrant, and urinalysis showed the presence of acetone and of 3.4 per cent sugar. Eighteen hours after administration of 20 unite of insulin the glyocosuria and acetonuria had subsided, but six hours after this the boy died. At autopsy purulent ascitic fluid escaped, and there was found a tumor, the size of a full term fetal head, arising from the junction of the jejunum and ileum and adherent to the pancreas. Neither in the pancreas nor the liver was there histologic evidence of invasion or metastasis of the THE DIGESTIVE TRACT 729 tumor, a primary lymphosarcoma. The author leaves open the question whether the severe diabetes was coincidental or due to compression of the pancreas by the tumor, but inclines to the latter explanation. F. CAVERB The Terminal Ileum, Appendix, Cecum and Ascending Colon from the Standpoint of the Internist, D. P. ABBOTT. Radiology 19: 135-144, 1932. Carcinoma of the ascending colon may reach a considerable size before causing subjective symptoms. The lumen of the bowel is wide and its contents fluid, so that obstruction occurs late in the course of tumor growth. The best means of early diagnosis, in addition to abdominal palpation, are fluoroscopy and chemical examination of the stool for blood. Polypi in the ascending colon or in the sigmoid lying in the right side of the pelvis may cause pain referred to the right lower abdominal quadrant and are sometimes confused with other lesions common to this location. GEORQET. PACK

Consideration of Carcinoma of the Large Bowel, FREDw. RANKINAND JAMEB T. PRIESTLY.J. Tennessee M. A. 25: 127-133, 1932. A general discussion of carcinoma of the colon, with consideration of symptoms, diagnosis, pathology and pathologic physiology, and treatment as carried out at the Mayo Clinic. (See also Surg. Gynec. & Obst. 53: 229, 1931. Abst. in Am. J. Cancer 16: abst. p. 1129, 1932.)

Three Cases of Carcinoma of the Colon Showing Colic as the Sole Symptom, B~QOUIN.La colique seul signe du cancer de l'intestin, Gas. hebd. sci. m6d. de Bordeaux 53: 573-574, 1932. The author reports three cases, all in women and all operated upon, in which colic was the only symptom complained of in carcinoma of the large bowel. In the first caRe the attacks of colic had begun about six months before admission to hospital because of sudden onset of acute obstruction. At operation it was found that the greatly enlarged cecum had undergone perforation, with escape of a large quantity of purulent fluid. The author first performed cecostomy and pelvic and subhepatic drainage, and a month later removed the transverse colon, which was the seat of a stenosing carcinoma greatly reducing the caliber of the bowel for a distance of 8 cm. The second patient had been treated for amebic enteritis, on account of her age (thirty-one years), negative x-ray examinations, and the presence of amebae in the stools. When this treatment failed a diagnosis of tuberculosis had been made. The author did an exploratory laparotomy and performed a right hemicolectomy for carcinoma of the right colonic angle. The third patient, with a two years history of colicky pains, was found at operation to have carcinoma of the left colon, which was resected. F. CAVERS

Carcinoma of Sigmoid-Colon Intussusception, CHARLESE. FARR.Ann. Surg. 95: 934-936,1932. A brief report of a carcinoma of the sigmoid with intussusception occurring intermittently for over two years.

Fistula of the Small and Large Intestines and the Uterus with Carcinoma of the Sigmoid Flexure, H. H. SCHMID.Diinndarm- und Dickdarm-Gebarmutter- fistel bei Flexurcarcinom, Arch. f. Cyniik. 150: 460-469, 1932. A case is reported of a perforation of a cancer of the sigmoid flexure into the uterus and into a loop of adherent small intestine with the development at the same time of a small fistula from the anterior wall of the uterus into the bladder at the ABSTRACTS point of perforation. The patient was a woman of fifty-two years, complaining of bladder symptoms and marked loss of weight. At the abdominal operation a primary carcinoma of the sigmoid flexure was found as a cause of all the other lesions. The very much weakened patient survived the radical operation but died of cachexia on the eleventh day. HOWARDC. TAYLOR,JR. Technic of Cauterization in Inoperable Rectal Cancers, D. KULENKAMPFF.Zur Technik der peranalen Verschorfunn inoperabler Mastdarmkrebse, Chirura 5: 106-167, 1933. Cauterization of inoperable rectal cancers results in the replacement of the growth by firm connective tissue. The electric coagulating and cauterizing currents are used, and the operation is carried out under direct vision through a rectoscope. Beginning at the upper border, the growth is destroyed as far as possible into the surrounding normal tissues. Patients are discharged from the hospital in from three to five days and return at regular intervals for examination and additional cauteriaations. BENJAMINR. SHORE

Block Extirpation of Ractosigmoid Carcinoma and the Uterus, A. CHALIER. Cancer recto-sigmoidien extirp6 en un seul bloc avec l’ut6rus par voie abdominale, Lyon chir. 29: 763-704, 1932. In a woman of fifty whose sole complaint was diarrhea there was found a large tumor of the rectosigmoid region, which had apparently never caused obstruction, although it had been growing for at least a year. The tumor hung down into the rectum like a large polyp, the point of attachment not being palpable on rectal examination. At laparotomy it was found to be neither invading nor adhering to the cul de sac or the uterus, yet the author decided to combine radical hysterectomy with removal of the involved length of bowel in block dissection [no reason being given for this combined procedure]. The upper part of the tumor was ulcerated and stenosing, and the lower part, felt on rectal palpation, was a downward pro- longation from one side of the annular mass. Nothing is said about the after- history. F. CAVERS

Case of Villous Tumor of the Rectum, VINCENTAND DAN~.A propos d’un CBB de tumeur villeuse du rectum, J. d. sci. m6d. de Lille 51: 87-88, 1933. The benign villous tumors of the rectum are analagous in histological structure to the papillomatous tumors of the urinary bladder. Of untreated cases, 45 per cent degenerate into true carcinoma. These tumors are manifested clinically by the spontaneous, painless evacuation of large quantities of glairy mucus, with occasional profuse hemorrhages and frequent prolapse of the gut or neoplasm through the anus with defecation. The onset of a malignant change can be detected early only by biopsy and microscopic examination. Perineal resection of the rectum may be the only certain cure in advanced cases. An illustrative case report is appended. GEORGET. PACK THE PANCREAS

Cysts of the Pancreas, G. DE SIMONE. Contributo clinic0 alla conoscenza delle cisti del pancreas, Policlinico (sez. prat.) 39: 375-379, 1932. Two cases of pancreatic cyst are described, occurring in patients aged thirty- five and thirty-six, respectively. Both patients complained of attacks of pain which originated in the epigastrium and radiated to the lumbar region. In both cases marsupialiration was done and the sinus tract closed after about a month. A short bibliography is included. C. D. HAAGENSEN THE BILIARY TRACT 731

Pancreatic Cysts, F. K. HICK. Med. Clin. North. Amer. 16: 555-563, 1932. A case report is presented which favors the pathogenesis of pancreatic pseudo- cysts as a sequel of fat necrosis. GEORGET. PACK

THE BILIARY TRACT

Thorotrast in the Diagnosis of Hepatic Carcinoma, E. CONTEAND G. CERUTI. I1 thorotrast nella diagnosi del carcinoma epatico, Minerva med. 2: 195-201, 1932. The authors describe three cases of carcinoma of the liver studied with thorotrast and followed to autopsy. The first case showed an enlarged and nodular liver, ascites, digestive symptoms, and cachegia. X-ray plates made after thorotrast injection showed many areas of decreased density in the liver. Autopsy fifteen days later showed primary carcinoma of the gallbladder with liver metastases. In a second case carcinoma was suspected clinically but not established. X-ray examination after thorotrast injection showed an enlarged, homogeneous liver shadow. Four months later, when the diagnosis was readily established clinically, another x-ray plate showed rounded areas of decreased density in the liver, which at autopsy corresponded to carcinomatous metastases. Histologic examination in this case showed the thorotrast granules in the Kupfer cells, some of which appeared to have burst, and also masses of the granules apparently free in the liver stroma. In a third case of carcinoma of the esophagus with suspected liver metastases an x-ray plate made after thorotrast injection showed a uniformly dense small liver. At autopsy two weeks later multiple small metastases were found in the liver. The dose used in these cases was 10 C.C. at daily intervals repeated up to a 50 C.C. total in two cases, a 40 C.C. total in the last. In the case where 40 C.C. was used a dense liver shadow was secured, as well as in the cases of 50 C.C. The authors feel that the question of whether there is permanent injury to the reticulo-endothelial system through thorotrast injection needs to be determined, and that the use of this contrast medium is of little value in early diagnosis of liver carcinoma. The article is illustrated by x-ray photographs and a microscopic drawing. JEANNETTEMUNRO

Adenocarcinoma of the Liver in a Young Man with Hepatic Syphilis, J. MONT- PELLIER AND J. LOUBEYRE.AdCno-cancer du foie avec cirrhose chez un homme jeune atteint de syphilis hbpatique, Bull. SOC.franp. de dermat. et syph. 40: 304-310, 1933. The authors present the case of a thirty-four-year-old man as evidence that hepatic syphilis predisposes to carcinoma of the liver. The patient had untreated syphilis for twelve years and finally developed abdominal pain, with ascites and a pleural effusion. The Wassermann reaction of the blood, ascitic fluid, and pleural fluid was strongly positive. The liver was large and irregular, and there was a small rounded mass in the anterior aspect of the left lobe. The condition, which was believed to be hepatic syphilis, was not relieved by bismuth injections. The small tumor of the left lobe did, however, decrease in size. After one and one- half months the patient died, and autopsy revealed an adenocarcinoma of the liver. There was also an extensive productive cirrhosis. The authors believe that the neoplasm probably arose in the new formed biliary canaliculi so abundant in the syphilitic type of liver cirrhosis. WM, MENDELSOHN 732 ABtSTlUCTL3

Mixed Tumor of the Liver in a Newborn Infant, W. OSTERMANN.Mischgesch- wulst der Leber bei einem Neugeborenen, Monatsschr. f. Geburtsh. u. Gynak. 92: 191-196, 1932. A tumor, found at autopsy in the liver of an infant dying twenty miuutes after birth, measured 10 cm. in diameter and consisted mostly of small, rounded or elongated cella of immature mesenchyme1 type. In the stroma formed by these cells, which had the general appearance of a sarcoma, there were islands consisting of cartilage and others of bone. A few similar congenital mesenchymatous liver tumors have been reported. According to Herxheimer they arise by progressive metaplasia of embryonal rests. One photomicrograph illustrates this report. F. CAVERS Cavernous Angioma of the Liver, G. POZZI. L’angioma cavernoso del fegato, Clin. chir. 35: 625-650, 1932. A woman of forty had for two years noticed a left upper quadrant tumor gradually increasing in sise. It was assumed to be the spleen. Mild digestive symptoms were the only subjective complaints. Quinine and arsenic therapy were without effect. At operation there was found a gravid uterus and a large tumor the size of a uterus at seven months replacing and attached to the left lobe of the liver. A simple exploratory operation was followed by spontaneous rupture of the tumor and death. At autopsy the angioma, empty of blood, weighed 2 kg. The fact that the patient waa in her tenth pregnancy is interesting in view of the theory that these angiomas grow mainly during pregnancy. The author considers that two signs pathognomonic of hemangioma cavernosa are a souffle over the tumor and diminution of volume on pressure. The article is illustrated by photomicrographs and a long bibliography is appended. JEANNETTEMUNRO

Primary Angiosarcoma of the Liver, A. J. BENQOLEAAND C. VELASCOSU~REZ. Sarcoma angioplhstico primitivo del hlgado, Arch. argent. de enferm d. ap. digest. y de la nutricidn 7: 185-204, 1931-32. In a twenty-two-year-old woman with symptoms of three years’ duration the liver was greatly increased in size and upon palpation several spherical tumors were found. The x-ray showed a circular shadow in the lower third part of the right lung. A diagnosis of hepatic and pulmonary hydatid cyst was made. At operation several reddish tumors in the liver were found. The diagnosis was primary angiosarcoma of the liver with pulmonary metastasis. Death followed two months after the operation. The text is illustrated by 11 photomicrographs, an x-ray picture, and 2 schematic figures showing percussion findings in the region of the liver. JOHANNESP. M. VOQELAAR

Bone Formation in a Carcinoma of the Gallbladder and Its Metastases, G. MICSEH. Knochenbildung im Gallenblasenkrebs und in seinen Metastasen, Frankfurt. Ztschr. f. Path. 44: 430-438, 1933. A fifty-Eve-year-old woman died of an extensive carcinoma of the gallbladder with metastases to the lungs, liver, and regional lymph nodes. Histologic study showed the formation of true bone with lamellae and marrow in the primary tumor and in all of the metastases. The author concludes that this represented a metaplasia of the connective tiseue due to a specific stimulus of the cancer. There was no necrosis and no sign of tuberculosis in any portion of the tumors. The article is illustrated with photomicrographs. BENJAMINR. SHORE MESENTERIC CYSTS 733

Adenoma of the Ampulla of Vater, F. CHRISTOPHER.Surg. Gynec. & Obst. 56: 202-204, 1933. The author adds one case to the 41 other cases already reported in the literature of benign tumors involving the extrahepatic bile ducts. An autopsy performed on a seventy-four-year-old patient showed marked dilatation of the common bile duct due to obstruction near the ampulla of Vater by a granular nodule 5 mm. in diameter. Histologic study showed the nodule to be an adenoma with chronic infection. Short abstracts of the other cases of benign tumors of the extrahepatic bile duct reported in the literature are included. BENJAMINR. SHORE

MESENTERIC CYSTS; PERITONEAL AND RETROPERITONEAL TUMORS

Urogenital Cyst of the Mesosigmoid, W. E. LEE. Ann. Surg. 97: 465469, 1933. A colored woman, forty-seven-years-old, complained of a dull, aching sensation in the lower left abdominal quadrant. She suffered also from constipation, eructations of gas, and nocturia. At operation a cystic mass measuring 10 x 8 x 5 cm. was found in the mesosigmoid extending into the pelvis. The mass was enucleated without rupturing or injuring the mesenteric vesselsand the patient made a good recovery. The cyst was mutiloculated and contained clear pseudomucinous fluid. Histo- logic study showed a lining of low, compressed epithelial cells supported by a framework of connective tissue. In one place there was a small polypoid mass of epithelial cells closely resembling those of the fallopian tubes. The diagnosis of a wolffian duct cyst was made. A photograph of the gross specimen and a photomicrograph are included. The author adds to this report a general discussion of mesenteric cysts and a bibliography. BENJAMINR. SHORE

Chylous Ascitis and Mesothelioma, G. CASTRONUOVO.Ascite chilosa e mesoteli- oma, Gior. ital. di mal. esot. e trop. 5: 141-147, 1932. Castronuova’s patient was a man aged fifty-three who died following colostomy for intestinal obstruction. There were three liters of chylous fluid in the abdominal cavity, and multiple tumor nodules scattered over the peritoneum, one of which formed an obstructing mass in the region of the splenic flexure. Metastases were also found in the prevertebral, tracheobronchial, and supraclavicular nodes. The author classifies the tumor as a ‘I mesothelioma arising from the peritoneum.” One unsatisfactory microscopical drawing is included. C. D. HAAGENSEN

Retroperitoneal Myxoleiomyoma, MARTINNORDLAND. Minnesota Med. 15: 779-781, 1932. A man twenty-six years of age, who complained of persistent epigastric distress, had a hard, rounded, fixed mass in the left upper quadrant, which was removed at operation. Study of the tumor showed it to be soft, encapsulated, and gelatinous. It measured 16 x 8 cm. Microscopic sections showed masses of smooth muscle cells with myxomatous degeneration. The patient was reported free of recurrence two years and three months after removal of the tumor. GRAYH. TWOMBLY 734 ABSTRACTS

THE SPLEEN

Primary Erythremic Splenomegaly with Anerythremic Blood Picture, Splenectomy, A. FONTANAAND V. PETTINARI.Die primllre anerythrlmische splenomegale Myelose: Splenektomie, Folia haemat. 49: 341-364, 1933. A man of forty-six, a month before admission to the hospital, had suffered severe pain, of sudden onset, in the lumbar region and left hypochondrium, requiring the administration of opiates. Clinical examination revealed diffuse tenderness of the abdomen, especially in the left upper quadrant; a tumor, evidently the enlarged spleen; and slight enlargement of the inguinal nodes. Roent- genograms showed displacement of the left renal pelvis, ptosis of the stomach, and ballooning of the transverse colon, due to the splenomegaly. The blood picture was within normal limits. The patient refused to have his spleen punctured, and splenectomy was performed. Twenty days later he left the hospital, after biopsy of the marrow of the sternum and femur had been made. The bone marrow was of normal structure. The spleen showed extensive amyloid change, associated with hyperplasia of the medullary strands and of the pulp cells. The latter changes were especially marked in a small nodule located centrally in the upper part of the spleen. The authors call the condition a myeloid hyperplasia and a hamartoma; the spleen tissue, especially in the nodule, showed increased numbers of megakaryocytes. The patient revisited the hospital every fortnight for nearly a year, and a blood examination was made each time. He gained in weight, but at the end of the year complained of loss of strength. The liver was found to have become larger, and two blood counts, separated by an interval of seven weeks, showed 8500 leukocytes in each case, and increasing numbers of erythroblasts and other primitive cells. After liver (hepatrol) treatment these again diminished in number. The patient was still under observation at the time of reporting. The authors claim that their case, showing an erythremic process with primary and apparently sole localization in the spleen, combined with complete absence of erythremic phenomena in the peripheral blood stream, differs from any that has been so far reported, and occupies a unique position among the primary diseases of the erythropoietic tissue. There are twenty-six illustrations. F. CAVERS FEMALE GENITAL TRACT End-Results of Treatment of Neoplasms of the Female Genital Organs and of the Breae t, H. WINTZ. Diagnose, Behandlung und Erfolge bei Karzinomen der Genitalorgane und der Mamma, bei Sarkomen und beim Chorionepitheliom. Miinchen. med. Wchnschr. 79: 1055-1056, 1932. The author has already published a number of reports of the results obtained at Erlangen, where deep x-ray irradiation forms a prominent feature in the treatment of malignant disease. In this brief report he summarizes the results obtained up to the time of writing. Carcinoma of the cervix uteri (1014 cases) showed for operable cases 61.7 per cent, and for inoperable cases 12.6 of five-year cures. For 161 treated cases of corpus carcinoma, the corresponding figures were 70.8 and 9.7 per cent. Irradia- tion of recurrent uterine carcinoma after hysterectomy gave 18 per cent of 137 cases cured three to four years, 11 per cent of 118 cases cured five to six years, 8.5 per cent of 94 cases cured eight to nine years. Of 82 patients with ovarian carcinoma traced for three to four years, 36.5 per cent were cured; of 66 followed for five to six years, 26 per cent were cured. Of 46 with vaginal carcinoma followed three to four years, 26 per cent were cured; of 38 followed five to six years, 21 per FEMALE QENITAL TRACT 735 cent were cured. The corresponding figures for vulvar carcinoma are 11 per cent of 63 patients and 7 per cent of 57 patients. The five-year cures of uterine sarcoma were 75 of 108 cases, those of bone sarcomas 46 per cent of 60 cases. Of 11 cases of chorionepithelioma 8 (72.7 per cent) were cured. The author’s figures for breast carcinoma are as follows.

Stage Cases followed Cases followed Cases followed Cases followed (Steinthsl) 3 to 4 years 5 to 6 years 8 to 9 years 10 to 11 years I and I1 97 (77.3% cures) 83 (55.4% cures) 70 (40% cures) 49 (30.6% cures) I11 81 (21% cures) 69 (10% cures) 50 (10% cures) - Recurrences after operation 211 (32.2% cures) 177 (18.5% cum) 136 (11.7% cures) 103 (6.8% cures)

F. CAVERB

After-Care of Patients Operated upon or Irradiated for Cancer of the Female Genital Organs, F. VON MIKULICZ-RADECKI.Die Karzinomnachbehandlung in der Gynakologie, Munchen. med. Wchnschr. 79: 1905-1908, 1956-1959, 1932. This paper is intended as a plea for vigilance on the part of the physician attending patients who have been operated upon or irradiated for carcinoma of the female genital organs, and in particular as a guide to the recognition in good time of untoward after-effects, such as inflammation, infection, damage to the neighboring regions, or recurrence. The various points requiring attention in this important matter of after-care are indicated in a terse, clear, common-sense manner. F. CAVERS

Correlation Between the Development of the Growth and the Symptoms of Carcinomas of the Uterine Cervix, H. SCHMITZ.Am. J. Obst. & Gynec. 24: 159-166, 1932. Believing that methods of treatment have attained their maximum effect in the cure of carcinoma of the cervix and that the control of this type of cancer can come only from earlier diagnosis, Schmitz has summarized four of the well known aspects of its development. These are (1) the macroscopic appearance, (2) the microscopic findings, (3) the extent of the growth, and (4) the signs and symptoms. The sequence of macroscopic findings are for the endophytic type, nodule, ulceration, necrosis, and finally sloughing with crater formation, while for the exophytic type the changes are nodule, papilloma, cauliflower growth with necrosis, and finally sloughing with crater formation. The histologic characteristics of carcinoma in the sequence of their appearance are the following: (1) atypia or anaplasia of the epithelial cells; (2) invasion or breaking through of the basement membrane; (3) destructive tendencies with infiltration and displacement of normal cells; (4) formation of metastases either by continuity into the adjacent tissues and organs or by emboli. The extent of the tumor will determine the clinical classification, which is as follows: Group 1, the clearly localized growth; Group 2, the doubtfully localized growth; Group 3, the invasive growth with involvement of parametria and lymph nodes; Group 4, the disseminating and fixed growths, including (a) the frozen pelvis; (b) invasion of bladder, vagina, or rectum, and (c) distant metastases. The symptoms in carcinoma of the cervix depend on the extent of the growth. The clearly localized nodular growth is free from symptoms; the doubtfully localized beginning ulcer and papilloma cause “ contact bleeding ”; the invasive 736 ABSTRACTS necrotizing carcinoma is accompanied by hemorrhage and discharge; and the fixed carcinoma with crater formation produces hemorrhage, discharge, and pain. In order that cancer of the cervix may be recognized in its Symptomless, clearly localized, and nodular stage, Schmitz recommends that women be educated to report for periodic health surveys after each labor and abortion and yearly thereafter, and that instruction in diagnosis be given to the general practitioner. HOWARDC. TAYLOR,JR. Anatomical and Functional Changes of the Rectum with Carcinoma of the Cervix, G. HALTER. Anatornische und funktionelle Veranderungen des Rectums beim Collumcarcinom, Arch. f. Gynak. 151 : 126-149, 1932. In this work, coming from the first University Frauenklinik of Vienna, a study has been made of all the cases of cancer of the cervix, 977 in number, treated from the beginning of the year 1922 to the end of 1931, in relation to the involvement of the rectum. The work is divided into three divisions: (1) relationship of the rectum to operable carcinoma of the cervix; (2) anatomical and functional changes in the rectum with inoperable carcinoma; (3) radiation changes in the rectum. In cases of operable cervical carcinoma the rectum is much less frequently involved than the parametria. During the operation itself, among 524 cases of supposedly operable cancer, an infiltration of carcinoma into the rectal wall was observed only three times. In four cases accidental injury to the rectum occurred during operation. The predominant number of secondary cancers of the rectum occur with the inoperable cases of groups three and four. The frequency of rectal involvement was as follows: stenosis without actual involvement of the intestinal wall, 14 cases; stenosis with fixation of the mucosa, 34 cases; fixation of the mucosa without narrowing of the lumen, 2 cases; fistula formation, 33 cases; and penetration of the cancer from the parametria without communication with the vagina, 4 cases. Rectoscopic examination is particularly valuable in the diagnosis of intestinal changes with cancer of the cervix, and for two years has been practiced routinely in the Vienna Clinic. The rectal changes observed are, first, a relative rigidity of the mucosa after distention of the intestine; secondly, a scar-like retraction of the mucosa; thirdly, an edema of the rectal mucous membrane, giving to it a glass-like surface; fourthly, a penetration of the tumor into the lumen. A proctitis is almost invariably present in advanced cases due to infection from the discharges from the cervix, which find access to the rectum as a result of atony of the sphincter. The symptoms of rectal involvement vary greatly. In the earlier lesions the patient may not perceive that anything i0 wrong. With more marked stenosis, there is tenesmus, a discharge of blood and mucus, and marked constipation. The almost complete lack of sensitivity of the rectal mucosa explains the absence of symptoms in the early stages. A diminution of the tone of the rectal sphincter and a distention of the ampulla is characteristic of the advanced stages. It is to be regarded as the result of an infiltration by the cancer of the sacro-uterine ligament and the tissue to the median side of the hypogastric artery, which destroys the hypogastric plexus. Injuries from x-rays usually occur in the sigmoid flexure and radiation damage to the rectum is in Halter’s opinion almost invariably the result of radium. In practically all cases of cervix carcinoma treated by radium there is an early redden- ing of the mucosa which, as a rule, disappears without treatment. The rectoscopic appearance of early radium proctitis resembles closely rectal inflammation of other etiology. The radium ulcer developing later, however, is more specific and is characterized by a tenacious greenish covering. The walls are often elevated and hard, so that confusion with carcinomatous ulcer is possible. When such ulcers are healed, scars are formed which may greatly constrict the lumen of the canal. FEMALE GENITAL TRACT 737

Among 696 radiated cases, injuries of the rectum by radium occurred in 23, or 3.3 per cent. The histories of these cases are abstracted in some detail by the author. They included 16 fistulas (2 per cent), one ulcer, one sclerosis with scar-like fixation of the rectal wall, and 5 stenoses. The only really valuable treatment of such rectal injuries is the avoidance of further irritation of radiologic or chemical nature. HOWARDC. TAYLOR,JR. Acid-Base Equilibrium of Blood and Urine in Uterine Cancer, in Other Uterine Conditions, and in the Puerperium, A. MARTA. I1 comportamento dell’ equilibrio acido-basico del sangue e dell’ urina nei tumori maligni dell’ utero in rapport0 anche ad altre forme dell’ apparato genitale femminile ed a1 puerperio in ispecie, Arch. di ostet. e ginec. 19: 697-715, 1932. Using a colorimetric method, the author determined the hydrogen-ion concentration of the blood and urine in women with uterine cancer (15 cases), uterine fibroid8 (6), pelvic inflammation (12), displacements (4), metrorrhagia at puberty (3)’ genital hypoplasia (18), and during the puerperium (22). The normal value of pH is taken as 7.8 for the blood and 6.2 for the urine, at 16 to 18’ C. According to the tabulated results the normal blood pH figure was obtained in practically all cases except those of uterine cancer and in puerperal women. In the cancer cases there was displacement to the acid side (7.2 to 7.6); the figures for puerperal women were very similar but with a slightly greater range (7.0 to 7.8). In the remaining tables the monotony of “ 7.8 ” is broken in only two cases of fibromyoma (7.4, 7.6) and in two cases of early metrorrhagia (ages fourteen and eighteen years; reading, 7.6 in each case). The determinations of the pH of the urine gave on the whole closely parallel results, though for obvious reasons less constantly so. [The greater part of this paper is occupied by a rather confused discussion of various topics relating to the chemistry of cancer, very incomplete and having little or no obvious bearing on the subject of the author’s investigation or his results. The latter agree with those of Guthmann and Wirz (see Abst. in Am. J. Cancer 15: 942, 1932) who covered similar ground, their series including a larger number of cases of uterine cancer but fewer of other conditions of the female genital tract]. F. CAVERS

Behavior of the Trypanocidal Function of the Liver with Carcinoma of the Uterus and during Gestation, H. EUFINQER,M. ROTHERMUNDT,AND H. WIEBBADER. Das Verhalten den trypanociden Leberfunktion beim Uteruscarcinom und in der Gestationsperiode, Arch. f. Gynak. 151 : 150-167, 1932. Also in abstract, in Monatschr. f. Geburtsh. u. Gynak. 93: 249-257, 1933. A study of the liver function in cases of uterine cancer and in pregnant women has been made on the basis of the finding of F. Rosenthal that a close relationship exists between the trypanocidal properties of the blood serum and hepatic function. The method is based on the fact that white mice injected with trypanosomes die without exception in a few days unless small quantities of human serum are injected simultaneously. The technic of the present writers required the injection of serum into a series of mice, the amount decreasing from 0.5 to 0.025 C.C. per 20 gm. mouse, immediately before infection. The trypanosomes used were those of the Prowasek strain of Nagana. Blood containing these organisms was diluted with normal salt solution until one to two trypanosomes were present in each microscopic field, and of this blood emulsion 0.2 C.C. were injected intraperitoneally. All injected mice were observed over a fourteen-day period. As a control 42 normal sera were studied. The results showed a considerable variation, the normal trypanocidal effect ranging from 0.025 to 0.3. Variations were also found in the same individual when the blood was taken at different times. The following were also investigated: 6 patients with pernicious anemia, 4 738 ABSTRACTS patients with cirrhosis of the liver, 17 with genital carcinoma, 49 undergoing a normal pregnancy, 10 with disease of the kidneys, 11 with eclampsia, 3 with hyper- emesis gravidarum, and 1 with chorionepithelioma. The results showed that with cirrhosis of the liver and in many cases of pernicious anemia there is an extraordinary decrease in the trypanocidal substance as an expression of a severe liver injury. With genital carcinoma there are slight decreases in this trypanocidal Hubstance, which also speaks for an impairment of this particular hepatic function. In the beginning of pregnancy there is a slight decrease in the trypanocidal material in the serum, while in the last month of pregnancy there is a compensatory increase. In the toxemias of pregnancy, renal disease, and eclampsia, there is in general no difference to be detected from normal pregnancy, although in the clinically severe cases a diminution of trypanocidal substance is observed. HOWARDC. TAYLOR,JR.

Radiosensitivity and Lipoid Content of Uterine Cancer, ALBERTBLAU. Strahlen- empfindlichkeit und Lipoidgehalt des Gebarmutterkrebses, Wien. med. Wchnschr. 82: 742-743, 1932. Various characteristics of malignant tumors have been studied in the hope of finding an index of radiosensitivity. Among supposed criteria may be mentioned the relative maturity as indicated in the structure of the tissue, the rate of mitosis, and various more theoretical concepts. One suggestion has been made that the radiosensitivity is proportional to the involution capacity of the organ from which the tumor arises, a theory which accounts for the effectiveness of radiation in uterine cancer. Following Warnekros, Rlau has studied by special stains the fat content in 12 cases of uterine cancer and found lipoids present in 7. Of these 7 patients, about 110 per cent were alive two years after combined treatment with x-rays and radium, whereas of the 5 with negative fat reaction only 40 per cent were alive. It is possible that any increased radiosensitivity may not depend on the lipoid content itself but that the appearance of fat indicates a tendency to spontaneous degeneration of the cancer tissue. HOWARDC. TAYLOR,JR.

Anatomy and Histology of Uterine Carcinoma, P. CAMPUZANOCACHO. Anatomia e histoligfa del chcer del dtero, Arch. med., cir. y espec. 35: 683-688, 1932. The author of this " modest communication " admits that he has no new facts or explanations to communicate. His unnecessary paper is illustrated by seven quite good photomicrographs of the well known forms of uterine carcinoma. F. CAVERS

Postoperative Recurrence of Cancer of the Cervix. Its Localization, Symptoma- tology, Diagnosis, DifFerential Diagnosis, Prophylaxis and Treatment, H. KAMNIKER.Das postoperative Rezidiv des Carcinoma colli uteri. Seine Lokalisation, Symptomatologie, Diagnose, Differentialdiagnose, Prophylaxe und Therapie, Arch. f. Gynak. 150: 339-392, 1932. The problem of recurrences in cervical cancer is an important one, for among the favorable cases operated upon, there are approximately 45 per cent five-year cures; 6 per cent of the patients die as the result of operation, 7 per cent die of intercurrent illnesses, and about 42 per cent die as a result of a recurrence. The types of secondary lesions may be divided as follows: (1) local recurrences, which include vaginal recurrence, the median local recurrence, the parametrial local recurrence, and finally recurrence in the sacro-uterine ligament; (2) node recurrences, including lesions in the inferior hypogastric nodes on the pelvic wall, the iliac lymph nodes, the higher regional nodes along the aorta, and the inguinal FEMALE GENITAL TRACT 739 nodes; (3) metastatic secondary lesions, including those about the urethra and in more distant sites, (4) implantation recurrences occurring in the Schuchardt incision for the vaginal operation and in the abdominal incision for the Wertheim operation. Among 374 recurrences, Kamniker observed local lesions in 242, regional node recurrences in 88, metastatic recurrences in 13, and implantation recurrences in 4, while in 27 the site could not be determined with certainty. As a general principle it must be conceded that local recurrences are of greater significance in regard to the value of an operation than node recurrences. It is noteworthy, therefore, that in the cases operated upon by methods other than the most radical procedure, local recurrences amounted to 86 per cent and node recurrences to 9 per cent. Cases treated by the Wertheim operation showed 69 per cent local and 26 per cent node recurrences. In the cases treated by the extended vaginal operation, with removal of both adnexa, there were 30 per cent of node recurrences and only 55 per cent of local recurrences. The extent of the disease has a large bearing on the type of secondary lesions. The great majority of recurrences develop soon after operation, and it is noteworthy that of all the recurrences in this series 53.7 per cent occurred in the first year, 23 per cent in the second year, 9.3 per cent in the third year, 7.6 per cent in the fourth year, 3.3 per cent in the fifth year, and 6.2 per cent after five years. The histologic division of the cases into well differentiated] moderately differentiated, and undifferentiated squamous carcinomas and into adenocarcinoma indicates, as Kamniker has shown elsewhere, that the histologic type of carcinoma plays an entirely subordinate r6le in the prognosis. It was observed, however, that the solid carcinomas of low maturity had a special tendency to recur early. This type also tended to produce a relatively large number of secondary lesions in the regional nodes, which suggests that this sub-type has the capacity to pene- trate the lymph vessels very early. The early diagnosis of a recurrence is as important as that of the original disease. In the first Vienna Clinic, from which this article comes, the women are observed following their operation at six to eight week intervals during the first year, at two to three months during the second, at four months during the third, at five months during the fourth, and at six months during the fifth year and later. The diagnosis of a recurrence is to be made by six methods, which Kamniker outlines as follows. (a) Gynecologic examination: In making such an examination great care must be made to distinguish postoperative inflammatory infiltration from recurrences. Following the extended operation, rectal examination is much more valuable than vaginal. (6) Biopsy: Microscopic examination of biopsy material is especially necessary in the diagnosis of possible recurrences in the vaginal vault. Attempts to con- struct harpoon like instruments for obtaining specimens from deeper lying recurrences have not met with complete success. (c) Roentgenograms are of value in detecting metastases in the bones and lungs. They are, of course, essential in studying the bladder and ureters. (d) Serologic methods are of doubtful value. (e) Urologic examination is most important. For proper diagnosis it is necessary to recognize the many anatomic changes which may result merely from the effect of the operation or the x-ray and radium treatments. The bladder changes with actual recurrence can be divided into five stages. In the first stage the cancer has not yet invaded the bladder wall but there is evidence of an extrinsic tumor pushing toward the bladder lumen and there may be some evidence of congestion. In the second stage, as a sign of the compromised lymphatic circulation] there appears what has been called wall edema, which gives to the mucosa a 740 ABSTRACTS yellow, wax-like appearance. The third stage is characterized by edema of the mucosa, the so-called bullous edema. In the fourth stage the cancer is detectable immediately beneath a thin covering epithelium, and at this stage, before ulceration occurs, material can be obtained for histologic study. In the fifth stage the carcinoma has penetrated into the bladder, and ulceration leading to possible fistula has begun. A further series of changes detectable by urologic examination is found in the ureters. The common lesion is a constriction or occlusion of the lumen of the ureter due to prewure from the growing cancer on the outside. Such occlusion lead8 to hydronephrosis and eventually to death from uremia. (j)Rectoscopic examination: As in the case of the bladder, so with the rectum, certain changes occur following radiation or operation which must be learned before the signs of recurrences can be properly evaluated. Recurrences in the rectum may be described in four stages. In the first stage there is evidence only of pressure on the rectal wall from an external growth. In the second stage a scar-like retraction of the mucosa is visible, which is identical with the fixed mucous membrane felt on manual examination. In the third stage there are edema of the mucosa and a beginning rigidity of the rectal canal, which does not collapse after expulsion of the air. In the fourth stage ulceration begins, which may lead also to fistula formation. A striking finding in instances of recurrences in and about the rectum is the paralytic appearance of the sphincter. Prophylaxis against recurrence depends first upon the selection of a radical type of operation and the avoidance of spreading cells which may become implanted. Kamniker believes, furthermore, that an improvement in the general health of the patient will increase resistance against recurrence. Postoperative radiation with radium and x-rays is also of great importance. The treatment of recurrences Kamniker considers under four heads; (a) the radical operation, (b) the palliative operation, (c) radiation, (d) palliative therapy. Under the radiation treatment of recurrences he includes x-rays, the insertion of radium in the vagina, use of a rectal applicator for radiation of the parametria, radium in large doses given externally, and the use of needles and seeds. These needles also may be inserted into the parametria by way of the rectum. The success of treatment depends upon the location of the recurrent growth, and most cures will be found among the local recurrences. Node recurrences give a much poorer prognosis, while the metastatic lesions remain practically unaffected by treatment. As permanent cures Kamniker has regarded all patients remaining well and free of disease for five years. Among 374 cases of his series there were 36 such cures, amounting to almost 10 per cent, which corresponds with most of the figures reported in the literature. [Kamniker’s work is an exhaustive but concise study of all the important aspects of recurrence in carcinoma of the cervix of the uterus following surgical treatment. The material is so well presented and the subject so completely covered that this paper should be of value to anyone wishing to obtain a fundamental introduction to this important matter.] HOWARDC. TAYLOR,JR. Postoperative Recurrence of Cancer of the Cervix of the Uterus. Clinical Aspects of the Special Forms, H. KAMNIKER.Das postoperative Rezidiv des Carcin- oma colli uteri. Klinik der einzelnen Erscheinungsformen, Arch f. Gynak. 151: 356-411, 1932. In the second part of his work on recurrences [see preceding abstract for first part] following operation for cancer of the cervix of the uterus, Kamniker considers separately local recurrences, node recurrences, metastatic recurrences and implantation recurrences. Each type is subjected to considerable subdivision and for each frequency, symptomatology, method of diagnosis, form of treatment and prognosis are discussed. FEMALE QENITAL TRACT 74 1

I. Local RecurrenceN: (a) The vaginal local recurrence is that in which the tumor reappears in the scar at the end of the vaginal tube, usually in the form of a granu- Iation-like structure but occasionally as a submucous nodule. Such recurrences are more common after conservative hysterectomy than after the radical operation, since with the former sufficient vagina is not removed. This type of recurrence extends either by the lymph channels into both parametria or as a submucous infiltration of the vagina. The symptoms consist in discharge and slight bleeding. The proper therapy is a combination of radium and x-rays, with special caution against injuries of the bladder and rectum. Permanent cures are to be expected in about 10 per cent of the cases. (b) The median type of local recurrence is that in which a nodule appears above the completely unchanged vaginal tube. Anatomically the growth appears between the bladder and rectum or in the peritoneum of the pouch of Douglas. Advance of the growth may take place towards the vagina or into the parametria. This type is more common after the more conservative operation. Early symptoms may be absent and the recurrence gives evidence of its presence only when the neighboring organs are involved. Treatment is by a combination of radium and x-rays, possibly also by the use of needles inserted from the vagina. The results are more unfavorable than in the preceding type, permanent cures being obtained in only 5 to 8 per cent. (c) The parametrial recurrence involves the lateral part of the pelvic connective tissue. This is the commonest typo of recurrence and appears usually very early. Extension may be toward the vagina or, more commonly, in the direction of the pelvic wall. The early symptoms are not characteristic, consisting in pain in the lower abdomen and sacrum, general weakness and loss of appetite, constipation, and loss of weight. The later symptoms depend upon the direction of extension. Treatment is relatively favorable because the cancer nodules are fairly close to the vagina and can be reached by intensive radiation from the vagina and the rectum. A cure rate of approximately 20 per cent is possible. (d) Recurrence in the uterosacral ligament is essentially a subdivision of the parametrial type. The extension is, however, in the direction of the rectum, and the first symptoms are usually those of involvement of that organ. Treatment is by a combination of radium and x-rays, especially by the pararectal application of radium tubes. 11. Node Recurrences: (a) Node recurrences at fhe pelvic wall represent the involvement of the inferior hypogastric nodes which are situated at the end of Mackenrodt’s ligament, to which also belong the ischiopubic nodes. This type of recurrence represents 18 per cent of all the secondary lesions. Extension may be either retrograde, toward the parametrium, or, more commonly, along the course of the efferent lymphatics into the higher iliac and retroperitoneal nodes. The symptoms are characteristic and depend upon the compression of the nerves running to the lower extremities. There results, therefore, pain in the hip and in the sacrum and in the upper and lower legs. Edema of the legs indicates an accompanying injury to the lymphatics. The labia are frequently edematous. Involvement of the urinary tract takes the form of a stricture of the ureter 5 to 8 cm. from the bladder. Involvement of the rectum is likewise high, 8 to 11 cm. from the orifice. Treatment is by x-rays, since radium is used with difficulty on a tumor in this position. In a few cases of movable nodes surgical excision is justifiable. Only about 7 per cent can be cured by radiation. (b) Nodes of the second station include the superior median and lateral iliac lymph nodes, which lie medial and lateral to the common iliac artery near the point of crossing of the ureter; likewise the interiliac lymph nodes and finally the inferior lateral and medial iliac nodes. Recurrences in these nodes are relatively less common except in the advanced stages and occur only after the 742 ABSTRACTS extended radical operation, somewhat more commonly in fact after the abdominal than after the vaginal procedure. Many of these recurrences develop quite late, 27 per cent of Kamniker’s cases appearing after the five-year period. Extension is chiefly along the lymphatics into the higher retroperitoneal and thoracic lymph nodes, as well as to the lungs and liver. The symptoms depend principally upon compression of the nerves and take the form of pain in the lumbar regions and in the lower limbs. Involvement of the ureter takes place 12 cm. above the bladder. Treatment is by the earliest possible administration of x-rays, although an operation with implantation of radium may be attempted. The results in these cases are bad. (c) Recurrence in the inguinal nodes results apparently from a change in the lymphatic flow from the true pelvis following surgical interruption of the normal lymphatic vessels. The only early symptoms are the tumors in the groin and moderate pain. Later, evidence of obstruction in the lymphatic flow to the lower legs appears. Here again radium and x-ray treatment are the principal measures, although the prognosis is bad and over-treatment with radiation may result in a long continued discharging ulceration. 111. Implantation Recurrence: (a) Recurrence in the Schuchardt incision used to give better access to the field of operation occurs, of course, only in cases treated by vaginal hysterectomy. The tumor appears either as a nodule in the scar or as an exophytic type of growth. In early cases surgical excision is strongly indicated. Unfortunately cures are rare, and further growth toward the parametrium takes place. (b) Recurrence in the abdominal wall occurs only after the abdominal type of operation. Here also surgical excision of the secondary lesion followed by radiotherapy is strongly indicated. The prognosis of the simple implantation recurrence in this region is relatively good, provided no other recurrences are present. IV. Metastatic Recurrences: Metastatic recurrences without other types of recurrence are relatively rare, representing only 3 to 5 per cent of recurrences after the radical operation and 1 to 2 per cent after operations of other types. These recurrences are usually early, but Kamniker has observed one ten years after operation. One of the most frequent metastatic lesions is the single nodule occuring in the lower part of the vagina, particularly near the urethra. Although these single recurrences can usually be healed, they indicate the probability of others being present, and the prognosis is bad. Other distant metastases which develop after recurrence are those in the bladder, in the liver, in the lungs, in the pleura, in the brain, and in the supraclavicular and infraclavicular fossae. In conclusion Kamniker presents briefly the case histories of ten women in whom recurrences in different regions developed at considerable intervals. In these patients the interval between operation and the first recurrence varied from one to twelve years; the intervals between the two recurrences was in 1 caae one year, in 3 cases two years, in 1 case three years, in 2 cases four years, in 2 cases five years and in 1 case seven years. [This classification and analysis of recurrent cervical cancer is an important contribution and offers a basis for constructive work upon a group of malignant lesions which, taken together, are only slightly less frequent than primary cervical cancer. The least that may be said is that these subdivisions give an unusually clear conception of cervical cancer in its post-treatment stages. The refinement in diagnostic methods required by the classification, furthermore, sets an excellent standard for the postoperative care of cervical cancer cases and perhaps points to a means which, by individualizing the cases and adapting a special method of treatment to each, might increase slightly the cure rate of the recurrent cases. A single criticism is found in the almost complete absence of statistical analysis in this paper, which perhaps points to the practical difficulty which must exist in the actual classification of many cases.] HOWARDC. TAYLOR,JR, FEMALE GENITAL TRACT 743

Cancerization of the Cervical Stump after Subtotal Hyeterectomy, 0. PRESTINI. Cancerizaci6n del mufl6n cervical, Semana m6d. 2: 738-739, 1932. The author reports five cases of cancer in the cervical stump after subtotal hysterectomy, performed in one case for adnexitis and in the others for myoma. The intervals between operation and the detection of carcinoma of the stump were three years, four years (2 cases), six years, and nine years. All five patients were treated by radium, the total dosage being 36 millicuries destroyed in three cases, 28.80 in one case, and 57.6 (in two applications of 28.8 each) in one case. At the time of reporting, two patients had been lost sight of after a few months; one seen a year and two seen two years after treatment showed clinical cure. The author calls special attention to the fact that apparently in none of these five cases had carcinoma been diagnosed when the subtotal operation was performed, and that, assuming that the diagnoses were correct, the occurrence in the cervical stump was of quite independent origin. He cites collected statistics showing that among 2700 cases of uterine fibromyoma there was coexistence of cervical carcinoma in 46 cases (1.7 per cent). F. CAVERS

Radiation Therapy in Carcinoma of the Cervix Uteri in India, S. MITRA. Brit. J. Radiol. 5: 581-588, 1932. In a five-year period 811 patients with cervical carcinoma were seen in the Polyclinic of Chittaranjan Seva Sadan Women’s Hospital in Calcutta, and of these 360 were treated. Two of the patients were under twenty-five, 41 were between twenty-five and thirty, 51 between thirty-one and thirty-five, 129 between thirty- six and forty-five, 100 between forty-six and fifty-five, 68 between fifty-six and sixty-five, and 2 over sixty. All but one patient had borne children. Bleeding was the chief complaint. In most cases it had been present for from six months to a year. Six cases were complicated by pregnancy. In 5 cases uterine fibroids were also present. The cases are divided into three groups, early, late, and terminal. Early cases, constituted 10.5 per cent of the series; 89.5 were late. No terminal cases received the systematic course of radiation. All cases were treated with radium and x-ray therapy. X-ray exposures were given through 5 different portals, viz., hypogastric, sacral, two lateral, and vulval, and each time a full “ skin erythema dose ” was given (640 7). Radium was applied partly in the vaginal vault touching and covering the growth, and partly in the cervical canal or in the uterine cavity. Generally the treatment was begun with radium and supplemented with deep x-rays: 6,000 mg. hours of radium element were divided into five doses applied at intervals of four to seven days. X-ray treatment was given three times a week. A second course of treatment, if required, is given after at least three months, when deep x-rays are more useful than radium. Of the 360 patients, 69 did not continue treatment and 98 could not be traced. These are counted as dead. On this basis the end-results showed 50 per cent of five-year cures in early cases and 16.6 per cent in late cases.

The Urinary Bladder and Radiation Treatment of Carcinoma of the Uterus, C. SCIIROEDER.Harnblase und Strahlentherapie des Uteruscarcinoms, Arch. f. Gyniik. 150: 147-158, 1932. The injuries of the bladder mucous membrane following combined radium and x-ray treatment of uterine carcinoma and not leading to the formation of fistulas are discussed by Schroeder on the basis of cases observed at the University Clinic Wiirzburg. For the recognition of such bladder injuries, a knowledge of the appearance of 744 ABSTRACTS recurrent carcinoma in the bladder is neceesary. Such recurrence appears first as an elevation of the mucosa, later as a bullous edema, and finally as a necrosis of the mucosa with perforations of the carcinoma into the bladder. The radiation changes in the bladder are characterized by their position in the fundus above the line connecting the orifices of the ureters. In such radiation injury three zones are detectable: a central zone in which definite necrosis of the mucosa occurs, a peripheral zone in which are found multiple deep red raspberry-like or wart-like granulations, and finally the normal bladder mucosa, which often shows marked vascularisation. The relative frequency of bladder injuries may be judged from their incidence in the 449 cases treated in the Clinic from 1923 to October 1931. In this group there were 6 vesico-vaginal fistulas, (1.83 per cent). Of these, 4 were in very advanced inoperable cases, for which the radium could not be regarded as the sole cause. There were 13 injuries of the bladder mucosa not leading to fistula formation, of which 5 have healed under observation and of which 8 are still under treatment with the outcome unknown. The time of appearance of symptoms from these radiation injuries varied in the present group from two and one half months to three years and eight months after the beginning of treatment. In regard to treatment the important consideration is the recognition of these injuries, in particular their differentiation from recurrent carcinoma, and the immediate discontinuation of radium when they are detected. HOWARDC. TAYLOR,JR.

Primary Mortality Attributed to Radium Therapy of Uterine Cancer, G. PAROLI. Mortalits primaria da radium nella terapia del cancro dell’utero, Arch. di ostet. e ginec. 19: 664-666, 1932. The author reports that among 600 cases of uterine cancer treated by radium in the gynecologic clinic of Florewe [the period covered is not stated] there were four fatalities directly attributable to treatment. These deaths were due to peritonitis. Autopsy, done in two cases, showed, in addition to purulent peritonitis, (1) cancerous ulceration in the right vaginal fornix, extending into the peritoneum, (2) bilateral purulent parametritis. In the second of these cases death followed the fist application of radium (500 mg. hours). The author points out that, despite the greatest care in technic (correct placing of applicators, antiseptic measures, eto.), there remains an element of risk which cannot be foreseen and prevented. He suggests that radium may damage the tissues in such a way as to cause perforation, or to lower their resistance against bacteria, or may stimulate latent bacteria into activity. F. CAVERS

Radium Therapy in Uterine Hemorrhages of Benign Origin; Clinical Study of 105 Consecutive Cases, L. E. PHANEUF.Am. J. Obst. & Gynec. 24: 225-233, 1932, A clinical study is presented of 105 cases of uterine hemorrhage of benign origin treated with radium. The cases are classified as follows: fibromyomas, 15; uterine hemorrhages of adolescence and in young women, 7; uterine hemorrhages of middle life, 72; uterine hemorrhages after the menopause, 11. The applicator used by Phaneuf consists of a brass tube 5 cm. in length and 1 mm. in thickness, carrying 50 mg. of radium. General anesthesia was used in the majority of the cases, but Phaneuf now regards local infiltration as so satisfactory that he plans to use it much more frequently. Fourteen of the 15 fibromyomas disappeared following treatment, and in 14 of the cases permanent amenorrhea was established. For the hemorrhages of adolescence the smallest dose was 400 mg. hours and the largest 600 mg. hours; FEMALE QENITAL TRACT 745

4 of the 7 patients were benefited by one treatment; one was improved after a second dose; one still needs another small treatment, and the last had a hysterectomy performed by another surgeon. Seventy of the 72 cases of uterine hemorrhages in middle life were considered cured, permanent amenorrhea being established. The 11 women having hemorrhages after the menopause were all permanently improved. In the discussion which followed the reading of this paper, the relatively high dosage employed by Phaneuf in many of his cases, amounting, as a rule, to 1800 mg. hours for the hemorrhages of middle life, met with considerable criticism. The necessity of care in the radium treatment of adolescent bleeding was also emphasized. HOWARDC. TAYLOR,JR.

Carcinoma and Sarcoma Coexisting in the Same Uterus, G. E. COWLEB. Am. J. Obst. & Gynec. 24: 200-201, 1932. A carcinoma and sarcoma were found in the same uterus. The sarcoma was found within a polyp protruding from the lower half of the corpus with a base of 2.5 cm. and a length of 4.5 cm. The uterine endometrium and myometrium was the site of an adenocarcinoma. No photomicrographs are offered in proof of the diagnosis of sarcoma. HOWARDC. TAYLOR,JR.

Polypoid Leiomyoma of Uterus Showing Hyaline Degeneration, E. A. VOTTA. Leiomioma pediculado de utero o mioma laevicelular de Virchow; degeneraci6n hialina, Prensa m6d. argent. 19: 1108-1115, 1932. A woman of forty had a tumor occupying the right hypogastrium and iliac fossa, first noticed a week previously. It was diagnosed clinically as a right ovarian cyst, but at operation a mass was found which filled the greatly dilated uterus, was attached by a stalk to the fundus, and was easily removed on severing thie stalk. The tumor, which was the size of an adult head and weighed more than a kilogram, showed on section a large cavity containing recent blood clot. Evi- dently the tumor had caused no symptoms until its rapid increase in size following hemorrhage into its substance. It conaisted of purely myomatous nodules, surrounded by a slight amount of connective tissue and showing in some regions hyaline degeneration, liquefactive necrosis, and calcareous deposits. There are five illustrations. F. CAVERB

Large Uterine Cysts. A Cyst of the Uterine Wall with Carcinoma, H. DWORZAK. Ein Beitrag zur Frage der grossen Uteruscysten. Cyste der Uteruswand mit Carcinom, Arch. f. Gynlik. 150: 631-642, 1932. Large cysts of the uterine wall have been ascribed various origins. The opinion of Robert Meyer is that displaced Mtillerian epithelium forms the basis of their development. By others, however, the origin has been attributed to Gartner’s duct or to an adenomyosis resulting from an inflammatory process. The size of these cysts, as reported, has varied from that of an orange to that of a uterus in the last month of pregnancy. Most of them have a single chamber with here and there small accessory cysts. Thqcysts lie for the most part in the median part of the posterior aspect of the uterus. The lining is found in many cases to be desquamated or poorly preserved, while in others the cyst mucosa suggests endometrium or, rarely, tuba1 mucous membrane. The cystic content has been reported as clear, mucoid, and, in some instances, brown, thick, and tar-like. The case reported by Dworzak occurred in a fifty-year-old nullipara. The uterus contained a cystic tumor some 15 cm. in diameter, developing from the lateral and anterior wall. Much free fluid was found in the abdominal cavity, and papillary nodules were scattered over the peritoneum of the bladder and a part 746 ABSTRACTS of the intestines, suggesting metastases from a malignant tumor. Histologic examination showed that the mucosa of the cyst consisted of a single-layered epithelium. The regularity of the epithelium disappeared toward the lower part of the cyst, where, instead, a papillary carcinomatous growth was present. This had invaded the cyst wall and extended into the parietal and visceral peritoneum. The cystic contents were brownish with much iron pigment and cholesterol crystals. The bleeding which had evidently taken place into the cyst may be interpreted as the result of the carcinomatous growth or of a former menstruation, Dworzak himself leaning towards the latter view. HOWARDC. TAYLOR,JR.

Obsemations Made During a Study of the Cytology of Endometrium, C. GRANT BAIN. Am. J. Clin. Path. 3: 237-241, 1933. The author studied more than 100 fresh specimens of endometrium obtained at operation and an equal number of specimens from the pathologic museums. There seemed to be a definite relationship between neoplasms and hypertrophy and hyperplasia. This was evident in polyps, adenomas, and carcinomas, and in fibromas, myomas, and sarcomas. There was no sharp dividing line between a benign and a malignant condition. A page of photomicrographs illustrates the article. These include illustrations of secondary cytoplasia, regeneration cells, and malignant cells.

Endometrioma Occurring in a Postcesarean Laparotomy Scar, WILLIAMF. MEN- GERT. J. A. M. A. 99: 469, 1932. A woman of thirty-one had had two cesarean sections, one six years and the other five years previously. About three years after the first of these procedures a small lump occurred in the scar. It was painful, especially at the menstrual periods, when, also, it showed an increase in size. It was easily removed and on examination showed, in a mass of connective tissue and fht, several cavities filled with red blood cells and lined by epithelium resembling endometrium. In several areas there were normal endometrial glands with typical supporting stroma. Hosoi and Meeker (Arch. Surg. 18: 63, 1929) collected 87 cases of endometrio- mas occurring in laparotomy scars, in 21 of which the pregnant uterus had been opened. One photomicrograph illustrates this report.

Aschheim-Zondek Reaction in the Diagnosis of Chorionepithelioma, M. UBANDI- ZAGA AND C. DfAs-MnNfo. El diagn6stico biol6gico del corioepitelioma, Arch. de m6d., cir. y especialid. 35: 921-923, 1932. The author reports briefly a case of uterine chorionepithelioma, with vaginal metastasis, following hydatid mole. Injection of 5 C.C. of morning urine into a rabbit (previously found on laparotomy to have normal ovaries) produced within forty-eight hours numerous hemorrhagic follicles. The rest of the paper consists in an enumeration of reports dealing with the results obtained by the use of the Aschheim-Zondek test in the diagnosis of chorionepithelioma, with a bibliography of 35 references. [Since this paper is apparently published for the enlightenment of general physicians, it is a pity that the author omits an account of the technic of the reaction and does not explain what is meant by such terms as “ A. Z. I, 11, I1 ” and 30,000 u. r.”] F. CAVERB FEMALE GENITAL TRACT 747

Malignant Chorionepithelioma with Metastases Chiefly in the Glands of Internal Secretion, M. LUTFIAND M. B. SCHUKRU. Malignes Chorionepitheliorn mit vorwiegender Metastasierung in die innersekretorischen Drusen, Beitr. z. path. Anat. u. e. allg. Path. 90: 666-667, 1933. The authors give their autopsy protocol in the case (mentioned by R. Meyer in Henke-Lubarsch, Band VII, Teil 1, p. 749, 1930) of a twenty-eight-year-old woman who died of heart failure six days after panhysterectomy. She had bled for two and a half years following a normal fourth confinement. In addition to the primary tumor in the uterine cavity, lymph node metastases in the inguinal and cervical regions and around the pancreas, hila of the lungs, and chest wall, the authors found numerous foci in the visceral pericardium, lungs, gastric mucosa, duodenum, liver, spleen, and both kidneys. Widespread metaetases were present, also, in the hypophysis, thyroid, pancreas, both adrenals, and the right ovary. The latter was sdme 3 cm. in diameter with a thin capsule and hemorrhagic, reddish cross-section. The left adnexa, portio, vagina, external genitals, bony, muscular, and central nervous systems were not involved. N. B. SACKETT Some Considerations upon Large Uterine Fibroids, N. BARDESCO.Quelques considCrations sur le fibrome gbant de l’utbrus, Gynbc. et obst. 25: 25-30, 1932. Six cases of fibroids are reported in which the tumors weighed, respectively, 14.0, 15.5, 28.0, 13.5, 17.0, and 8.2 kilograms. These tumors were all of the pedunculated variety and had numerous adhesions to the omentum, in which large vessels ran to the tumor. It is to these features that Bardesco attributes the capacity of the tumors to grow to such a size. It is recommended that in such cases hysterectomy be performed first and the adhesion separated afterwards, so that the otherwise troublesome bleeding may be reduced to a minimum. H. C. TAYLOR,JR.

Myom of the Uterus and the Heart, J. J. ARKUSSKY AND E. R. NOWOTJELNOWA. Uterusmyom und Here, Arch f. Gynak. 151: 293-301, 1932. The material for the authors’ study consisted in 103 cases of uterine myoma from the State Institute for Roentgenology of Leningrad. Study of these cases showed that in 54 there was absolutely no abnormality of the heart and in only 23 or 22.3 per cent could the changes in the myocardium be placed in any relationship with the fibroid. This figure corresponds rather closely to the incidence of myocardial changes in general cases coming to post-mortem examination. In conclusion the opinion is stated that the term “ fibroid heart ” has neither clinical nor pathological justification and that it should not be used. Cardiac disease, when it occurs in a patient with a fibroid, is to be regarded as an independent condition and treated accordingly. HOWARDC. TAYLOR,JR. Myoma and Pregnancy, T. P. MATVEIEFF. Myome et grossesse, Gynbc. et obst. 25: 300-305, 1932. Upon the basis of a review of the literature and his own experience, Matveieff recommends myomectomy as the treatment of choice for fibroids of the uterus discovered in pregnancy. His reasons are twofold. The danger of fibroids in pregnancy, based on their tendency to rapid growth and the development of such complications as infection, hemorrhage, necrosis and torsion is great. On the other hand, such tumors can be removed with little risk to mother or fetus. In 9 cases treated by myomectomy only two abortions are reported, one of these having apparently started before the operation, the other being an hydatidiform mole. HOWARDC. TAYLOR,JR. 748 ABSTRACTS

Clinical Case of Fibroma and Pregnancy, BOTELLA. Un caso clinic0 de fibroma y embarazo, Gac. med. espafi. 7: 165, 1932. -4 short discussion of a case, in a multiparous woman, of a large fibroid occurring in conjunction with pregnancy. Hysterectomy was performed. No details are given. JOHN E. WIRTH

Radium Treatment of Uterine Fibromas, E. VILLARD. Traitement des fibromes par les agents physiques, Lyon chir. 30: 79-85, 1933. Villard first records 10 cases in which roentgen therapy failed to arrest hemorrhage or continuation of growth, or both, in uterine tumors diagnosed as fibromes. In every case hysterectomy was later performed, and the following findings were made at operation and on histologic examination of the organs removed: (1) gangrenous fibroma; (2, 3, 4, 7) peritoneal adhesions extending throughout the pelvis, with increased growth of tumor in case 2; (5) greatly increased growth of tumor, with pain attributed to peritoneal irritation; (6, 8) enlargement of a fibroma, which showed in places the features of carcinoma; (9) enlargement of tumor, histologically a malignant leiomyoma with regional metastases; (10) enlargement of tumor with histologic signs of sarcomatous change. The author considers that in probably all of these cases the unfavorable results were attributable to the roentgen therapy, and that all should have been given radium treatment with or without preliminary hysterectomy or tumor enucleation. He prefers radium to x-ray therapy since the former acts directly on the source of hemorrhage, destroying the mucosa, while, if applied intratumorally, it exerts a maximum action on the tumor tissue without risk of damaging the neighboring tissue and setting up peritonitis. During the last few years Villard has treated 56 cases of hemorrhagic fibroma with radium. In two cases hysterectomy was necessary; in one of these cases the dose was insufficient (19 millicuries destroyed). In the remaining cases the results were good. The author’s usual procedure is to dilate the cervix sufficiently to allow of curetting the uterine cavity and examining histologically the fragments of mucosa thus obtained, and to insert in the uterine cavity two tubes, each containing 50 mg. radium bromide, filtered by 1 mm. platinum to be retained for forty- eight hours. F. CAVERB

Radium and X-Ray Treatment of Hemorrhagic Uterine Fibromas, LOUIEITIXIER. Traitement des fibromes hhorragiques par les agents physiques, Lyon chir. 30: 101-105, 1933. In an analysis of 4000 cases of uterine fibroma collected from the literature, the author found that in half of the cases the symptom which caused the patient to seek advice was hemorrhage. He also discusses, from the point of view of choice of treatment, the patient’s age, the presence and extent of anemia and of sepsis, and the local findings (size and position of tumor, coexistence of adnexitis, etc.). His conclusions, based on personal experience, are as follows. Hemorrhagic fibromas, even when causing considerable blood loss, rarely imply immediate danger to life. In women at or about the menopause, arrest of bleeding by radiation castration is usually indicated. In young women, and in those of any age in whom there is grave anemia associated with sepsis, radiotherapy is contraindi- csted; such patients should be operated upon. Radium therapy is usually the best treatment in diffuse fibromatosis. In fibromatosis with several submucous or intramural nodules, however, x-rays are preferable to radium, the rays being delivered to the ovaries by a posterior lumbar port of entry in order to avoid damage to the abdominal wall. Should surgery ultimately be required, the abdominal route is preferable to the vaginal. F. CAVERB FEMALE GENITAL TRACT 749

Total Inversion of the Uterus due to a Submucous Fibroma, J. ~ELLENO. Bratisl. lak&r. listy (supp. No. 1) 12: 1-5, 1932. A case report. Total hysterectomy was done.

A Further Contribution to the Clinical Course and Microscopic Anatomy of the Granulosa-cell Tumors of the Ovary, E. KLAFTEN. Weiterer Beitrag zur Klinik und mikroskopischen Anatomie der Granulosazelltumoren des Eier- stockes, Arch. f. Gyniik. 150: 843-689, 1932. In this rather long paper Klaften combines considerable miscellaneous material upon various aspects of the granulosa-cell tumor of the ovary, drawn partly from the literature, partly from a study of his own cases. Four new cases are reported in detail. In the first patient, a forty-eight-year-old woman with a history of continuous bleeding of one year’s duration, a well differentiated granulosa-cell tumor was removed. Three months later the patient died with symptoms of an extensive abdominal tumor and at autopsy a cancer of the stomach was found. Klaften emphasizes the fact that had no autopsy been performed, the granulosa-cell tumor would have been credited with malignancy which it did not possess. The second case was chiefly remarkable for the large size of the tumor, which, before the operation was performed, led to a diagnosis of carcinoma of the ovary. The third patient was first observed at the age of nineteen, at which time she was suffering from abdominal discomfort and had not yet menstruated. A granulosa-cell tumor of the folliculoid type, the size of a child’s head, was removed from the left ovary. Menstruation occurred one year after this operation, and a few years later the patient underwent a normal delivery. Seven years after operation, however, her periods ceased for three years, following which a few months of continuous slight bleeding ensued. At a second operation a retroperitoneal tumor on the left side of the pelvis, of the same histologic variety as that removed eleven years before, was extirpated. Klaften discusses the question of whether this second growth was a metastasis or a new tumor, leaning to the latter view. In his discussion Klaften considers the histology of the granulosa-cell tumor, its probable origin, prognosis, and age incidence, and the evidence of its hormonal activity. In relation to the latter aspect he mentions an increase in basal metabolism amounting to 24 per cent, which has been observed, a stronger development of the breasts with secretion, an increased growth of the uterus as the result of hyperplasia, an emphasis of the secondary sex characteristics, an increase in the glycogen content of the endometrium, and occasional evidence of functional activity of the endometrium, suggesting a high corpus luteum activity of the tumor cells. The tumors have also apparently some influence on the uninvolved ovary, for menstruation frequently ceases or is disturbed, but the follicle-ripening process is only inhibited, while menstruation tends to return after the removal of the tumor. The occurrence pf hirsutism is not due, in the author’s opinion, to the granuloia-cell tumor itself, because this condition does not disappear with the removal of the growth. The hirsutism is to be regarded as a somatic accompaniment of the sexual lack of differentiation with which various ovarian disturbances and ovarian tumors are found. HOWARDC. TAYLOR,JR.

Granulosa-Cell Tumors of the Ovary, W. P. PLATE. Uber Granulosazelltumoren des Ovariums, Arch. f. Gyniik. 151: 26-43, 1932. The literature of this much described tumor is once more reviewed and two new cases are reported, each with incidental points of special interest. The first patient was a fourteen-year-old girl with intermittent amenorrhea and 750 ABSTIULOTS bleeding. At operation there was found a smooth-walled tumor of the left ovary, the size of a child's head, which had undergone a revolution of 270 degrees. The right ovary was cystic, and from this a small piece was removed. Histologic examination showed that the tumor of the left ovary was a benign form, the so- called adenoma folliculare. In the immediate neighborhood of the granulosa cell islands were cells of a different type, resembling the theca interna cells. In the fragment of right ovary there were also small collections of cells, which the author suggests may have represented the beginning of another granulosa-cell tumor. The second patient, a woman of sixty-one, had a large tumor of the left ovary, weighing 600 gm. This tumor was composed of two parts, the one being a granulosa-cell tumor of the folliculoid and cylindromatous type, the other a teratoma containing such elements as glands, bone, and myxomatous tissue. HOWARDC. TAYLOR,JR.

Postclimacteric Bleeding and the Brenner Tumor of the Ovary, J. SCHIFFMANN. Postklimakterische Blutung and " Brennerscher Ovarialtumor," Arch. f. Gynak. 150: 159-175, 1932. Two cases of the so-called Brenner tumor of the ovary are described, the one solid, the other cystic. The findings in the fast patient, a sixty-year-old woman with post-climacteric bleeding, consisted in a typical Brenner nodule in a pseudomucinous cystoma and the beginning of a Brenner tumor in the apparently atrophic ovary of the other side, a uterus without atrophy but with a cystic hyperplasia of the mucosa and an internal adenomyosis, and finally a fallopian tube in which there was no evidence of senile change. In the second patient, a sixty-one-year-old woman with a single attack of bleeding twelve years after the climacterium, there was found a solid tumor of the right ovary, measuring 3 x 4 x 3 cm. The microscopic structure was characteristic, the tumor being composed of dense connective tissue, areas of calcification, and cell masses partly solid, partly filled with small cystic spaces. The uterus and the other ovary were unfortunately not available for study. In view of these two cases Schiffmann concludes that one cannot rule out a possible endocrine effect of these tumors upon the uterus and the tubes, although he believes that such a stimulus is probably of lesser degree than is found with the granulosa-cell tumor. HOWARDC. TAYLOR,JR. Cystic Adenofibroma of the Ovary, H. DWORZAK.Zur Frage des Adenofibroma ovarii partim cysticum (" Fibroma ovarii adenocysticum " 0. Frankl), Arch. f. Gynak. 150: 622-630, 1932. Frankl collected 17 cases of cystic adenofibroma of the ovary and from these the chief characteristics of the tumor can be outlined. It is usually a partly cystic, partly solid growth, and is of variable size. The cysts are prominent, usually multiple, and have a content which is generally serous but may be mucoid. The solid parts are fibrous and appear either as nodular thickenings in the cyst wall or as large solid nodules. In the fibromatous tissue are numerous glandular and cystic structures. The cysts and the glandular spaces are lined with a single layer of cuboids1 epithelium, while in the larger cysts fibrous, papillary structures are sometimes found. A tumor of this type is described by Dworzak, occurring in a sixty-three-year- old woman. Both ovaries were involved with cysts and fibrous tumors containing multiple small glands. In addition, in each ovary there were epithelial invagina- tions penetrating from the surface and having an apparent connection with the cystic structures below. There appeared, therefore, in this case to be some evidence for the origin of these tumors from the surface epithelium of the ovary. HOWARDC. TAYLOR,JR. FEMALE GENITAL TRAOT 75 1

Symptomatic and Diagnostic Considerations from a Series of 102 Cases of Inter- vention for Ovarian Cyst, G. AJELLO. Semiotics e considerazioni diagnostiche sopra 102 casi d’intervento per cisti ovariche, Rassegna d’ostet. e ginec. 41 : 382-394, 1932. This is a general discussion of the symptoms and differential diagnosis of ovarian cysts as evidenced in a series of 102 cases. There were 10 emergency interventions for twisted pedicle, 2 for suppuration, and 5 for rupture of the cyst. Beyond these facts no detailed data are included in the report. C. D. HAAQENBEN

Ovarian Cysts in Infancy, A. ELBIMAND L. MJ~RIQOT.Torsion des kystes ovariens chez l’enfant, Rev. franc. de gyn6c. et d’obst. 27: 358-366, 1932. This paper is a compilation from the French literature of cases of torsion of ovarian cysts occurring in infancy and childhood. F. CAVERB Contribution to the Knowledge of the Necroses in the Wall of Ovarian Cystomas, L. N~~RNBERQER.Zur Kenntnis der Nekrosen in der Wand von Ovarial- cystomen, Arch. f. Gynak. 151: 16-25, 1932. A case is reported of an immense ovarian tumor in a thirty-four-year-old virgin, causing sudden severe pain in the right lower abdomen. A typical pseudomucinous cystoma was removed containing 4500 C.C. of dark bloody fluid. In numerous places on the cyst wall were visible, irregular, circumscribed spots, gray and brown in color. Sections showed a disappearance of the epithelium of the inner surface and in the underlying connective tissue a disappearance of the nuclei. In the more central part of these necrotic areas, the connective-tissue fibers were swollen and stained poorly, and only remnants of nuclei were found. In the extremely necrotic sections only a little viable stroma immediately beneath the peritoneum was preserved. The cause of necrosis in such cysts without torsion is not well understood. Vascular disturbances have been suggested, and within the necrotic area of the present tumor, thickening of the central wall and thromboses were numerous. The practical significance of these necroses lies in their possible relation to rupture of the cyst. It is to be noted, however, that previously reported cases do not always show that the site of rupture corresponds with such a necrotic area. HOWARDC. TAYLOR,JR.

Asthma and Ovarian Cyst. Cure of the Asthma by Extirpation of the Genital Lesions, MARANON,M. DIM, AND HARO. Asma esencial y quiste ovhico: curaci6n del asma por la extirpacidn de las lesiones genitales, Arch. med., cir. y espec. 35: 1021-1023, 1932. A woman of twenty-one had for about four years suffered from attacks of asthma, chiefly at night. Clinical investigation, including radiography of the chest, blood counts, etc., revealed nothing abnormal. Finally, after an Aschheim- Zondek reaction of the urine proved positive for prolan A but not prolan B, a tumor was found which seemed to be a right ovarian cyst. At operation there was found, besides a polycystic right ovary, a uterine fibromyoma as large as the head of a ten-year-old child. Directly after these tumors had been removed, the asthmatic attacks ceased completely and the patient gained in weight. The authors suggest three possibilities: (1) the absorption of the cystic fluid may have caused asthmatic sensitivity; (2) the presence of the tumor may have set up allergic instability, comparable with that of the nasal, gastric, and other lesions that have been found to cause asthma; (3) the surgical intervention may have acted psychically on the patient’s nervous system. The reading of this paper gave rise to a long discussion, in the course of which various other explanation4 were suggested. F. CAVERB 752 ABSTRAUTS

Unusual Case of Ovarian Cyst, HAROLDR. WORTH.Chinese M. J. 46: 671-672, 1932. A report of an ovarian cyst macroscopically typical except for the complete absence of a pedicle. The cyst was adherent at one point to the omentum, which was lightly twisted into a thick rope just over an inch in diameter for a length of 4 or 5 inches and then spread out over the surface of the tumor over a circular area with an irregular crenated margin about 4 in. in diameter. The history of the patient would indicate that a simple left-sided cyst had gradually become twisted on its pedicle, that omental adhesions developed, and as the blood supply through the natural pedicle became weaker and that though the adhesion more adequate, the tumor was finally able to exist solely on the latter.

Case of Aplasia of the Kidney Combined with Dermoid Cysts of the Ovaries, A. MEY. Ein Fall von Nierenaplasie, kombiniert mit Dermoidcysten der Ovarien, Ztschr. f. Urol. 26: 830-832, 1932. The author found a large tumor occupying the right flank of a thirty-year-old woman. A diagnosis of tumor of the right kidney was made and operation undertaken, but the mass proved to be a dermoid cyst of the right ovary. During operation no trace of a kidney could be found on the right side, so that the condition was more properly a congenital absence of the organ than a true aplasia. Five weeks after removal of the right ovary a rapidly growing mass was found in the lower left quadrant of the abdomen and operation was again undertaken. This tumor proved to be a dermoid cyst of the left ovary, which had become infected subsequent to the earlier operation. R. s. FERGIJSON Dermoid Cysts as an Obstacle to Delivery, V. FURST.Bratisl. lekkr. listy (supp. NO. 1) 12: 10-16, 1932. Three case reports and a discussion of the indications for treatment.

Stnrma Ovarii and Intraligamentous Cystic Myoma Exhibited in the Same Patient, J. T. WITHERSPOON.Am. J. Obst. & Gynec. 24: 240-247, 1932. The author reports the occurrence of a strums ovarii and an intraligamentous cystic myoma in a white woman thirty-five years of age. The history waR of further interest on account of attacks of right lower quadrant pain which had recurred at frequent intervals over a period of five years. These attacks were apparently due to a tendency of the ovarian growth to twist on its pedicle, the final acute stage being brought on by a complete revolution of the tumor. Ovarian tumors composed exclusively of thyroid tissue are of infrequent occurrence. Seven cases of intraligamentous cystic myomas reported in the literature are briefly reviewed. HOWARDC. TAYLOR,JR. Primary Carcinoma of the Oviduct, with a Report of Two Cases, W. S. SMITH. Am. J. Obst. & Gynec. 24: 267-270, 1932. Two cases of primary carcinoma of the oviduct are reported. The first occurred in a colored woman, fifty-three years of age, who had been suffering from cramp-like pains in the lower abdomen and frequency of urination for three months. Both tubes were involved by the neoplasm, but the uterus itself was free. Histologic section showed that the tumor had a papillary structure ind was composed of mucus-secreting cells. The second case was more advanced and there was involvement of the body of the uterus. In spite of a complete hysterectomy with bilateral salpingo-oBphorectomy, a recurrence in the vaginal wall developed after about fifteen months. HOWARDC. TAYLOR,JR. FEMALE OENITAL TRACT 753

Large Cell Solid Carcinoma of the Female Sex Glands (Disgerminoma of R. Meyer) in Non-Hermaphroditic Persons, HANSDWORZAK. Uber das gross- sellige solide Carcinom der weiblichen Keimdrtise (Disgerminom nach R. Meyer) bei nichtswittrigen Personen, Arch. f. Gyniik. 151: 281-292, 1932. The tumor now known as the large-cell solid carcinoma or the disgerminoma of R. Meyer has been variously described in the past as a “solid granulosa-cell tumor,” as an endothelioma ” or a lymphangio-endothelioma,” as a “ seminoma,” and as a “ large-cell alveolar sarcoma.” This tumor is known to occur in the sex glands of normally developed men and women, but is found frequently in persons with hypoplastic genitalia and malformations of the sex glands and also with male and female pseudo-hermaphroditism and true hermaphroditism. Such tumors are common in inguinal and abdominal testes. In the present article Dworzak concerns himself only with cases occurring in non-hermaphroditic women. Histologically the tumor is made up of large round or polygonal or irregularly flattened cells. These are joined in nests and cords which are irregularly circumscribed against the surrounding connective tissue. The irregular contours of these cords are regarded by R. Meyer as characteristic of this type of tumor. Often there is also seen a definite alveolar structure, but in other places the cells are scattered singly or in small groups through the connective tissue, and diffuse areas with a sarcoma-like appearance are found. The connective-tissue framework of the tumor is variably developed, often finely fibrillar and hardly visible, but more often well developed. The regular infiltration of these tumors with round cells is characteristic. Four new cases of this tumor are reported by Dworzak. Two of these occurred in young women of eighteen and twenty years respectively. Two others occurred in older women, thirty-seven and forty years old. No abnormality of the sexual organs was discoverable in the histories of these cases, these being, however, somewhat incomplete. The two older women had each been delivered of full- term children and in neither case with available history was there any evidence of menstrual disturbance. The occurrence of these tumors in fertile women with normal menstrual history is somewhat unusual. Three photomicrographs illustrate this paper. HOWARDC. TAYLOR,JR.

Primary Adenocarcinoma of the Vagina, G. I. STRACHAN.Proc. Roy. SOC.Med. 25: 1245-1248, 1932. Also in J. Obst. & Gynec. Brit. Emp. 39: 566572,1932. The author describes two cases of vaginal adenocarcinoma occurring in women about 6fty years of age. The chief points of interest are the rarity of adenocarcinoma as compared with epithelioma as a primary vaginal tumor and the promising results obtained by radium treatment [see the valuable report by Moench: Am. J. Obst. & Gynec. 22: 837, 1931. Abst. in Am. J. Cancer 16: abst. p. 1452, 19321. Secondary vaginal cancer is also mostly of squamous-cell type, arising by direct spread from cervical cancer. Secondary adenocarcinoma is usually meta- stastic from cancer of the corpus. In both of the cases here reported the tumor occupied the mid-posterior wall of the vagina and was readily detached digitally. In the first case 70 mg. of radium were inserted, rolled in gauze, for twenty-four hours, and the vagina remained clear, but a year later the tumor had recurred. It was again easily removed, 150 mg. radium were applied for forty-eight hours, and at the time of reporting (twenty months after the patient was first seen) there was no recurrence. In the second case the radium dosage was 88 mg. for thirty hours; at the time of reporting (only four months afterwards), a puckered scar was seen, with no bleeding or sign of recurrence. The author discusses the pathogenesis of the lesion, and points out that in his two cases the tumor occupied the midline, away from the lateral positioy of 754 ABSTRACTS wolffian remnants. He suggests that the seat of origin was most likely in aberrant or heterotopic cervical glands which had become incorporated with the surrounding vaginal epithelium. He points out that the clinical course of vaginal carcinoma is usually rapid, the thinness of the vaginal wall allowing early extension to the rectum and bladder, so that radical operation is in a large proportion of cases out of the question. The general expectation of life has been estimated at about eighteen months. [The two papers cited are almost identical, though published in different journals; each contains two illustrations-in the first paper line diagrams showing the site of the tumor, in the second paper photomicrographs, a difference hardly justifying multiple publication.] F. CAVERS

Tumor of Vagina in a Child; Papilloma or Sarcoma, TAVERNIERAND POUZET. Tumeur du vagin de l’enfant; papillome ou sarcome, Bull. SOC.franp. de dermat. et syph. 39: 833-836, 1932. A girl of three had lower abdominal pain and loss of appetite. A vaginal tumor was noticed one month later, which was larger in the mornings and when the child was in the erect position. This was removed, but no pathological study was made. Three months later a recurrence, similar to a bunch of grapes, was removed with part of the vaginal wall. Histologically it showed no signs of malignancy, only hyperplasia of the mucous membrane with edema, ulceration, and granulation tissue. Five months later there wa8 a second similar recurrence. No nodes were involved. The general condition of the child was good. Pus was present in the vagina behind the tumor. The authors planned wide removal by electrocoagulation and a search for Spirilla such as are found in intestinal polyposis. JEANNETTEMUNRO

THE GENITO-URINARY TRACT Carcinoma of the Kidney: Degree of Malignancy in Relation to Factors Bearing on Prognosis, J. R. HANDAND A. C. BRODERB.J. Urol. 28: 199-216, 1932. The authors review 193 cases of carcinoma of the renal cortex seen at the Mayo Clinic from 1901 to 1927 inclusive. The grade of malignancy was studied in relation to the age of the patient, the gross characteristics of the tumor, treatment, metastasis, and recurrence. Eight structural types of carcinoma of the renal cortex are defined, as follows: adenocarcinoma, papillary carcinoma, the clear-celled carcinoma, carcinoma solidum, squamous-cell carcinoma, neuroblastoma, and lymphosarcoma. The authors state: “ The gross pathologic character of a renal carcinoma is dependent primarily on the degree of malignancy. . . .” This statement rather reverses the general conception. With regard to the prognosis of renal carcinoma, the authors found the disease slightly more malignant under the age of forty. Sex had no influence on the prognosis. Twenty-three per cent of the patients in the series reviewed survived five years or more. R. S. PERGUSON Carcinomas of the Kidney, E. BAZTERRICA.Epiteliomas del ri66n, Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 762-773, 1932. This is an interesting comparison of renal papillary carcinoma and adenocarcinoma with clear cells by means of a single case report of each type. The first patient, demonstrating papillary carcinoma, was a woman thirty-four years old with a history of hematuria of twenty days’ duration and pain in thelumbar region while walking. She had slight anemia, no pyuria, about 50 per cent less function in the involved kidney, and a tumor the she of an orange. The second patient, THE GENITO-URINARY TRACT 755 with an adenocarcinoma with clear cells, was a woman twenty-seven years old with a ten months’ history of anorexia, intermittent fever, rather constant pain in the lumbar region, and loss of about 8 pounds in weight. She had marked anemia but no pyuria or hematuria. There was no elimination of indigocarmine from the involved kidney. The tumor was the size of a child’s head. At the time of the report the first patient had been alive without recurrence for eleven months and the second one for six months. The article contains a good discussion of the cases, a fair bibliography, and a photomicrograph of each lesion. JOHNE. WIRTH

Malignancy of the Kidney, A. G. LEE. Tri-State M. J. 4: 969-970, 1932. The author attempts a general discussion of “ malignancy of the kidney,” which is quite without value. R. 5. FERQUSON

Papillary Tumors of the Kidney, M. B. WEBSONAND W. P. STOWE. Urol. & Cutan. Rev. 36: 627-631, 1932. The authors report two cases. In the first, occurring in a man of sixty-one years, a papillary adenocarcinoma of the renal cortex was found. In the second case a papillary tumor arose in the left renal pelvis in a man of fifty-seven. Both patients were treated by nephrectomy. The first recovered, although a tumor thrombus was found in a renal vein. The second patient succumbed one month after operation. R. S. FERQUSON

Squamous Carcinoma of the Kidney, P. ROSENSTEIN.Uber ein Plattenepithel- karzinom der Niere, Ztschr. f. Urol. 27: 90-94, 1933. The author estimates that squamous carcinoma arising from the renal pelvis constitutes but 2 per cent of all kidney tumors. A woman, thirty-nine years of age, had a large tumor in the right flank. Radiographic and cystoscopic studies revealed the presence of a partially calcified mass occupying the right kidney. A diagnosis of renal tuberculosis was made and nephrectomy undertaken. On section the tumor proved to be a squamous carcinoma, originating in the renal pelvis. At autopsy, three days later, a tumor thrombus was found extending into the vena cava for a distance of 4 cm. There were also metastases to the adjacent lymph nodes. R. S. FERQUSON Case of Melano-epithelioma of the Kidney, L. COBELLIB. Su di un caso di melanoepitelioma del rene, Riforma med. 48: 352-355, 1932. This is a brief histologic description of a tumor of the kidney, a “dendritic epithelioma ” which had almost entirely destroyed the renal parenchyma. The tumor contained a great deal of melanotic pigment. The author indulges in a lengthy discussion of the theories which would account for the development of a primary melanoma of the kidney. He believes that his case is the first instance to be recorded of a primary melanoma in the kidney. Three poor photomicrographs are included. [Since Cobellis tells us nothing about the patient from which this kidney was removed, his claim that the melanoma was primary in the kidney cannot be allowed. Only a complete autopsy report, or at least a meticulous examination of the skin and eyes, would convince us that a tumor of this type was not metastatic.) C. D. HAAGENSEN Contribution to the Study of Renal Tumors, J. P~EZRfos. Contribuci6n a1 estudio de 10s tumores renales, Rev. espafl. cir. y urol. 14: 211-217, 1932. A male fifty-two years of age with intermittent hematuria for six months gave radiographic evidence of a renal tumor. A nephrectomy was performed and a 756 ABSTRACTS kidney of normal size and shape was removed. On section a tumor, some 3 to 4 cm. in diameter, was found involving part of the oortex of the kidney but not involving any part of the medulla, so that it had given no symptoms of compression, A flat stone, 1 cm. in diameter and 1 mm. thick, which had not been seen radiographically, was found in one of the lower calices. The microscopic diagnosis was carcinoma. JOHNE. WIRTH

Malignant Nephroma (Hypernephroma), B. A. GINQOLDAND D. H. RE~ESEN. M. J. & Rec. 136: 283-285, 1932. A brief report dealing with four cases of hypernephroma in which there were no unusual features. R. S. FERQUSON

Hypernephroma of Kidney and Carcinoma of Stomach Obscured by Metastases, W. C. CURPHEY.J. Kansas M. SOC.33: 451-453, 1932. Curphey describes the autopsy findings in a man fifty-six years of age who died two weeks after admission to the hospital. No diagnosis of the primary tumor had been made due to the presence of multiple metastatic masses in the liver. At autopsy, in addition to the liver metmtases, a hypernephroma primary in the lower pole of the left kidney was found. There were also metastases in the lungs from this tumor, and a second small primary carcinoma in the stomach. R. S. FERGUSON

Liposarcoma of the Fatty Capsule of the Kidney, H. K~HLER.Ein Lipo-Sarkom der Nierenfettkapsel, Ztschr. f. Urol. 27: 95-98, 1933. A woman, aged fifty-one, had complained for twenty years of indefinite gastric symptoms. Four years previously hysterectomy had been done for fibromyoma of the uterus. On admission a large tumor was found in the left epigastrium. Although there were no urinary symptoms and no hematuria, a renal tumor was suspected. Pyelographic study confirmed the diagnosis. At operation a tumor 12 cm. in diameter was found overlying the upper pole of the left kidney. The mass was well encapsulated, vascular, lobulated, and cystic. On section the tumor was found to infiltrate the upper pole of the left kidney. The microscopic diagnosis was liposarcoma. R. S. FERGUSON

Vious Tumor of the Left Renal Pelvis, N. HORTOLOMEIAND T. BURQHELE.Zur Kasuistik der ZottengeschwIllste des Nierenbeckens, Ztschr. f. Urol. 27: 87- 90, 1033. The authors briefly review the literature of papillary tumors of the renal pelvis and add a single case report. The patient was a man forty years of age who had complained of hematuria for three months. At operation a large papillary tumor of the renal pelvis was discovered. No implants were found in the ureter. R. S. FERQUSON Case of Ledtoplakin of the Ureter, G. KRAUCHER.Ein Fall von Leukoplakie des Ureters, Ztschr. f. Urol. 26: 273-277, 1932. The autopsy findings in a man forty-two years of age, who died of sepsis are reported. At autopsy the right kidney was contracted and filled with small cysts with a granular lining. The right renal artery was thrombosed and there was a small adenoma in the upper pole. The left kidney was occupied by many larger cysts containing cholesteatomas. The left ureter was blocked at the junction of its middle and lower third by a similar large concretion. The mucosa of the left ureter was the site of an extensive leukoplakia. R. S. FERQUSON THE OENITO-URINARY TRACT 757

Bladder Tumors in Anilin Workers, H. SCHULLER.Blasentumoren bei Anilin- arbeitern, Ztschr. f. Urol. 26: 284-286, 1932. The author reports two cases of bladder tumor arising in anilin workers, one aged thirty-eight and the other forty-two. In the former there was a twenty- three years’ occupational history followed by the development of an ulcerating squamous carcinoma in the vault of the bladder. The patient died shortly after resection. In the other case there was a twenty-eight years’ occupational history, and a single tumor of low grade was found in the bladder. The patient recovered. R. S. FERGUSON

Partial Resection of the Bladder for Squamous-Cell Carcinoma, E. CASTAROAND R. DE SURRA. Resecci6n parcial de vejiga por epitelioma espinocelular tfpico, Semana med. 2: 729-731, 1932. A man of thirty had, three days before admission, had painless hematuria, which had diminished in the interval but had not disappeared. Catheterization showed absence of urethral stricture, and rectal examination revealed a normal prostate. Cystoscopy showed a small cauliflower-like tumor on the left wall of the bladder, about 3 cm. from the left ureteral oritice. Electrocoagulation was done three times at intervals of a fortnight, but the tumor became larger. Cystot- omy was performed, and the involved portion of the bladder removed. Good recovery followed. On histologic examination the tumor proved to be a typical squamous-cell carcinoma with pearl formation. A rather poorly reproduced photomicrograph is given. F. CAVERS Presentation of a Case of Transplantation of the Ureters into the Rectum Because of Carcinoma of the Bladder, H. C. PITTS. New England J. M. 208: 427-430, 1933. This report is a transcript of a clinic presentation of a patient who had had a bilateral transplantation of the ureters because of inoperable carcinoma of the bladder. R. 5. FERQUSON

Preliminary Note on the Structure and Growth Mechanism of Papilloma of the Bladder, R. PASCHKISAND S. BR~~QEL.Beitrage zum Aufbau und Wachstums- mechanismus des Blasenpapilloms, Ztschr. f. urol. Chir. 36: 220-223, 1933. A few of the growth peculiarities of bladder papillomata are briefly discussed. A more extensive report based on the study of serial sections and reconstructed models is promised in the future. The authors state that they found evidence of newly formed inflammatory elements in the basement layers of the epithelial mucosa. They reason that this promotes the formation of new vessels and the overgrowth of the overlying epithelium. R. S. FERGUSON Treatment of Papilloma of the Bladder; Report of Cases, P. A. TREAHY.New Zealand M. J. 31: 328-333, 1932. The author offers a brief elementary discussion of the treatment of bladder papilloma by fulguration and illustrates his thesis with six brief case reports. R. S. FERGUSON

Neuro5bromatosis of the Bladder, I. H. KASS. Am. J. Dis. Child. 44: 1040-1047, 1932. Neurofibromatosis of the bladder occurring in a child of seven, who also suffered from a generalized von Recklinghausen’s disease, is described. The author reviews the six reported cases in the literature and finds his to be the first in a child. The patient died of scarlet fever subsequent to tonsillectomy and at autopsy the 35 ABSTRACTS entire bladder wall was found to be thickened from 2 to 4 cm. by the presence of multiple neurofibromas. No other part.of the genito-urinary tract was involved. A complete review of the literature is given and the report is well illustrated. R. 8. FERQUSON

Aspiration of a Bladder Tumor under Visual Control, a Hew Method of Treatment, 0. HENNIQAND J. LECENIR. Absaugung von Blasentumoren unter Sicht, ein neuea Behandlungsverfahren, Ztschr. f. Urol. 26: 55&561,1932. This material dupIicates that in Ztachr. f. urol. Chir. 34: 342, 1932 (Abat. in Am. J. Cancer 17: 271, 1933). R. S. FERQUSON

Treatment of Cancer of the Prostate, G. G. SMITH. New England J. Med. 208: 57-65, 1933. X-ray in carcinoma of the prostate is not curative and should be restricted to the relief of pain due to metastases. Also, the implantation of gold seeds of emanation has not been productive of good results. Of 29 patients treated only 6 are alive, although " large doses " were used, the maximum dose cited being 4100 millicurie hours. The author discusses the difficulties of accurate placement of this type of applicator in the prostate. For early operable cases total prostatectomy is advocated. Of 39 patients so treated, 21 are alive, but only 3 of these over five years. Two of the latter have recurrent disease. The author believes that progress in the treatment of cancer of the prostate will be limited to surgery. R. S. FERQUSON

How Can the Patient with Inoperable Cancer of the Proetate be Relieved? KIRSCHNER.Wie liisst sich das Schicksal der Kranken mit inoperablem Prostatakrebs erleichtern?, Ztschr. f. urol. Chir. 36: 191-194, 1933. The various means of relieving urinary obstruction and intractable pain due to cancer of the prostate are discussed. Permanent cystotomy is advised as the treatment of choice for urinary obstruction. For the rare case with rectal obstruction due to the local extension of the tumor, colostomy is advised. The pain due to metastasis from carcinoma of the prostate may be relieved by cordotomy or preferably by the author's methods. He advises the injection of 2 or 3 C.C. of 70 per cent alcohol with an equal amount of air into the subdural space in the lower lumbar area. The patient is then placed in the Trendelenburg position for twenty-four hours. The anesthesia to be derived from this injection is said to persist for one to three months and the measure can be repeated as often as necessary. [This procedure would be regarded as hazardous in this country.] The author states that, if the apiaal anesthesia cannot be given by the above method, alcohol injected in the caudal canal will produce a somewhat similar relief from pain, although more transient. R. 5. FEEQUSON

Carcinoma of the Proetate, B. H. HAQER. Urol. & Cutan. Rev. 36: 631-633,1932. A brief general discussion of carcinoma of the prostate. R. S. FERQUSON

Occult Carcinoma of the Prostate with a Single Giant MetaBtaSiS Adjoining the Bladder, EMU. Okkultea Proetatakareinom bei Rieeeneinselmetastase neben der Blase, Ztschr. f. Urol. 26: 301-304, 1932. A man sixty-four years of age succumbed shortly after the discovery of a large tumor lying between the bladder and the rectum just above the right lobe of the prostate. The mass was palpable, abdominally. The prostate itself did not appear to be involved, and a clinical diagnosis of cancer of the prostate could not SUPRARENAL TUMORS 759

be made. At autopsy, a small solid adenocarcinoma was found in the prostate, and the large single metastasis proved to have the same structure. R. S. FERQUSON

Variations in the Course of Malignant Tumors of the Kidney, Bladder, and Pros- tate, STUTZIN.Uber verschiedenartigen Verlauf der bbartigen Tumoren der Niere, Blase, und Prostata, Ztschr. f. Urol. 26: 650-654, 1932. This is a so-called popular lecture of a general nature for the layman. The author uses three case reports to illustrate his thepis on the wide variations in the natural progress of tumors of the genito-urinary tract. R. 5. FERQUSON Malignancy of the Testicle, with Report of Three Cases, J. F. BALCH. J. Indiana M. A. 25: 453454, 1932. Three cases of teratoma of the testicle are reported, including a large adult type of teratoid tumor in a nine-months-old infant. All of the patients were treated by simple orchidectomy. The second patient, fifty-one years of age, died of the disease two years after operation. The third patient, twenty-three years of age, is well eleven months after operation. R. 5. FERQUSON Unusual Case of Seminoma and Syphilis, E. SOSCIA.Su di un caso non frequente di epitelioma seminale e sifilide, Gior. ital. di dermat. e sif. 73: 1154-1163, 1932. A man of thirty-two had a hard tumor of the left testis. Orchidectomy was done, and histologic study of the testicle showed evidence of syphilis in addition to the seminoma, which had largely replaced the normal structure of the organ. Two photomicrographs are included which fail to present convincing evidence of the existence of the syphilis in the testicle. A short bibliography is included. C. D. HAAGENSEN

Fibroma of the Spermatic Cord, T. GIOIA. Fibroma puro del cord611 espermtitico, Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 676-681, 1932. An Italian thirty years old was lifting a wooden beam when he felt a sharp pain in the right inguinal region and noticed a small tumor mass believed to be a hernia. At operation a firm oval tumor the size of a large walnut was found closely applied to the elements of the cord. It was excised without damage to the cord. Micro- scopic and gross examination showed it to be a benign fibroma. A photograph, 2 photomicrographs, and a short review of the literature accompany the report. JOHNE. WIRTH Case of Lipoma of the Inguinal Canal Simulating a Direct Hernia, G.MUZZARELLI. Su di un caso di lipoms del canale inguinale simulante un’ernia diretta, Poli- clinic0 (sez. prat.) 39: 768-769, 1932. A case is reported of a man aged forty-six, in whom a round, elastic, reducible tumor of the inguinal canal proved at operation to be a lipoma. C. D. HAAQENSEN

SUPRARENAL TUMORS

Hypertension, Obesity, Virilism and Pseudohermaphroditism as Caused by Suprarenal Tumors, HOWARDL. CECIL. J. A. M. A. 100: 463-466, 1933. A woman thirty-one years of age complained of pain in the left side and weakness, loss of libido, amenorrhea, increased distribution of hair on the face, and shortness of breath. A tumor was readily palpated in the upper left quadrant of the abdomen. A diagnosis of cortical tumor of the adrenal was made and opera- 760 ABSTRAUTS tion undertaken. The tumor weighed 720 grams and on section proved to be an adenocarcinoma of the left adrenal cortex. Death occurred twelve hours after operation. At autopsy tumor emboli were found throughout both lungs. The tumor had also invaded the left renal vein and the vena cava. The opposite adrenal was atrophied. The literature on tumors of the adrenal cortex is briefly reviewed. R. S. FERQUSON

Case of Adrenal Newoblastoma, J. SMITH. Lancet 2: 1214-1215, 1932. A male infant of seventeen months was brought to the hospital because of anorexia, diarrhea, and loss of weight. Examination showed emaciation, a brownish pigmentation of the skin, and a number of scattered subcutaneous nodules over the trunk and extremities. While thc child was under observation a rather remarkable growth of downy hair occurred over the trunk and face. Biopsy of a subcutaneous nodule proved the growth to be a neuroma, “ containing ganglion cells in addition to numerous nerve bundles.” A subsequent necropsy revealed a tumor of the right suprarenal gland, a “ medullary neuroblastoma,” and metastases in the pancreas, subcutaneous tissue, and lymph nodes. EDWINM. DEERY THE NERVOUS SYSTEM Diagnosis of Tumors of the Central Nervous System, J. S. LASTRA. Diagn6stico de 10s tumores del sistema nervioso central, Bol. Liga contra el cSncer 7: 302-308, 1932. The cranium is a rigid structure without the ability to accomodate itself to a new growth for long. Nevertheless, a tumor starting in a dent area may grow steadily and cause a great deal of damage, as well as a marked increase in intracranial pressure, before its definite recognition is possible. Roentgenograms have proved a valuable aid in the diagnosis of intracranial tumors. Tumors in the region of the sella often cause characteristic changes in the bony outlines of that structure, making a diagnosis possible. If a brain tumor is partially calcified, the shadow cast in the roentgenograms may lead to a definite localization. Ven- triculography and arteriography have made localization possible in many otherwise obscure cues. The technic of intracranial surgery has advanced greatly in recent years. This has been accomplished in part by improved methods of hemostasis, chiefly the use of muscle and the electrocautery. Roentgen and radium therapy are giving good results when used in conjunction with surgery. The diagnosis of spinal cord tumors is in general a less difficult problem than that presented by brain tumors. Any suspicion of a spinal tumor should lead to an examination of motor power, reflexes, and superficial and deep sensibilities. A spinal manometric test will usually establish or eliminate the presence of cerebrospinal fluid block. Roentgenograms of the spinal column often give valuable information. Lipiodol may be injected into the spinal subarachnoid space to demonstrate obstruction by a tumor. EDWINM. DEERY

Remarks on the Diagnosis of Intracranial Tumors, ANDRETHOMAS. Quelques remarques sur le diagnostic dcs tumeurs c6r6brales, Gas. d. h8p. 105: 1685-1688, 1932. Neurological diagnosis and diagnostic methods as well as the technic of intracranial surgery have advanced a great deal in recent years. Contributions of importance have come from ophthalmologists and a routine neurological examination now includes a thorough investigation of the eye. The symptoms and signs associated with a brain tumor are based upon several possible factors other than THE NERVOUS SYSTEM 761 the actual tumor. There may be a decrease or increase in circulation to a considerable area; there may be extensive degenerative, necrotic or hemorrhagic changes in the brain, and the secretion and absorption of the cerebrospinal fluid may be greatly altered. Certain areas of the brain are relatively silent, and in such areas a tumor may grow to considerable proportions before discovery. Tumors of the brain generally produce two distinct sets of symptoms: those due to a general increase in intracranial pressure and those of a local nature. Symptoms and signs dependent upon an increase in the general intracranial pressure include headache, vomiting, and papilledema. Local symptoms vary greatly and are in general due to irritation or paralysis of some cerebral function. A lowered excitability of the vestibular mechanism is suggestive of an acoustic nerve tumor. Mental symptoms are most prominent when a tumor involves the frontal lobes or the corpus callosum. Patients with a cerebellar tumor may show a characteristic position of the head. Visual hallucinations are common with either occipital or temporal lobe lesions. While the macrogenital syndrome is associated with pineal tumors, many patients with a new growth in this region are without these somatic changes. Lesions about or causing distention of the third ventricle may produce a variety of autonomic disturbances. Roentgenography of the skull now forms an important addition to diagnostic procedures. It may be possible thus to localize a lesion in the sella turcica by changes in its bony outline. Other tumors may cause asatrophy or hyperplasia of bone (meningiomas), and still others may show shadows of calcification, thus making a localization possible. When all other methods fail to localize an intracranial lesion, recourse may be had to air studies. Encephalography consists in introducing air into the subarachnoid and ventricular spaces by way of a needle in the lumbar region. Ventriculography or the introduction of air directly into the lateral ventricles by way of brain punctures provides still another diagnostic measure. Likewise arteriography or the injection of a solution opaque to x-rays into the carotid artery may visualize a tumor by demonstrating abnormal vessel topography. [In this connection see review of Egas Moniz’ work on arterial encephalography in Am. J. Cancer 16: 1531, 1932.1 The determination or estimation of the type of tumor preoperatively is becom- ing possible with a fair degree of accuracy, and often proves of great value in planning the surgical treatment. Various syndromes have now been clearly defined which make it possible to predict the nature of the tumor, as pituitary adenoma, fourth ventricle medulloblastoma, the acoustic neuroma, the cranio- buccal pouch cyst, etc. Biopsy of infiltrating tumors is very important. These lesions are often unsuited to complete surgical extirpation and a knowledge of the pathological nature of the neoplasm serves as a guide to roentgen therapy. EDWINM. DEERY Brief Considerations on the Diagnosis of Brain Tumor, B. DAVILA.Breves consideraciones sobre el diagn6stico del tumor cerebral, Bol. Asoc. m6d. de Puerto Rico 25: 53-57, 1933. Brief remarks upon the clinical diagnosis of intracfanial tumors in general. Brain tumors may cause focal, sharply localized signs and symptoms, or may manifest themselves by a syndrome of generalized increased intracranial pressure. Usually symptoms of both types are present, and localization demands a knowledge of cerebral function. Of the general symptoms of brain tumor, headache, vomiting, vertigo, papilledema, mental changes, and convulsions are the commonest. Bradycardia, subnormal temperature, glycosuria, and obesity are sometimes found. To illustrate focal symptomatology two cases are presented, one a cerebellopontine angle neurinoma, the other a midline cerebellar medulloblastoma. EDWINM. DEERY 762 ABSTRAOTS

Frequency with which Tumors in Various Parte of the Brain Produce Certain Symptoms, F. A. GIBBS. Arch. Neurol. & Psychiat. 28: 969-989, 1932. The usual method of investigating the relation of symptoms to position of the tumor is to select for study only those patients with the tumor in a given area. Analysis of such a series yields only information as to what symptoms are produced and their frequency in regard to the particular area studied. It gives no idea of the frequency with which these symptoms occur with tumors in other parts of the brain. The fundamental question as to the relative effectiveness of variously located tumors in producing a given symptom can be answered only by analysis of a random series of aufficient size to contain a large number of cases of tumor located in each area considered, and of sufficient size to contain a large number of cases with each symptom considered. The data presented was obtained from a study of 1,545 verified cases of tumor of the brain (1340 from Dr. Cushing's service at the Peter Bent Brighsm Hospital and 205 cases from the Johns Hopkins department of pathology). Aphasia occurred most often with left temporal lobe tumor. Focal convulsions were most frequent among cases in which the tumor involved the parietal lobe; generalized convulsions, with tumor of the left temporal lobe. Tumors of the left lenticular nucleus caused a resting tremor of the arms or legs more often than others. Involvement of the left thalamus by neoplasm caused olfactory hallucinations. Gustatory hallucinations were oftenest found with tumor of the left caudate or lenticular nucleus. Visual hallucinations occurred most frequently with tumors of the right thalamus. Irritability or ill humor occurred oftenest among cases in which the tumor involved both caudate or both lenticular nuclei. Jocularity occurred with tumors of the left thalamus. Difficulty in micturating was found most frequently with tumors involving the caudate or lenticular nuclei; urinary incontinence, with tumors of the left caudate or left lenticular nucleus; projectile vomiting with tu'mors of the right lenticular nucleus; drowsiness among cases of pineal region tumor; amenorrhea and anaphrodisia with tumors of the hypophysis or pineal ; sexual hypoplasia with suprahypophyseal region tumors. Acromegaly occurred only when the tumor involved the hypophysis. Polydipsia was present with suprahypophyseal region tumors; craving for sweets with tumors of the left thalamus; rapid gain in weight with tumors of the right thalamus; impairment of hearing, nystagmus, and a positive Romberg sign with cerebellopontile angle tumors; high-grade choked disk with tumors of the fourth ventricle; hemorrhage in the optic nerve head or retina with tumors of the thalamus; dilated veins of the eyelids with tumors of the left thalamus; exophthalmos with tumor of the temporal lobe. These results are compared with the classical teachings upon the cause of various symptoms or signs and the discrepancies noted. In conclusion the writer states that: 1. Generalized convulsions are not most readily produced by tumors that compress the occipital lobe. 2. Visual hallucinations are not most readily produced by tumors that compress the motor cortex. 3. The frequency with which tumors of the midbrain and the pineal region give symptoms usually associated with a lesion in the floor of the third ventricle is not satisfactorily explained by assuming that such tumors injure the floor of the third ventricle by producing an internal hydrocephalus. 4. Projectile vomiting is not a general pressure symptom. 5. Tumors that block the ventricular system are not markedly superior to all others in producing high grade choked disk. 6. Other symptoms beside aphasia are produced more readily, though to a less marked degree, by tumors on one side than on the other. THE NERVOUS SYSTEM 763

[If an intracranial tumor irritated or paralyzed a single group of nerve cells responsible for a single function the correlation of clinical symptoms with tumor location would be simple. An intracranial tumor, however, may interfere with remote I‘ centers ” by circulatory or pressure factors, either general or local. It may also interfere with conduction pathways between remote points. Such studies as the present one illustrate the complexity of the problem.] EDWINM. DEERY

Disorders of Optic Nystagmus due to Cerebral Tumors, J. C. Fox, JR. Arch. Neurol. & Psychiat. 28: 1007-1029, 1932. The possibility of exploiting optic nystagmus as an aid in cerebral localization depends on the fact that in certain cerebral lesions optic nystagmus may be present to one direction of movement of visual objects, but absent or defective in the other direction. The present study is based upon detailed observations in 12 cases of verified tumors variously situated in the cerebral hemisphere. In three patients with parieto-occipital lesions there was found a disturbance of optic nystagmus when the visual objects were moving in a direction toward the side of the lesion. One patient with a tumor situated in the right temporoparietal region had a complete absence of pursuit when the objects were moving from left to right, or towards the side of the lesion. A second patient with an abscess in the left temporo- sphenoidal region showed disturbed optic nystagmus to both directions, but the pursuit pattern was more defective when the objects were moving toward the side of the lesion. In two cases of parietal or frontoparietal lesions it was found that optic nystagmus was not disturbed. In both of these cases, however, the pathologic process was confined chiefly to the surface of the brain. In two of five cases of frontal lesions optic nystagmus was disturbed when the visual objects were moving in a direction towards the side of the lesion. With one exception, in all cases in which optic nystagmus was unaffected the lesions were situated in the anterior part of the brain in the frontal or parietal regions. On the other hand, with two exceptions, all the lesions that did disturb optio nystagmus were located in the posterior part of the hemisphere in the temporal and parieto-occipital region behind the supramarginal gyrw. The intermediate region is not represented by positive cases. There follows a series of discussions on (a) the primary importance of the optomotor system or corticofugal pathway of the optic radiation, (b) the secondary r61e played by the conjugate eye movement centers in the frontal lobe, and (c) the probable existence of a transcortical pathway connecting the occipital and frontal centers. Disorders of optic nystagmus cannot be explained solely on the basis of im- perfect recognition of visual objects emerging from the contralateral, inattentive, or blind fields. Interruption of the corticofugal system or optomotor pathway at any point in its course disturbs the ocular response to a certain direction of movement of the visual field, i.e. toward the side of the lesion. A defect in this corticofugal system is the primary cause for a disturbance of optic nystagmus regardless of whether the neighboring corticipetal system or sensory visual radiation is also involved by the lesion. The volitional eye movement centers in the frontal lobe obviously play a secondary r61e in the mechanism underlying optic nystagmus. The writer believes that in such studies some form of graphic recording device is essential. The “ nystagmograph ” used in this study employs the principle of photographing the horizontal deviations of the conjugately moving closed eye. EDWINM. DEERY 764 ABSTRACT0

Ocular Signs of Intracranial Hypertension, L. DUPIJY-DUTEMPS.Signes oculaires de l’hypertension intracranienne, Gas. d. h8p. 105: 1694-1696, 1932. The characteristic appearance of papilledema caused by an increase in intracranial pressure includes dilatation of the retinal veins, and edema of the nerve head and adjacent retina, forming a measurable elevation. The arteries may be partly hidden by the edema and there may be many small hemorrhages in the region of the optic nerve head. In contrast to a true inflammation of the optic nerve, the visual acuity may remain relatively good for many months, although occasionally vision may fail rapidly. With papilledema of long standing there comes a progressive concentric contraction of the visual field. There also follows an optic atrophy. Papilledema, while characteristic of brain neoplasm, is by no means a specific sign, as it also occurs at times with syphilis, meningitis, meningeal hemorrhages, tuberculosis, and Cysticercus disease. It must be recalled that the optic nerve is surrounded by an extension of the meninges, to as far as the entrance of the nerve into the posterior surface of the eyeball. Between the nerve and its meningeal sheath is a freely circulating cerebrospinal fluid. An increase of intracranial pressure acts not only upon this fluid but secondarily interferes with the venous return from the retina. The temporary losses of vision (first described by Jackson) which not infrequently occur in patients with papilledema are to be explained by the variations in pressure in the cerebrospinal and vascular factors involved. EDWINM. DEERY

Blood Pressure Observations in Tumors of the Brain, A. A. WILSON. Arch. Neurol. & Psychiat. 28: 891-895, 1932. To substantiate an impression that patients with brain tumor tend to show a blood pressure that is lower than usual, the writer studied 100 cases of verified intracranial tumors from this point of view. The cases were taken consecutively, the only patients excluded from the study being those with pituitary tumors and those under twenty years of age. Pituitary tumors are usually accompanied by an altered basal metabolism, which might influence the blood pressure. Blood pressure tends to become more “ established I’ after the age of twenty years, and therefore patients below this age were excluded. However, even if the cases in this younger group were included, the blood pressure averages for the series analyzed would not be raised. Search through the literature reveals little consideration of the relation between intracranial tension and general arterial pressure. In the group studied, some of the lowest blood pressures were found in patients without papilledema. Of the 100 patients, 68, all of whom were more than twenty years of age, had a systolic pressure below the I‘ American standard for the age of twenty. Seven patients in the series had a definite high blood pressure, but all these showed evidence of cardiovascular renal disease. A study of the 100 patients appears to justify the opinion that an elevation of blood pressure above normal is infrequent in uncomplicated tumor of the brain. If the blood pressure is elevated above the normal in such cases it is usually due to an accompanying disease. EDWINM. DEERY

Brain Tumor and Hyperthennia, V. DIMITRIAND L. VELASCOBLANCO. Tumor cerebral e hipertermia, Arch. am. de med. 8: 58-69, 1932. The clinical history of a girl of eight years is given in some detail. The family history was normal and the child had been in good health up to one month before being studied. She had sharp pains in both shoulders and the neck, an elevated temperature, severe headaches, diplopia, vomiting, and progressively increasing somnolence. She also became increasingly ataxic. Examination revealed evidence of incoordination and a pronounced tendency to retropulsion. There THE NERVOUS SYSTEM 765

was also evidence of a marked increase in intracranial pressure. After a two months period, during which time she continued to show an elevated temperature, she succumbed and a necropsy was performed. An extensive '' gliosarcoma " involving the thalamic region of both sides was found. Its major extension was on the right side. The downward extent of the lesion included the hypothalamic area and the posterior part of the diencephalon. The tumor extended into the mesencephalon and as far posterior as the pons. The case is reported as one which provides both clinical and anatomical proof of the location of the heat-regulating centers. There follows a general discussion of the mechanism of heat regulation reflecting the accepted facts. [A case to show the location of the heat regulation centers along the midline of the brain. Practically, however, intracranial tumors situated in areas very remote from this region are sometimes associated with disorders of temperature. The problems of " central " or ('neurogenic " temperature disturbance are still largely unexplained.] EDWINM. DEERY

Tumors of the Third Ventricle, 5.5. ALLENAND H. W. LOVELL. Arch. Neurol. & Psychiat. 28: 990-1006, 1932. Tumors primarily located in the third ventricle are rather rarely encountered, when the relative frequency with which other parts of the brain are involved by neoplastic diseases is considered. Tumors of the posterior part of the third ventricle often produce little if any clinical evidence of their existence. A series of eight cases is given in some detail. In only one case was a tumor of the third ventricle suspected from the clinical findings alone. In one case the not infrequent error of localizing the tumor in the cerebellum was made. In this series there were three cases of ependymoma, one of astrocytoma, one of 8pongiob~astomaunipolare, one of cysticercus, and two tumors of the pineal body. Of tumors affecting the posterior part of the third ventricle, those arising from the pineal body are the most common. Tumors arising in this region produce no characteristic symptoms or localizing signs. Those that are found depend on two distinct factors: (a) the production of generalized increase in intracranial pressure by obstruction of the aqueduct of Sylvius and (b) involvement of structures adjacent to the ventricle. The constant symptoms are those due to increased intracranial pressure, but these offer no aid in localization. They include headache, drowsiness, a progressive failure of vision, and vomiting. The most commonly noted findings are papilledema, increased intracranial pressure, hypersomnia, disturbances of pupillary reactions, extra-ocular palsies, vegetative dyscrasias, and precocious sexual development. Cerebellar symptoms are often confusing. Sudden death is frequent. The diagnostic value of pupillary inequalities and pupillary reaction is often questionable, as the degree of optic atrophy present and not a lesion of the third nerve may well account for the loss of reaction. Of the extraocular palsies, conjugate paralysis of the eye movements may be regarded as diagnostic in tumors of this type. Paralysis of associated upward movement is probably the most significant of all the neurologic signs. Such a paralysis undoubtedly results from the involvement of the mid-brain in the region of the aqueduct of Sylvius, either by direct extension of the tumor into the brain or by pressure. Ventricu- lography is often necessary for a correct diagnosis. EDWINM. DEERY Symptoms of Tumors of the Third Ventricle and Infundibulum, J. LHERYITTE. Symptomes des tumeurs du 111" ventricule et de l'infundibulum. Gas. d. h6p. 105: 1688-1694, 1932. Thanks to the modern clinicaI and pathological studies of new growths in the region of the third ventricle and infundibulum, it now becomes possible to recognize ABSTBAOTEI these hitherto very difficult lesions. They lend themselves to a satisfactory surgical approach and in many cases can be completely removed. [They are sometimes benign epidermoid cystic tumors, which, when the fluid content is evacuated, permit of a complete removal. No more satisfactory operation can well be imagined.] The signs of general increase of intracranial pressure are usually prominent and are due largely to the obstructive hydrocephalus. They may include multiple cranial nerve palsies, particularly of the third, fourth, and seventh pairs. There are also papilledema, headache, and often convulsive attacks. Among the direct pressure signs commonly found are bitemporal hemianopsia, a progressive hemi- plegia or paraplegia, cerebellar ataxia, or some suggestion of parkinsonism. Vege- tative nervous system symptoms include polyuria, glycosuria, hyperthermia, and vasomotor disorders such as flushing or increased sweating. The male patient with a tumor of this region may show evidence of endocrine imbalance, displayed as a tendency to sexual hypoplasia and feminine body characteristics. Female patients tend to have amenorrhea and obesity. The macrogenital syndrome associated with tumors of this region is very apt to occur when the tumor begine before puberty. Hypersomnia, commonly shown by patients with a third ventricle tumor, may occur as a continuous state or may be paroxysmal. In contrast to a true stupor, it may be broken by appropriate stimulation. There may be other psycho-sensory symptoms, including confusion, disorientation, hallucinations, or narcolepsy. In childhood we may expect to find a combination of hydrocephalus, infantilism, difficulty in hearing, oculomotor palsies, papilledema, bitemporal hemianopsia, polyuria, and either narcolepsy or hypersomnia. In adults the signs and symptoms are less definite or constant. The more usual findings include hypersomnia, polyuria, ocular palsies, and temporal field defects. In the study of such a patient, encephalitis and syphilis must be considered in the differential diagnosis. They are to be excluded by the findings in the cerebrospinal fluid. Craniopharyn- geal-pouch tumors usually reveal themselves by suprasellar calcification. If all other methods fail in establishing a definite diagnosis, air studies of the ventricles will usually solve the problem. EDWINM. DEERY

Tumour of the Hypothalamus, W. VICKERSAND F. TIDSWELL.M. J. Australia 2: 116-1 17, 1932. A boy of eight years showed the sexual development of a youth of about eighteen; according to the mother, the external genitals were large at birth. The boy was mentally deficient, and his condition had been previously diagnosed as endocrine dysfunction, presumably hypophyseal. There were, however, no general growth disturbances, no signs of acromegaly, no modifications of carbohydrate, fat, or water metabolism, and no radiographic evidence of intra- or suprasellar tumor. About two years later the boy was seen again, having had six to twelve epileptiform fits daily for a week and having been unconscious for two days. He died next day. The chief autopsy finding was a tumor, the size of a walnut, in the floor of the third ventricle, diagnosed histologically as an astrocytoma. The hypophysia was of normal size and histologic structure. There are three illustrations. F. CAVERS Roentgenographic Aspects of Meningiomas Lying in Both the Anterior and Middle Craninl Possae, L. STUHL. Aspects radiologiques de quelques meningiomes ‘I h cheval sur lee Btages antbrieur et moyen du crlne, Bull. et m6m. SOC.de radiol. m6d. de France 20: 546-547, 1932. Meningiomas arising from the dura along the base of the skull not infrequently oauae changes in the bone of the cranium beneath them which are recognizable in THE NERVOUS SYSTEM 767

roentgenograms of the skull. In the group of tumors arising from the region of the sphenoid, there are some which grow both forward and backward, thus lying in both the anterior and middle cranial fossae. "he bone underlying such a tumor may show enlargement of the vascular channels or may undergo a partial destruction, or there may be thickening and hyperplasia of the bone. Bone atrophy is probably a pressure effect; the hyperplasia is often due to actual invasion of the bone by tumor. Finally, meningiomas often are partially calcified, and such calcification may be evident in the roentgenogram. Thus the combination of a tumor shadow with changes in the underlying sphenoid wing make for the diagnosis of meningioma. EDWINM. DEERY

Changes in the Skull Bones Associated with Meningiomas, J. WIENBECK.Unter- suchungen tiber Schldelknochenveranderungen bei Meningeomen, Arch. f. klin. Chir. 174: 151-161, 1933. Wienbeck reports three cases of intracranial meningiomas in which he studied various portions of the skull bones histologically. The changes in all of the cases were the same. Histologic study of the macroscopically unchanged portion of the calvarium showed a slight increase in the space between the outer and inner tables and a marked congestion of the blood vessels and capillaries of the spongiosum. In the region o€ the hyperostosis of the skull associated with each of the meningiomas these changes were more marked and the space between the tables was filled with loose connective tissue. These changes were considered to be the result of congestion of the blood vessels associated with a low-grade infection. The article is well illustrated with a roentgenogram, photograph, and photomicrographs. BENJAMINR. SHORE

Generalized Epilepsy Caused by a Dural Cyst, V. MARADEVANAND T. B. MENON. Indian M. Gaz. 67: 681-682, 1932. That focal fits (Jacksonian epilepsy) can be caused by lesions in the brain is now generally recognized. More recently it has been realized that a focal lesion may sometimes produce generalized convulsive attacks, at times without localizing features of any sort. A case is reported of a " dural cyst l1 causing generalized epilepsy. A laborer of forty-five had sustained an injury to the right frontal region some twenty years previously. " Some years " after this injury generalized convulsive seisures began and continued at intervals thereafter. Roentgenograms of the skull demonstrated an old depressed fracture of the right frontal bone. At operation it was apparent that the fractured fragments of bone had torn through the dura, followed by bleeding. The resultant lesion was a cystic cavity formed by the dura and containing a thin brownish fluid. Following removal of thh traumatic cyst the patient made a good recovery and has had no further convulsive attacks. EDWINM. DEERY

Tumors of the Posterior Cranial Fossa, A. AUSTREQESILO,JR. Tumeurs de la fosse cranienne postkrieure, Rev. Bud.-am. de m6d. et de chir. 3: 959-966, 1932. Four case reports are presented, illustrative of cerebellar tumors. 1. A boy of nineteen years suffered from headache, vertigo, vomiting, and ataxia. Examination revealed a marked increase in intracranial pressure, signs of cerebellar incoordination, and bilateral pyramidal tract signs. At operation a large cystic " schwannoma " was found in the right cerebellopontile angle. 2. A woman of thirty years complained of right-sided deafness, vertigo, and headache. Upon examination she was found to have increased intracranial pressure, marked cerebellar signs on the right, and paralysis of the right fifth, sixth, seventh, and eighth cranial nerves. There were also evidence of pyramidal 768 ABSTRAOT8 tract dysfunction and a right exophthalmos. A ‘I transcerebral ventricular puncture and injection of lipiodol and air ” was carried out. At subsequent operation a right-sided acoustic nerve “ schwannoma l1 was found. 3. A woman of twenty-six years suffered from headache and vertigo. She showed increased intracranial pressure, bilateral signs of ataxia, and mild bilateral pyramidal tract signs. She died before operation and no necropsy was obtained. 4. A boy of fifteen years complained of unsteadiness, headaches, and vomiting. Upon examination he showed evidence of an expanding lesion of the cerebellum. He died following a suboccipital decompression. At necropsy a diffuse “ glioma ” of the pons and left cerebellar hemisphere was found. EDWINM. DEERY

Case of Cerebellar Tumor, A. GASBARRINIAND A. SPANIO. Sopra un caso di tumore cerebellare, Gior. med. d. Alto Adige 4: 313-345, 1932. This is a long discussion of the differential diagnosis in the case of a man aged twenty-five who had symptoms suggesting a .cerebellar tumor. Since the author was not confident’enough of his diagnosis to advise operation, the true nature of the lesion remains unproved. C. D. HAAOENBEN Cavernous Hemangioma of the Mesencephalon, J. A. PRINOLE.Med. Bull. Vet. Admin. 9: 181-183, 1932. The cavernous type of angioma is characterized by widely dilated blood vessels with thin connective-tissue septa. This type of angioma commonly develops from a congenital nevus and grows steadily over a period of years. The skin is the most frequent site of angiomas. Of the internal organs, the liver is most often involved. Cavernous angiomas of the brain are rare. They are somewhat more apt to occur in the meninges. A male of thirty-seven years died after one year’s illness, during which time he displayed a right oculomotor palsy, muscular weakness of the left side, delayed vibratory perception, greater on the left, a disturbance of taste, choreiform movements of the left side, and a slight bilateral tremor. At necropsy a cavernous hemangioma of the mid-brain was found. EDWINM. DEERY

Tumour of the Mid-Brain in a New Guinea Native, H. T. ILLINOWORTH.M. J. Australia 1 : 802-803, 1932. The patient, a man of about forty years, gave a history of increasing weakness of the left arm and leg, first noticed about six weeks prior to admission to the hospital. His general aspect suggested parkinsonism. Examination narrowed the differential diagnosis to cerebral malaria, frambesia, tuberculous meningitis, encephalitis lethargica, or cerebral tumor. Failure of antimalarial and anti- frambesial treatment and absence of tubercle bacilli in the cerebrospinal fluid left encephalitis and neoplasm as the only possibilities. The man died a few weeks later, and autopsy showed a mass in the posterior part of the optic thalamus, histologically a tuberculoma. There is one illustration. F. CAVERS

Tumor of the Motor Area of the Brain, B. RODRIOUEZAND J. Ju~cosa. Un caso de tumor de la zona motriz cerebral, Gac. med. espafl. 7: 221-222, 1933. A child five years of age had gradually developing aphasia and right pyramidal tract irritative symptoms. There was no evidence of an increase in intracranial pressure and no papilledema. Roentgenograms of the skull showed an abnormal shadow in the region of the left Rolandic area and, although no operation was done, the caBe is reported as a left cerebral tumor. The parents of the child had lost several children at birth, and the probabilities of congenital syphilis in this case are great. EDWINM. DEERY THE NERVOUS SYSTEM 769

Suprasellar Tumor. Operated, C. VINCENT,R. ONFRAYAND L. MATHE. Tumeur supra-sellaire ophrhe, Bull. SOC.d. opht. de Paris, pp. 472-481, October 1932. A woman of forty-three years had complained of failing vision for “ a long time.” More recently she had headaches. Upon neurologic examination she showed a marked euphoria, polyuria, a bitemporal hehianopsia, and optic atrophy. There were also anosmia on the right and a left facial palsy. The sella appeared normal in roentgenograms. A preoperative diagnosis of suprasellar meningioma was made. At operation a large meningioma under the right frontal lobe was found and removed. It is difficult to say whether its primary origin was in the olfactory groove or whether it was suprasellar. Following operation the patient’s mental condition promptly returned to normal, and the visual acuity and visual fields improved steadily. In the discussion following the presentation of this case some contended that in the presence of a tumor causing the (‘ chiasmal syndrome ” the patient should first be subjected to roentgen therapy, since it is well, if possible, to avoid a surgical operation of the magnitude required here, and, should the chiasmal tumor be a pituitary adenoma, it would be favorably influenced by roentgen therapy. Differential diagnosis, however, has progressed to the point where we can be reasonably certain whether or not we are dealing with a pituitary adenoma or some radio-resistant lesion. In this particular instance a definite diagnosis of meningi- oms, a radio-resistant tumor, was made and surgical measures were indicated. EDWINM. DEERY

Clinical Syndrome of Basophile Adenoma of the Hypophysis, G. P. GORALONS. El sindrome clinico del adenoma bas6filo de la hipbfisis, Prensa m6d. argent. 20: 502-503, 1933. A woman of thirty-six years showed the basophile adenoma of the hypophysie syndrome.” She had amenorrhea, a peculiarly distributed obesity, hypertrichosie, and a cyanotic facies. The blood pressure was high. A necropsy was obtained, and the findings are briefly mentioned. The hypophysis was “ of normal size.” [Since the recent presentation by Dr. Harvey Cushing of a series of cases of this condition (Bull. Johns Hopkins Hosp. 50: 137, 1932. Abst. in Am. J. Cancer 18: 504, 1933), the literature has contained many case reports, usually clinical, of the same condition.] EDWINM. DEERY

Basophilic Adenoma of the Pituitary (Pituitary Basophilism-Cushing Syndrome), R. C. MOEHLIO. J. A. M. A. 99: 1498-1500, 1932. A woman of forty-three years complained of nervousness, palpitation of the heart, spontaneous bleeding into various parts of the skin, flushing of the face, and joint pains. There was found a masculine facies, with a plethoric, livid appearance of the face and a well developed beard. The patient was over weight, with adi- posity largely confined to face, neck, and trunk. Hair of the scalp and eyebrows was thick, and the eyes were prominent. The heart was enlarged, and the blood pressure was high. The abdomen was distended and showed purplish striae. There were also hyperglycemia, polycythemia, leukocytosis, polyphagia, and poiydipsia. Following death from myocardial failure, necropsy, limited to the head, showed an enlarged pituitary. Microscopically there was a diffuse adenomatous hyperplasia including both the basophilic and the eosinophilic elements. In one area of the anterior lobe was a rapidly growing basophilic papillomatous neoplasm. EDWINM. DEERY 770 ABSTRAOTB

Tumor of the Peduncle of the Hypophysis, V. M. BUSCAINO.Tumore del pedun- colo ipofisario, Rassegna internas. di clin. e terap. 13: 207-222, 1932. This is a detailed clinical report of a case which, in the author’s opinion, p.re- sented the symptoms of a tumor of Rathke’s pouch. No pathological confirmation is presented. C. D. HAAQENSEN Case of Glycosuria, Simulating Cerebral Thrombosis : Postmortem Diagnosis, Brain Tumour, P. M. MACDONNELL.Canadian M. A. J. 29: 65-66, 1933. To the information given in the title of this report it may be added that the patient, a woman of fifty-three, died four days after admission to hospital. At autopsy, limited to the head and abdomen, there was found a soft tumor of the right frontal lobe, extending backwards so as to involve the anterior part of the internal capsule, measuring 6 X 4 X 3 cm., with cystic degeneration and a considerable area of hemorrhage into its substance. Histologically it corresponded to the spongioblastoma multiforme of Bailey and Cushing. Nothing abnormal was found in the pancreas and liver. F. CAVERS JuxtameduUary Tumors, V. CH~ISTXAN~EN.Autour des tumeurs juxtam6dul- lakes, Acts psychiat. et neurol. 7: 896-947, 1932. General remarks upon the clinical and surgical aspects of spinal cord tumors, based on a series of some 40 cases, and reflecting the aocepted facts. Many tumors reported in the literature as intradural growths probably have important relations with either the bony spinal canal on the one hand or with the spinal cord itself, which have been overlooked. The motor and sensory signs and symptoms produced by spinal tumors are discussed in some detail, and case histories in illustration of various points are included. The writer is in general opposed to “ occipital puncture ” as a diagnostic procedure and urges obtaining spinal fluid for exadnation, by a lumber puncture instead. In comparing the albumin content of spinal fluid taken from above and below tumors, it is apparent that an increase of albumin occurs only below the lesion. The use of lipiodol for the visualization of an obstruction is discussed; the writer favors its very restricted use. EDWINM. DEERY

Contribution to the Study of Extramedullary Spinal Tumors, E. JACARELLI. Contributo a110 studio dei tumori spinali extramedollari, Policlinico (ses. med.) 39: 139-152, 1932. A man aged forty-two had had pain in the right flank for a year. Because he had passed a few small calculi, a diagnosis of nephrolithiasis had been made. Neurological examination showed a classical Brown-SBquard syndrome. Spinal tap and the injection of an opaque medium showed a block at the level of the tenth dorsal vertebra. Operation revealed a dural endothelioma at this point. It was succesafully removed. Two roentgenogram and a drawing of the tumor in situ, as well as a brief bibliography, accompany the report. c. D. HAAQENBEN Blood Veseel Tumors of the Spinal Cord, P. C. BUCY. S. Clin. North America 12: 1323-1337, 1932. A patient of fifty-eight years had difficulty in walking, loss of sensation up to the level of the fifth thoracio segment, and low back pain. A spinal manometric test showed “ a complete block.” At operation an extradural cauernou8 hemangioma was found and removed. A patient of forty-eight years suffered intenee pain radiating down both legs, but showed no very convincing physical findings. Lipiodol injection gave evi- THE NERVOUS SYSTEM 771 dence of a tumor, and at operation a large, vascular growth intimately adherent to the roots of the cauda equina was found. Biopsy proved it to be an hemangio- endolhelioma. Since removal of the growth was not possible, roentgen therapy was given, with good results. A patient of thirty-one years had pain in the right leg and a progressive motor weakness of both lower extremities. There was found a sensory loss involving all sacral and lumbar segments. At operation a large pulsating cmgioma of the dorsal surface of the spinal cord was found. It was left untouched, and following roentgen therapy the patient has made a good recovery. No angiomatous lesion of the associated skin dermatomes was found in these patients. EDWINM. DEERY

Clinical Report of Cases of Spinal Carcinoma, M. LOUIBEHURRELL. Med. Woman’s J. 39: 153, 1932. Two of the 3 cases of spinal carcinoma briefly reported here were metastases following radical operations for carcinoma of the breast; in the third a nodule was discovered in the breast only a few weeks before death.

Case of Meningioma of the Spinal Cord, H. GARINAND M. J. COIIEN. South African M. J. 6: 404-406, 1932. In a man of forty-two, complaining of pain in the legs and difficulty in walking, the history and niurologic symptoms led to a diagnosis of either syringomyelia or spinal cord tumor. Ascending lipiodol showed block at the second dorsal segment, and at operation a small reddish tumor, diagnosed histologically as I‘ typical meningioma,” was removed from the left posterior side of the cord at this level. It was firmly adherent to the dura and had small bony spicules penetrating it. At the time of reporting, a year after operation, the patient was able to walk any distance.” F. CAVERS

Experimental Research regarding the Behavior of the Reticulo-endothelial System in the Hereditary Familial Syndrome of von Recklinghausen’s Disease, M. CIMMINO.Ricerche sperimentali sul comportamento del sistema reticolo- endoteliale nella sindrome di Recklinghausen a carattere eredo-familiare, Pediatria 40: 236-247, 1932. The physical findings are described in the cases of a mother and her five-year- old daughter, both of whom had von Recklinghausen’s disease. The mother had both pigmented spots and subcutaneous nodules, the daughter only the characteristic coffee spots. A nodule removed from the mother showed neurofibroma. Good clinical photographs of the patients are presented. Cimmino blocked the reticulo-endothelial system with injections of trypan blue in six rabbits. They were then given repeated intravenous injections of blood from the mother and daughter affected with neurofibromatosis. Nothing happened to the rabbits. C. D. HAAQENBEN Bilateral Tumors of the Acoustic Nerve in Newofibromatosis, J. HELBMOORTEL, JR., THIENPONTAND L. VAN BOGAERT.Tumeurs bilat6rales de I’acoustique dans la neuro-fibromatose, Ann. d’otolaryngol., pp. 815-819, July 1932. A woman of twenty-seven years was first operated upon for a tumor attached to the seventh cervical nerve on the right side. It proved to be a I‘ schwannoma.” After about two years a “ fibroglioma ” lying partly within and partly outside of the spinal dura was found when a laminectomy was performed. Within a year the patient returned with symptoms pointing to an increase of intracranial pressure. Roentgenograms of the skull showed a bilateral dilatation of the internal 772 ABSTRACTS auditory canal, and this finding is considered evidence for bilateral acoustic nerve tumors. Evidence of general neurofibromatosis was apparent in the routine physical examination. The patient’s family are being investigated for evidence of the disease in other members. EDWINM. DEERY

Case of Cutaneous Neuroflbromntosie, G. PEREZDfAz. Un caso de enfermedad de Recklinghausen. (Historia clinics), Arch. de med., cir. y especialid. 33: 1014-1017, 1932. A case is reported of multiple neurofibromatosis [biopsy not mentioned] involving the front and back of the trunk in a woman of fifty-one, who showed no other abnormal clinical finding except achlorhydria and mental apathy. She complained of severe epigastric pain after meals, of nausea, and of attacks of diarrhea. X-ray investigation of the digestive tract revealed nothing abnormal. There are three gross photograph of the skin lesions. F. CAVERS

Large Neurorna of the Seventh Cervical Nerve with Especial Considemtion of the Bone Changes. V. JURA. Uber ein grosses Neurinom des 7. Halsnerven mit besonderer Bemcksichtigung der Knochenverllnderungen, Arch. f. klin. Chir. 174: 341-348, 1933. Jura reports the case of a man forty-seven years of age who died following a laminectomy for a large neuroma of the left seventh cervical nerve. Study of the vertebral column at autopsy showed a marked widening of the intervertebral foramen between the sixth and seventh cervical vertebrae with considerable atrophy of the surrounding bone. Histologic study showed marked replacement of the osseous tissue by fibroblasts, and large numbers of osteoclasts lining How- ship’s lacunae. These changes were considered to be the result of pressure caused by a relatively slow growing neuroma or neurofibroma of the seventh cervical nerve. The article is illustrated with a photograph and roentgenogram. BENJAMINR. SHORB~

BONES, TENDON SHEATHS, AND MUSCLES

Tumors of the Pelvic Bones, C. B. FRANCISCO.J. A. M. A. 99: 1845-1849, 1932. Primary malignant tumors of the pelvic bones are always difficult to diagnose in the early stages, repeated x-ray examinations being necessary. The author reports 5 illustrative cases. In the first case the roentgenogram showed a typical metastatic carcinoma of the pelvic bones, which suggested metastasis from carcinoma of the prostate, although there was no clinical evidence of the latter. At autopsy, a small carcinoma of the prostate was found, and also bone metastases in the left femur nnd left 0s calcis, as well as in the pelvic bones. In the second case, the presence of a bony growth in the left ilium was shown by x-rays; the tumor mass gradually increased in size, but the patient’s general health remained good until nearly a year after the onset of symptoms. Death occurred a year and a half after the first appearance of symptoms, with metastases to the spinal cord resulting in complete paraplegia. This tumor, apparently a chondroma, proved to be an osteogenic sarcoma. In the third case, a tumor of the left ischium developed following an injury. The x-ray appearance suggested a chondroma. The tumor was removed, and the laboratory report showed it to be malignant, but whether a carcinoma (metastatic) or a sarcoma could not be definitely determined. The patient died from metastases to the abdominal organs, but no autopsy was permitted. BONES, TENDON SHEATHS, AND MUSCLES 773

In the fourth case a tumor mass was found in the right ilium after a thyroidec- tomy for an apparently malignant growth of the thyroid. By roentgen-ray treatment advance of the growth has been prevented and the patient kept in good condition, The fifth case was one of multiple osteochondroma of the pelvis with symptoms of long duration; one of the tumors is apparently undergoing malignant degeneration. The author is of the opinion that benign tumors of the pelvic bones occur relatively infrequently, and every tumor in this region should be considered as possibly malignant. If the tumor is a chondroma it should be radically resected as early as possible to prevent malignant degeneration.

Treatment of Sarcoma of the Long Bones, W. B. COLEY. Ann. Surg. 97: 434-460, 1933. Although extensive study and classification of bone sarcomas is useful, for practical purposes all the surgeon needs to know is (1) whether the tumor in question is a periosteal or a central sarcoma; (2) whether it is an osteogenic sarcoma or an endothelial myeloma; and (3) if a central sarcoma, whether it is a benign giant-cell tumor, a central malignant sarcoma, a multiple myeloma, or a metastatic carcinoma. All other histologic subdivisions are of little importance in deciding upon the method of treatment in a given case. A correct diagnosis can be made from the clinical and radiologic evidence alone in about 75 per cent of the cases, while in the remainder a correct diagnosis is impossible without histologic examination of the tumor. In Coley’s opinion the dangers and dis- advantages associated with a biopsy have been greatly over-emphasized. Of a total of 261 patients with malignant sarcomas of the long bones treated prior to November 1927, or five years ago, 54 (20.7 per cent) have remained well for five years or more. Twenty-two of the tumors were classified as endothelial myelomas, and 22 as osteogenic sarcomas. Coley’s toxins were used in 44 of these five-year recoveries. The limb was saved in 21 of the 54 cases. In all but 2 cases the diagnosis was confirmed by microscopic examination, and in these 2 there was a rapidly growing extensive tumor of the femur involving the upper half of the shaft. According to Coley, the cases reported in this paper comprise a series different from all others in two important points: (1) it includes a large number of inoperable, hopeless patients who have recovered under treatment and have remained well for more than five years, and (2) it contains a large number (19) of permanent recoveries that have taken place prior to 1913. The author’s only possible explanation of these results is that in the majority of cases Coley’s toxins, either alone or in conjunction with some other method, were used. The article is illustrated with roentgenograms and photomicrographs. BENJAMN R. SHORE

Mesenchymoma, W. KLEIN. J. M. SOC.New Jersey 29: 774-778, 1932. Under the term mesenchymoma, the author includes the so-called endothelio- myeloma of Ewing and other “ extremely primitive ” bone sarcomas, which are made up of more or less uniform cell types resembling undifferentiated mesenchyme, or at most differentiated only to the point of blood channel formation. Ewing’s tumor is the type tumor of this group. It usually occurs in young persons. The character of the x-ray picture varies according to the stage and location of the tumor. The author’s patient was a boy sixteen years of age, who complained of pain in the left ankle and difficulty in walking since spraining the ankle fourteen months previously. For five months the ankle had been swollen. X-ray examination 774 ABSTRAOTS showed three or four punched-out areas in the tarsal scaphoid near but not involving the joint. A diagnosis of sclerosing osteitie was made, and a cast applied. The pain became worse and two months later, when the cast was removed, the swelling had increased; x-ray examination at that time showed destruction in the distal half of the tarsal scaphoid and diatention of the joint space. Biopsy showed endothelial myeloma of Ewing. Under deep x-ray therapy, the symptoms were relieved for six months; in this period pneumonia developed, and x-ray examination of the chest showed pulmonary metastases. After convalescence from the pneumonia, the ankle again began to swell and x-ray therapy was resumed, the chest and lower part of the femur (where another area of metastasis was found) being treated as well. Symptoms were not relieved; pain in the head, especially at the base of the neck, and in the arm developed, and the patient died in a few months.

Osteogenic Sarcoma, R. E. D6NovaN. A prop6sito de ‘‘ Sarcoma osteoghico,” Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 519-523, 1932. Ddnovan presents the case of a girl eighteen years old with an osteogenic sarcoma apparently arising in the right ilium. The entire duration of the tumor was one year and eight months, during which time it grew from a small lump to a mass the size of a child’s head. It filled the pelvis and distended the soft parts of the medial aspect of the upper third of the right leg. No metastases werefound, at autopsy and it is evident that death was due to cachexia. Microscopic sections showed osteogenic sarcoma with areas of myxosarcoma. JOHNE. WIRTH

Chronic Purulent Osteomyelitis. Circumscribed Myositia Osslfieans. Bone Sarcomas, H. v. SEEMEN.Schleichende eitrige Osteomyelitis. Myositis ossificans circumscripta. Knochensarkom. (Zusammenhlinge und Abgrenz- ung), Deutsche Ztschr. f. Chir. 239: 160-183, 1933. The difficulty of the correct clinical diagnosis of various forms of chronic osteomyelitis and sarcomas without histologic study of biopsy specimens - is illustrated by several case histories. The author also reports one case of myositis ossificans following a known pyogenic infection. The article is illustrated by roentgenograms, photomicrographs, and a photograph of a gross specimen. BENJAMINR. SHORE

Central Chondrosarcomae of the Metaphysea, GULEKE.Uber die sentralen Chondrosarkome der Metaphysen, Arch. f. klin. Chir. 174: 401-416, 1933. Guleke records the histories of two patients with central chondrosarcomas of the head of the femur, and one of the upper portion of the humerus. The clinical history and course of the disease were essentially the same in all three cases. The progression of the disease was slow and the course extended over many years, but there was no evidence in any of the cases that the chondrosarcoma had developed on a previously existing benign chondroma. In fact, in one case this possibility was absolutely excluded, and in the other two it was considered highly improbable. A clinical history covering seven, eight, and fourteen years was given in the three cases. In the differential diagnosis of central chondrosarcomas the important lesions to consider are enchondromas and the more localized lesions of osteitb fibrosa. The treatment consists of early and complete radical excisions of the growths and even in advanced cases radical surgical removal may result in permanent local cures. In all cases where the tumors involve areas of bones adjacent to joints, complete and thorough excision of the joint capsule is necessary. The article is illustrated by excellent roentgenograms. BENJAMINR. SHORE BONES, TENDON SHEATHS, AND MUSCLES 775

Chondromyxosarcoma of the 0s Calcis, ERNSTA. POHLEAND WILLIAMD. STOVALL.Radiology 18: 1146-1148, 1932. Following a fall on the ice in January 1930, a twelve-year-old girl complained of pain in the left heel. After some months this increased in severity and the heel became slightly swollen. Roentgenograms taken in February 1931 showed a sharply circumscribed, circular, punched-out area about 1.5 cm. in diameter on the medial margin of the plantar surface of the 0s calcis and perforating the cortex. There seemed to be no bone atrophy but moderate sclerosis around the margin of the lesion. A tentative diagnosis of bone abscess or bone cyst was made. At operation the cavity seen in the roentgenogram was found to be filled with a pearly gray gelatinous material which had perforated the cortex but had not invaded the soft tissues. Microscopic diagnosis was chondromyxosarcoma. Deep x-ray therapy was instituted and was " of definite benefit in clearing up the local lesion." From March 5 to April 10, 1931, a total of 1,200 r (surface dose) was applied over the incision, using a, field of 6.5 X 6.5 sq. cm., 50 cm. F. 5. R., and an effective wavelength of 0.16 Angstrom unit. The child was still under observation at the time of the report, well and able to walk freely. Successive roentgenograms of the foot and a photomicrograph illustrate the report.

Roentgenologic Manifestations of Giant-cell Tumor, B. R. KIRKLINAND CLAUDE MOORE. Am. J. Roentgenol. 28: 145-150, 1932. The authors summarize their observations as follows: " In a series of 86 proved cases of giant-cell tumor two roentgenologic types of the growth have been encountered with approximately equal frequency. " The first variety has been accurately described by many observers. It is a central tumor, situated most often in the end of a long bone, and it exhibits trabeculae and expands the cortex but does not break through it. Other tumors of bone which may be confounded with this type of giant-cell tumor are enchondromas and cysts of bone. " In the second type of giant-cell tumor . . . trabeculation is conspicuously absent. The roentgenograms give evidence of homogeneous lysis of the affected area; the cortex is not only expanded but is dissolved wholly or in part, and the tumor projects into the soft tissues. In many cases, the irregularly destroyed cortex has the appearance of a thin layer of melting ice. This variety of giant-cell tumor might be mistaken for primary sarcoma or a massive metastatic growth. "Giant-cell tumor is not necessarily confined to the end of a long bone; exceptionally it may occur elsewhere in the shaft. Besides the long bones, the bones of the face, the vertebrae, the ribs and the tarsal bones are subject to the disease. " In this series, outstanding differences from other series reported were not observed in respect to age and sex of the patients or duration of the disease." Six roentgenograms illustrate this paper and a bibliography of ten references is appended.

Myeloplaxoma; End Result of Curettage of a Femoral Condyle, HAMANTAND CHALNOT. Tumeurs 8, mybloplaxes; rbsultat bloignb de 1'6videment d'un condyle f6mora1, Rev. mbd. de l'est. 60: 748-749, 1932. In one case a tumor showing the radiological appearance of a myeloplaxoma in the region of the condyle of the femur was removed with curettage of the cavity and subsequent immobiliaation. The results were excellent; the last examination showed complete obliteration of the cavity with the bone radiologically normal and no signs of recurrence [interval since operation not stated]. In a second case there had been repeated fractures in the upper part of the humerus; the radiological 776 ABSTRAOTS appearance suggested localized osteitis fibrocystica, but biopsy showed a veeoular tumor with numerous giant cells. As spontaneous fractures are rare in this type of tumor, the growth was apparently an atypical myeloplaxoma with some of the characteristics of localized osteitis fibrocystica. The patient refused operation.

Carcinoma of the Base of the Skull in a Two-and-a-Half-Year-Old Child, G. V~LOER.Beobachtung eines Karzinoms an der Schadelbasis bei einem zweieinhalb Jahre alten Kinde, Ztschr. f. laryng., Rhin., Otol. 23: 235-236, 1932. The author reports two similar cases. A fifteen-year-old girl showed a firm, elastic swelling and redness at one side of the soft palate, of six months’ duration. There was no fever but the child was thought to have a deep lying peritonsillar abscess. Tonsillectomy was performed. The upper tonsillar pole was found to contain a mass which on section showed non-cornified carcinoma of the stratified squamous epithelium. The child died eighteen months later of pneumonia with an evident recurrence. A second case is reported in a girl of two who showed obstructed nasal breathing and dysphagia. Muscle paralysis of one eye developed. A firm, elastic tumor resembling a retropharyngeal abscess was found under the slightly red mucous membrane of the nasopharynx. Incision yielded no pus. The tumor on removal was a solid carcinoma. The child died of meningitis. JEANNETTEMUNRO

Osteoma of the Frontal Bone, W. 0. OTT. Ann. Surg. 97: 314-318, 1933. Ott reports the successful surgical removal of a supra-orbital osteoma from a sixteen-year-old patient. The growth evidently originated in the frontal bone above the supra-orbital ridge and gradually extended in all directions until it involved the orbital plate of the frontal bone, the lateral and frontal wails of the right frontal sinus, and the external angular process of the frontal bone. The line of demarcation between the tumor and normal bone was very definite. Histologic study showed the tumor to be composed of osteoid trabeculae which were laid down in a very orderly fashion and comple€ely differentiated bony lamellae. Osteo- blasts were numerous. The lesion was considered to be a neoplasm graded in malignancy somewhere between the benign osteomas and the malignant osteo- sarcomas. The patient is free from symptoms and shows no evidence of recurrence eighteen months after operation. The article is illustrated by photographs of the gross specimen and a roentgenogram. BENJAMINR. SHORE

Osteoma of the Humerus Treated by Resection and Graft, A. CEBALLOS.Os- teoma del hSImero tratado por resecci6n e injerto, Bol. y trab. de la SOC.de cir. de Buenos Aires 16: 612-621, 1932. A boy of fifteen had a tumor of the humerus which had been present as a small swelling for eight years and then increased rapidly in size for six months. At operation the upper third of the humerus, containing the entire tumor, was excised, leaving only the head and a few centimeters of the proximal part of the shaft. A bone graft 19 cm. long was used to join the two fragments. Eight months after treatment a perfect functional and anatomical result had been obtained. The tumor was diagnosed as a pure osteoma. There are photographs, radiographs, photomicrographs, and a discussion at the end of the article to emphasize the fact that the tumor was an osteoma and not a cyst of an osteitis fibrosa. JOHN E. WIRTH BONES, TENDON SHEATHS, AND MUSCLES 777

Chordoma of the Third Lumbar Vertebra; Report of a Case, R. ZOLLINOER.Am. J. Surg. 19: 137-139, 1933. A white woman, sixty-two years of age, was admitted to the hospital complaining of pain in the lower back and both legs, of fourteen months’ duration. Roentgenograms of the spine showed irregularity of outline of the third lumbar vertebra which suggested an old compression fracture. At operation the cauda equina was found to be dislocated posteriorly and to the right by a ventral tumor mass which reached from the first lumbar vertebra to the sacrum and which had grown through the dura into the subdural spaces. The neoplasm apparently arose in the body of the third lumbar vertebra. Histologic study of the growth showed it to be a typical chordoma. There was some temporary clinical improvement following operation, but this was soon followed by a progressive decline which terminated in death one year later. The article is illustrated with drawings of the tumor and a photomicrograph. BENJAMINR. SHORE

Plasma-Cell Myelomata of the Skull and Dura, J. D. WILSONAND L. A. MILKMAN. Pennsylvania M. J. 35: 842-843, 1932. A man aged fifty years had a soft, pulsating tumor in the right frontotemporal region which was not tender or discolored. X-rays showed a large bone defect in this region, and, in the bones of the vault and the base, numerous discrete, punched- out areas. Later there were pain at the site of the tumor, photophobia, lacrimation, and moderate proptosis of the right eye, and, before death, drowsiness and mental confusion. At autopsy the skull bone showed numerous punched-out areas on its inner surface, varying in size, filled with a soft gray-red, “ almost gelatinous ” tissue. In the right frontoparietal region was a large, perforating dural tumor, and in the dura other smaller tumors, fitting into some of the excava- tions in the bone, but not attached to or infiltrating the bone. Histologic study of several of the dural and osseous tumors showed them to be composed of groups of plasma cells with scanty hyaline stroma.

Hyperproteinemia Due to Bence- Jones Protein in Myelomatosis, J. W. SHIRER, W. DUNCANAND R. L. HADEN. Arch. Int. Med. 50: 829-835, 1932. Two cases of myelomatosis with a high serum protein are reported. Enough Bence-Jones protein was present to account for the excess of total protein above normal. Both patients also had high blood calcium. [The presence of Bence- Jones proteinemia is also reported and discussed by Magnus-Levy, Ztschr. f. klin. Med. 119: 307-362, 1932. Abst. in Am. J. Cancer 18: 259, 1933.1 H. Q. WOODARD

Case of Xanthomatosis Treated by Teleradium, G. JONSSON.Acta Radiol. 13: 518-526, 1932. The author presents a brief review of the clinical features and pathology of xanthomatosis and of the previously published therapeutic methods and results. His own patient, a Swedish girl, eighteen months old when the disease began, was treated at the age of two and a half years. At that time the child presented tumor- like swellings of the skull, exophthalmos, a roentgen picture typical of xanthomatosis, and a histological picture which supported the diagnosis of the Schiiller- Christian syndrome. During a period of twelve days, the patient was treated with teleradium distributed over the four tumor areas. A total dose of 19.5 gram hours at a distance of 6 cm. and with a filtration equivalent to 6 mm. lead was given. The teleradium apparatus used was devised by Sievert and has been described by Berven (Acts Radiol. Suppl. XI, 1931). Daily doses of 1.5 gram hours were given alternating 778 ABSTRACTS on the dserent fields, the extent of which was indicated by the destruction wen in the roentgen picture. Improvement in the patient’s general condition and a well marked reduction of the swellings was noticed before treatment was completed. Two weeks later the swellings were no longer palpable. One month later a second series of teleradium treatment was given in the same manner, but with a smaller dosage. One year later no clinical evidence of the disease remained, and roentgen examination of the skull showed that the defects had healed with a uniform replacement by bone tiaeue. The author believes this case to be the first one treated with radium, although Sosman previously published good results from the use of roentgen rays (Am. J. Roentgenol. 23: 581, 1930; J. A. M. A. 98: 110, 1932). W. BAYARDLONG Secondary Malignant Disease of Bone, R. W. RAVEN. St. Bartholomew’s Hosp. Rep. 65: 243-282, 1932. Among 60 autopsy cases in which secondary tumors were found in bones, the author found that in 11 the bones were involved by direct spread, while in 6 the primary tumor was not identified. This leaves 44 cases of actual metastasis from known primary tumors. The greater part of the paper is occupied by citations from the literature of statements regarding the explanation of metastasis, and especially of reports by various writers concerning the incidence and distribution of bone metastases from primary neoplasms in various organs. For carcinoma in these different sites, the author compares the metastask incidence in his material with that reported by other writers. This is a useful and interesting paper. F. CAVERS Differential Diagnosis of Multiple Osteoplastic Carcinoma Metnames and Osteitis Deformans of Paget, T. CANIGIANI. Zur DZerentialdiagnose der multiplen osteoplastischen Karzinommetastasen und der Ostitis deformans Paget, Rhtgenpraxis 5: 85-91, 1933. Several case histories and accompanying roentgenograms are given to illustrate the difficulty of the correct radiologic differential diagnosis between osteoplastic carcinomatous metastases to bone and osteitis deformans. Of special importance are the adjoining areas of unusual density due to new bone formation and areas of rarefaction often seen in the pelvic bones in Paget’s disease. This picture, according to the author, is never observed in true osteoplastic metastases of carcinoma. BBNJAMINR. SHORE

Metastatic Vertebral Cancer, A. J. PAVLOVSKYAND M. J. FITTE. Clncer metas- tlsico vertebral, Bol. y trab. de la 9oc. d. cir. de Buenos Airee 16: 736757,1932. Four cases are presented to illustrate the typical destruction of a vertebra by metastatic cancer from various primary foci. The differential diagnosis between this type of lesion and involvement of the spine by numerous other diseases which may simulate it is briefly discussed. The fact is strewed that cancer destroys the body of the vertebra and tends to leave the intervertebral discs intact. The article is well illustrated by 8 radiographs with their schematic representations, and 2 photomicrographs, but no new ideas or methods of diagnosis are expressed. JOHNE. WIRTH

Osteitie Fibrosa, F. J. LANQ. Am. J. Path. 8: 283-270, 1932. A general discussion of osteitia fibrosa, which the author regards not as an independent bone disease, but as a secondary process dependent upon localized congestion and irritative influences. It is present both in rickets and osteomalacia, BONES, TENDON SHEATHS, AND MUSCLES 779 as a result of the localieed circulatory disturbances which follow the action of functional and mechanical trauma upon insufficiently calcified and softened bone. “ The development of osteitis fibrosa following a trauma, producing a congestion, a resorptive inflammation and finally a progressive hematoma, is comparable to the induration in parenchymatous organs following chronic passive congestion.” Eight photomicrographs are included, and a bibliography.

Two Cases of Fibrocystic Osteitis, E. ALLENBACH.Deux cas d’ostbite fibreuse kystique, Rev. m6d. de l’est 60: 753-754, 1932. Two cases of localized fibrocystic osteitis treated by curettage and bone graft are reported. The first patient was a boy of ten with the lesion in the left tibia; the second a boy of five with the lesion in the trochanter. In both, healing was complete with obliteration of the cystic cavity by normal bone tissue in less than six months. In the first case histologic examination showed fibroid or myxoid tissue with numerous fusiform or star-shaped cells. In the second case the fibrous tissue contained but little collagen and few fibroblasts, but was composed of a slightly acidophilic substance of a myxoid type.

Osteitie Fibrosa Cystica at an Unusual Age, E. L. RYPINS. J. Bone and Joint Surg. 15: 509-512, 1933. Rypins reports the case of a female infant, twenty months old, with the skeletal lesion8 of osteitis fibrosa cystica. The blood calcium was normal and no parathyroid enlargement was noted. Histologic study of a biopsy specimen led to the diagnosis of osteitis fibrosa cystica. Reports of only two younger patients have been found in the literature. The article is illustrated by roentgenograms. BENJAMINR. SHORE Osteitis Defonnans Especially of the Cancellous Bones, BIERING. Om Ostitis deformans saerlig i de spongiose Knogler, Hospitalstid. 75: (Dansk radiologisk Selskabs Forh.) 7-16, 17-23, Sept. 15 and 27, 1932. Most writers emphasize the classical location of osteitis deformans in the long bones. Pelvic involvement, which is much more common, has been less discussed, though it presents special difficulties in differential diagnosis. Roentgenography and the Wassermann test serve to differentiate the condition from syphilis. Cases of primary or secondary sarcoma of the pelvis seen by the author did not resemble osteitis deformans but showed more destructive lesions, resembling those seen in tuberculosis. The onset of osteitis deformans is insidious. Trauma is not so commonly the cause of the disease as it is of roentgen examination leading to its discovery. The disease often begins in the pubic bone and ischium, but may also originate in the ilium, and spreads gradually to the other bones until it becomes generalized. It is then similar to diffuse osteoplastic carcinosis, which is also common in the pelvis. These two diseases occur in the same age group and have similar symptoms, at leaat in the beginning. The roentgen findings are also similar. In caroinosis the destruction keeps pace with the regeneration, so that the sclerosis is not so marked as in osteitis deformans. In the vertebrae this is often reversed. Carcinosis shows a marble-like compactness, while osteitis deformans has a wide- meshed structure. The sclerotic process of carcinoRis is more irregular, with normal, clear areas. The trabeculae are irregular and the spongiose meshes are filled with bony masses. In osteitis deformans the productive processes produce a striped or streaked appearance according to the normal structure of the bone, which may become very compact but retain its regular benign aspect. Both conditions cause pain of a similar character, though pain may be slight or ABSTRACTG even absent. The course may be confusing, as diffuse bone carcinosis may progress so slowly that its nature and malignancy are doubted, especially if it has been modified by roentgen therapy. It is possible, too, that both osteitis deformans and cancer may be present in the same patient. Seven cases are reported in detail. From a pathologic standpoint there seems to be no sharp distinction between such diseases as osteitis fibrosa of Reckling- hausen, leontiasia ossia, and osteitis deformans, though clinically they are quite different. Most writers agree that the osteitis of Recklinghausen and Paget’s osteitis are genetically distinct, and one is tempted to suggest that osteitis deformans of the pelvis may perhaps be a different disease from osteitis deformans of the long bones. Osteitis Deformans and Trauma, E. LEWIN. Ostitis deformans (Paget) und Trauma, Rontgenpraxis 5: 208-214, 1933. The author reports two cases in which the earliest signs of osteitis deformans were observed in roentgenograms taken because of fractured femurs. In each instance rapid advancement of the process was observed after the trauma. In one case this was noticeable in three weeks, and in seven weeks the entire shaft of the femur including the new callus showed lesions typical of advanced osteitis deformans. The author believes that the trauma greatly accelerated the process. The article is illustrated by excellent roentgenograms. BENJAMINR. SHORE Generalized Osteitis Deformans of Paget, E. KORNER. Generalisierte Ostitis deformans Paget, Rantgenpraxis 5: 196-199, 1933. The author describes a case of osteitis deformans involving almost all of the bones of R fifty-seven-year-old patient. The article is illustrated with roentgenograms. BENJAMINR. SHORE Osteitis Defonnans of Paget, BACHMANN.Ein Beitrag zur Ostitis deformans Paget, Rontgenpraxis 5: 161-170, 1933. The author reports 4 cases of osteitis deformans and discusses the differential diagnosis of this disease from osteitis fibrosa cystica. In no case has he observed a spontaneous pathological fracture on the basis of an uncomplicated Paget’s disease and he believes that such fractures occur only in bones which have undergone cystic or malignant degeneration. The article is illustrated with roentgenograms. BENJAMINR. SHORE The Roentgenologist and X-Ray and Radium in Bone Disease, JOBEPACOLT BLOODQOOD.Am. Med. 38: 202-205, 1932. The author emphasizes the importance of thorough examination in bone lesions, including x-ray studies and the Wassermann test. If other methods of diagnosis fail and a proper trial of irradiation is without effect, a biopsy may be done. Metatypic Synovialomas and Primary Joint Tumors, Benign and Malignant, without Marked Organoid Characteristics, J. SABRAZ%a, J. MONTPELLIER,D. DUBOUCBERAND R. DE GRAILLY.Synovialomes mbtatypiques et tumeurv articulaires primitives, bbnignes et malignes, sans caractdrea organofdes marqubs, Gas. hebd. d. sci. m6d. de Bordeaux 53: 769-778, 1932. Among the tumors of the synovial membrane, there are some that resemble certain portions of the membrane, and others that show no resemblance to it. Both these types differ from typical synovialomas. They may be either benign or malignant. A transitional stage between typical synovialomss and joint BONES, TENDON SHEATHS, AND MUSCLES 78 1

tumors that are entirely atypical is represented by a group of metatypical synovial tumors, such as villomas or villous angiofibromas. An illustrative case of this type occurred in a woman thirty-two years of age. Five years previously she had injured the right knee, and from that time had had intermittent hydrarthrosis. On opening the joint, a polypoid mass was removed. There was no evidence of an acute or subacute inflammatory process, but the histological picture was that of a neoplastic hyperplasia of the villi.

Primary Solid Tumor of the Synovial Membrane of the Knee, E. LOUBATAND J. MAQENDIE.Sur un cas de tumeur solide primitive de la synoviale du genou, Gar. hebd. d. sci. m6d. de Bordeaux 53: 760-763, 1932. A young woman eighteen years of age had had pain and difficulty in movement of the right knee for five years; for the last two years, after an injury to the knee, the pain had increased in severity and there was a swelling on the external side. Examination showed a definite tumor mass in the region of the head of the fibula; the roentgenogram showed some decalcification of the fibula at the point of attachment of the tumor and also of the tibia, while the tumor showed areas of calcification. A diagnosis of tuberculoma was made. At operation a well encapsulated tumor was found, originating from the synovial membrane, and adherent to the fibula and the tibia. It was removed and proved on examination to be a synovial- oma, a tumor of a sarcomatous nature, but containing tissue of the same structure as that of the synovial membrane; in this case the tumor was relatively benign histologically. Deep x-ray treatment was given. There was some recurrence of pain in the knee two and a half years later, and a second series of roentgen-ray treatmente was given. In another six months (Le., three years after operation), there were no symptoms and a roentgenogram showed no evidence of recurrence.

Tumor of the Tendon Sheaths, FRANCEBCOBELLELLI. Su di un tumore delle guaine tendinee, Riforma med. 48: 630, 1932. This is a long account of a giant-cell tumor removed from the sheath of the extensor digitorum communis in a woman of twenty-five. Two poor photomicrographs and an extensive bibliography are included. C. D. HAAQENSEN

Myeloma of Tendon Sheath, E. HENRIETTAJEBENS. Proc. Roy. SOC.Med. 25: 1098-1099, 1932. A woman of forty-nine first noticed a small tumor on the flexor surface of the second phalanx of the little finger of the left hand in August 1931. As it increased in sire and caused some discomfort and inconvenience, it was removed in February 1932 and proved on examination to be a myeloma surrounding the flexor and extensor tendons. It differed from the cases usually described in the rapidity of its growth and its pale yellow color and absence of hemorrhagic areas.

Angioma of the Synovial Membrane of the Knee, E. S. BASTOS. Angioma da synovial do joelho, Bol. SOC.de med. e cir., SBo Paulo 15: 475-478, 1932. A thirty-nine-year-old man was admitted to the hospital with a large swelling of the right knee. Eight hundred C.C. of a bloody liquid were removed by puncture. Palpation revealed the existence in the joint of a large tumor of sponge-like con- sistency. An operation was performed and a large diffuse angioma was removed. JOHANNESP. M. VOQELAAB 782 ABSTRAOTS

Osteoma of the Crural Muscle, G~~RARD.Ost6ome du muscle crural, Rev. m6d. de Vest. 60: 788-790, 1932. A girl of sixteen had pain in the left hip with considerable limitation of movement, but no deformity. Radiological examination showed a bridge of bone between the ischium and the intertrochanteric line. An incision along the gluteal ridge was made and a bony mass was found and removed.

Case of Angioma of the Muscle of the Forearm, MONTANT.Sur un cm d’angiome musculaire de l’avant-bras, Bull. et m6m. SOC.d. chirurgiens de Paris 25: 66-59, 1833. A man, twenty-three years of age, had a painful tumor on the right forearm after an injury. The tumor was soft and could be compressed. As it caused considerable pain, it was removed and was found to be a cavernous angioma of the muscle tissue.

THE LYMPHATIC SYSTEM; LYMPHOSARCOMA; HODGKIN’S DISEASE; THE LEUKEMIAS Case of Extensive Tumor Formation in the Lymphohemopoietic System, R. GLAUNER.Uber ausgedehnteste Blastomatose des lymphatischhtimatopoeti- schen Apparates. (Metaatasierendes Carcinom + Retikulose?, Carcinom + Retothelsarkom?), Frankfurt. Ztachr. f. Path. 44: lOS-llt3, 1932. A man of fifty had noticed, about eighteen months before admission to the hospital, enlarged nodes behind the ear and in the axillae and groins. A year later he had pain in the lumbar region and below the right costal margin, and was treated in several hospitals for gastric ulcer and also given x-ray irradiation to the enlarged nodes. Just before admission to the author’s clinio a supraclavicular node had been found on biopsy to contain solid carcinoma, presumably metastatic. During the past three months the patient had lost 26 pounds, and hie skin had become yellowish. Periosteal thickenings were felt on the right tibia, and the enlarged lymph nodes were very hard and easily movable. A deeply located tumor was felt to the left of the umbilicus. Blood examination showed 60 per cent hemoglobin, 2,100,000 erythrocytes, 5,300 leukocytes (polymorphonuclears 57 per cent, eosinophils 3, monocytes 3, lymphocytes 37), with anisocytosis, poikilocytosis, and poly- chromasia of erythrocytes, and 5 normoblasts to each hundred leukocytes. X-ray of the skeleton led to a diagnosis of widespread carcinomatous metastasis. The patient became increasingly cachectic and died six months after admission. At autopsy small whitish nodules were observed in the spleen, liver, stomach, intestine, pleura, lungs, heart musculature, kidneys, vertebral bodies, muscles, brain, and hypophysis. Hietologically these showed, with slight variations, the picture of a partly finely reticular and partly dense connective-tissue network of fibers, in the meshes of which lay cells, either isolated or in syncytial or epithelioid masses. The cells varied considerably in siae and in shape, and mostly had a single large round nucleus. Some multinucleate giant cells were seen; also cells showing phagocytosis and storage of finely granular fat. Tumor cell nests showing definitely epithelial structure were seen lying free in lymph spaces and vessels. No primary tumor could be found, though the presence of carcinoma had been demonstrated in the supraclavicular node removed eight months before the patient’s death, but in every histologic preparation examined there was found a nest-like arrangement of epithelioid cells. On the other hand, the fact that LYMPHATIU SYSTEM 783 definite tumor formation was limited to organs belonging to the reticulo-endothelial system, the reticular structure of the tumor nodules, and the phagocytosis and fat storage shown by many of the tumor cells seemed to favor the interpretation of the oase as one of systemic disease of the reticulo-endothelial apparatus. Finally, taking all the clinical and histologic findings into account, the author suggests as a third alternative that, in analogy with the development of reticuloses on acute and chronic infections, the case may be regarded as one of tumor formation resulting as a reaction of the reticular portion of the reticulo-endothelial system to the stimulus of metastatic carcinomatous cells or of their “ toxins.” He points out that the nodules found in the brain substance and in the muscles differed from the rest in showing purely epithelial structure; also that the hypophysis, though not enlarged, showed the structure of an adenoma, which might have been the primary tumor, though, as a rule, a hypophyseal tumor metastasizes only in the central nervous system. Four good photomicrographs are given. F. CAVERS

Primary Reticulo-endothelial Sarcoma of the Lymph Nodes and Other Lymphoid Organs, F. ROULET. Weitere Beitrage zur Kenntnis des Retothelsarkoms der Lymphknoten und anderer Lymphoiden-Organe, Virchows Arch. f. path. Anat. 286: 702-732, 1932. In a previous paper (ibid. 277: 15, 1930) the author concluded, from a study of eleven cases, that, in addition to the lymph-celled and lymphoblastic sarcomas which arise from mature and immature lymphocytes, there is a distinct group of primary sarcomas of the lymphatic organs which arise in the reticulo-endothelial tissue. He states that in his experience these tumors have a better prognosis than the ordinary lymphosarcomas. Eight additional cases are described. In all cases the superficial lymph nodes were involved. In two cases the tumors were limited to these nodes. In the remaining six cases tumors also occurred in the tonsil (l), epipharynx (2), and mediastinum (l), or were generalized (2). In the first two cases the process began in the axillary nodes, and no internal metastases occurred; histologically there was only a slight degree of malignancy. In the three cases with throat tumors, there was more outspoken malignancy, and the tumor extended into the larynx and metastasieed to the regional deep nodes. In Case 6 the tumor was apparently primary in the mediastinum, but the liver and spleen were infiltrated, besides the intraperitoneal and intrathoracic nodes. This case seemed to be transitional to Hodgkin’s disease. In one of the generalized cases there were indications of a transition to lymphatic leukemia; in the other it was possible to make a clear distinction between reticulum cells and endothelial cells. There are fifteen illustrations, mostly photomicrographs. F. CAVERS

Lymphosarcoma, Case Report, MAY OWEN. Southern M. J. 25: 1248-1252, 1932. A case of lymphosarcoma in a boy three years of age is reported, which is of interest because of the difficulties of diagnosis. The child was admitted to the hospital markedly anemic and weak, with enlargement of the spleen and liver, necrotic lesions in the throat, and a low total leukocyte and neutrophil count. The necrotic membrane removed from the throat presented the same appearance as in fatal cases of agranulocytic angina. A diagnosis of agranulocytosis was based on these findings, and the anemia was attributed to the severe toxemia. Treatment with liver extract and blood transfusion improved the red cell count, and the administration of macerated fetal spleen by mouth was followed by a rise of the white cell and neutrophil count, diminution in the size of the spleen and liver, and marked improvement in the general condition. Suprarenal cortex 784 ABSTRACTS was also given, hypodermically, and caused an increase of both red and white cells. During this period, enlargement of the cervical lymph nodes was noticed, but was attributed to the inflammatory throat lesions. After the throat lesions had entirely subsided and the child had been discharged from the hospital, the lymph nodes rapidly increased in size. Roentgeno- grams of the chest also showed a mediastinal tumor. Biopsy of one of the cervical nodes showed lymphosarcoma, with absence of lymph follicles and a diffusegrowth of lymphoid cells with vesicular and hyperchromatic nuclei. Three x-ray treatments were given over the cervical nodes, but the child was taken from the hospital and died about a month later. Glandular enlargement is usually the first sign of lymphosarcoma, but acute general symptoms may be severe and so dominate the clinical picture that the gland enlargement is considered relatively unimportant, as in this case.

Histologic Changes in the Lymph Nodes in Hodgldn’s Dieease, H. HAMDIAND SAIM-ALLDie histologischen Veranderungen der Lymphdrtisen bei der Granulomatose (Lymphadenosis granulomatosa), Frankfurt. Ztschr. f. Path. 44: 338-342, 1932. The material examined by the authors consisted of lymph node masses taken from eight cases of Hodgkin’s disease. In six cases the disease was first manifested, or at any rate diagnosed, by involvement of the cervical nodes; in one the mesenteric nodes were first affected, then those of the groins and elsewhere; in one, first the mediastinal nodes, later the cervical and axillary nodes. The authors found certain histologic differences between the smaller nodes, which are usually found occurring singly, and larger ones, which are usually harder and form the bulk of the node aggregates in such regions as the neck, axillae, and groins. The former showed the earlier histologic changes more clearly than the latter. These changes consisted in an increase in the number of lymphocytes, while at the same time most of the follicles and medullary cords became stretched out and fused together, though remaining sharply demarcated in the vicinity of the lymph sinus. Among the lymphocytes were scattered eosinophil and plasma cells in considerable numbers. In some of the nodea examined, epithelioid cell forms were seen lying singly or in groups around the vessels. The authors consider that apart from this finding it would be impossible at this stage to distinguish histologically between banal inflammation and Hodgkin’s disease. In the larger nodes the predominant tissue element waa the epithelioid Stern- berg cell. Between the masses of these cells there lay larger or smaller numbers of lymphocytes, polymorphonuclear neutrophils and eosinophils, plasma cells, and giant cells. These larger nodes often showed granulation tissue with necrotic dbbris, and in the peripheral region of such nodes there were frequently found lymphadenoid tissue remnants in the form of dense masses of lymphocytes, without normal adenoid Organization, the latter being replaced here by flattened lymph- containing spaces, probably formed by disturbance of the lymph circulation by the granulation tissue. The characteristic epithelium-like cells were round, oval, or lobulated, and in many places polygonal owing to mutual pressure. They had dense cytoplasm, frequently with pseudopodium-like outgrowths. The nucleus was large and round, oval, or lobulated, either vesicular or containing small rods and granules of chromatin, and there were one or two nucleoli. Mitoses were frequently observed. Transitions to multinucleate giant cells were also seen, the formation of the latter being attributed by the authors to the fusion of epithelioid cells. They also claim to have observed the origin of the epithelioid cells from the perithelial cells of the vessels and also from the endothelial cells of the sinus, and they believe that the epithelioid cells may arise in a third manner, namely, by transformation of plasma cells, though no description is given of definite findings in support of this belief. LYMPHATIO SYSTEM 785

The authors next describe the changes, mostly degenerative, occurring in the oldest and largest nodes, in which the granulation tissue becomes abundant and finally undergoes sclerosis. In some of these degenerating nodes they found, using the Gram method, abundant bacteria of the coryne group. Small pieces of such nodes were inoculated into rabbits and mice [number of animals not stated]. In one mouse the inoculum developed, and on examination was found to contain abundant coryne bacteria but showed no trace of granulomatous change. It is unfortunate that’this interesting article is not accompanied by illustrations. F. CAVERS

Classification of Lymphogranulomatosis, N. GOORMAOHTIOH.Considbrations sur le cadre nosographique de la lymphogranulomatose, Cancer, Bruxelles 9: 262-271,1932. In his experience the author has found that the diagnosis of malignant lymphogranulomatosis can be made only histologically. The clinical symptoms of Hodg- kin’s disease may be associated with other lesions of the lymphoid tissues- lymphosarcoma or reticulo-endothelioma. A detailed histological analysis follows. General Features of Hodgkin’s Disease, P. H. CARPENTIER.La maladie de Hodgkin, Scalpel 85: 617-631, 1932. The author, without contributing anything new, gives a general account of Hodgkin’s disease, based almost entirely on French publications. F. CAVERS Hepatic Form of Hodgkin’s Disease, I. GOIA. Contributions B la forme h6patique de la lymphogranulomatose maligne, Bull. et m6m. SOC. m6d. d. hap. de Bucarest 14: 493-500, 1932. Goia’s report is based on observation of 90 cases of Hodgkin’s disease in the Cluj medical clinic. The interesting point brought out is that the degree of liver enlargement was roughly parallel with the diminution in the erythrocyte count. In 29 cases with 3 to 4 million red cells per c. mm. the liver was usually enlarged moderately; in 16 with counts of 2 to 3 millions hepatic enlargement was an outstanding feature; in 3 with counts of 1 to 2 millions the hepatomegaly was still more pronounced. F. CAVERS

Malignant Lymphogranulomatosis, J. NICOL~OAND H. P6voa. Linfogranuloma- tose maligna, Arch. brad de med. 22: 25-29, 118-129, 1932. The authors’ patient was a boy of five years, born at term of normal parents. His present illness had begun at the age of two years, when, slowly and insidiously, in the submaxillary region near the left mandibular angle, a moderate glandular enlargement appeared, accompanied by a slight rise of temperature with respiratory disturbances. Some days later another swelling appeared, on the opposite side. Next, a severe eruption of measles supervened, after which the glandular swellings completely disappeared within a few days. The child was regarded as cured, when suddenly all the glands again became swollen. When seen by the authors, the patient’s genital organs and lower limbs were edematous and the upper limbs emaciated, except for the hands, which were likewise edematous. Blood examination showed a count of 2,480,000 per cubic millimeter; leukocytes, 6,800; hemoglobin (Gowers-Sahli) 42 per cent. The leukocyte formula revealed: eosinophils 2.85 per cent; neutrophilic polynuclears, 64.28 per cent; monocytes, 8.56 per cent; lymphocytes, 24.28 per cent. Examination of a biopsy specimen from a cervical node showed lymphogranulomatosis. In the second part of their article, the authors survey the evolution of the 786 ABSTRAOT8 anatomo-clinical data since Paltauf’s publication in 1897, and the work of hie pupil Sternberg, in 1898. They state that practically all authorities are now agreed that malignant lymphogranulomatosis is a systemic pathological entity of the lymphatic apparatus, of inflammatory type and infectious character.

Lymphogranulomatosis and Pregnancy, PALLASBE,RHEUTER AND SANTY. Lym- phogranulomatose et grossesse, Lyon m6d. 150: 531-535, 1932. Two cases of lymphogranulomatosis are described in women twenty-six years of age, who became pregnant during the course of the disease, The pregnancy appeared to cause a slight exacerbation of symptoms in each case, which was relieved by x-ray therapy. Labor was normal in both patients; in one it occurred somewhat before term; in the other there was slight fever without signs of infection, which persisted for about twelve days. In both cases, the infant, although small, was entirely normal; neither child has shown any symptoms of lymphogranulomatosis.

Case of Malignant Granuloma in the Form of Subacute Septicemia, J. PAVIOT, LEVRATAND H. JARRICOT.Un cas de granulome mah h forme de septic6mie subaigue, Lyon m6d. 150: 413-418, 1932. In a woman twenty-eight years of age a swelling of the breast, apparently an abscess, appeared three months after a normal labor. A moderate amount of fluid was evacuated. Enlargement of the cervical nodes was observed at this time; and there were marked asthenia and fever, with a variable temperature curve. Three months later the patient was admitted to the hospital, very ill with symptoms of septicemia. Liver and epleen were markedly enlarged, and the cervical nodes slightly enlarged. Death ensued in a few days. Autopsy showed the typical lesions of malignant granulomatosis with many Sternberg cells in the retroperitoneal lymph nodes, the spleen, and the liver. The authors note that Hodgkin’s disease rarely runs so acute a course as in this case; the symptoms suggested a septicemia, but although a focus of infection was carefully sought for, none was found either clinically or at autopsy.

Case of Hodgkin’s Disease, A. D’ANNA. Considhtions sur un cas de maladie de Hodgkin, Union m6d. du Canada, 62: 114-118, 1933. A report of a case of Hodgkin’s disease with a discussion of differential diagnosis. WILLIAMJ. HOFFMAN

Latent Cardiac Dilatation in Hodgkin’s Disease, L. GENIBSEL. Dilatation cardia- que latente chea un hodgkinien, Bull. et m6m. SOC.radiol. m6d. de France 20: 286-288, 1932. Geniesel reports a case in which radiography revealed unsuspected dilation of the heart coexistent with mediastinal lymphogranulomatosis. F. CAVERS

Hodgkin’s Disease, P. CHEVALLIERAND J. BERNARD.La maladie de Hodgkin, Lymphogranulomatose maligne, Bull. et m6m. SOC.m6d. de Paris No. 12: 424- 427, 1932. Chevallier and Bernard described a single case of Hodgkin’s disease, apparently showing nothing unusual. F. CAVERS LYMPHATIC SYSTEM 787

Absorption Curves of Conin Secondary Anemias, Progressive Pernicious Anemias and Leukemias, G. CERUTIAND 0. MAESTRI. Curve di sssorbimento del COI nelle anemie secondarie, nelle anemie perniciose progressive e nelle leucemie, Clin. med. ital. 63: 785-843, 1932. The author studied the carbon-dioxide absorption of the plasma, total blood, and the red cells in 10 cases of secondary anemia, 5 cases of pernicious anemia, and 3 leukemias. He found that in illnesses associated with diminution of blood pigment there is a constant disturbance of the acid-base equilibrium and the ability to absorb Cog. This he attributes directly to the decrease in hemoglobin and in the bases attached to hemoglobin. JEANNETTEMUNRO Leukemic Changes of the Upper Respiratory Tract and Ear, RICHARDH. JAFF%. Arch. Otol. 15: 939-942, 1932. Jaff6 divides the leukemic changes in the upper respiratory tract into two groups: (1) the inflammatory ulcerative group; (2) the tumor-like group. The inflammatory and ulcerative changes may occur in association or independent of similar lesions in the oral cavity. The tongue, soft palate! pillars, and tonsils are covered with a gangrenous, sloughing foul-smelling, dirty grayish exudate,. or there may be irregular deep ulceration. These lesions are seen more frequently in acute leukemia. Occurring in the chronic form, they indicate the imminence of an acute stage. Tumor-like infiltration of the tissues by the leukemic cells usually originates in the tonsils and may extend to the pharynx and epiglottis. It is more commonly seen in chronic lymphatic leukemia, particularly the so-called aleukemic form. In this latter form diagnosis is difficult and enlargement of the lymph nodes of the greatest differential importance. In one case autopsied by the author the tonsils had been removed and the patient had bled to death. Enlargement of the tonsils in an elderly person, otherwise unaccounted for, is always suggestive of leukemia. The tonsils may also be involved in leukosarcomatosis and there may be extensive infiltrations of the upper respiratory tract in chloroma. The author has never seen leukemic infiltrations of the nasal mucosa, though they have been reported. In one of his cases rhinitis was the initial symptom of a persistent leukemia in a child, and otitis media is common. Paralysis of the cerebral nerves, especially the facial and acoustic, is not rare, with hemorrhage into the nerves or leukemic infiltrations. So-called hemorrhagic fibrinous labyrinthitis is said to be of frequent occurrence in leukemia and may be followed by leukemic infiltrations. Other changes which occasionally occur in leukemia are hydrops of the endolymphatic spaces of the labyrinth with extreme distension, and leukemic infiltration in the vestibular ganglion.

Differentiation of Lymphatic Leukemia from Agranulocytic Angina, H. A. ROTHROCK.Am. J. M. Sc. 184: 689-694, 1932. In his introduction to this careful case study the author shrewdly remarks that when a new or supposedly new disease entity has been described, “ atypical states of well known though uncommon conditions are reported as one of the newer clinical entities.” A review of numerous reported cases of agranulocytic angina has led him to criticize the correctness of the diagnosis in many cases, and he reports a case in order to impress, among other things, the fact that any conclusion drawn from a non-autopsied case must be very conservative. A man of thirty-two ‘was admitted to the hospital in a critical state. About six weeks previously he had returned from work feeling very tired and weak; about three weeks before admission he had continued oozing of blood from the 788 ABSTRAOTS gums, which medical treatment failed to control; five days before admission he complained of sore throat, and three daya.later a peritonsillar abscess was excised, with some relief. After admission the patient continued to expectorate bloody material and to breathe with great difficulty; there was constant oosing from the gums; the throat was red, swollen, and ulcerated, with purpuric spots on the palate; and the cervical lymph nodes were enlarged. The temperature remained about 104 to 105" F., and the patient grew progressively worse. He died three days after admission. Four blood counts showed 1,300,000 to 1,400,000 erythrocytes; the leukocyte counts were 19,000, 18,000, 7,700, and 6,700 (lymphocyte percentages 89, 95,85,91; neutrophil percentages 11,4,5,6). No immature forms of the lymphocytic series were found. At autopsy the spleen showed lymphoid hyperplasia with loss of normal structure. In the liver infiltrating lymphocytes were found scattered between the liver cells, and in massive collections around the portal canals. A mesenteric lymph node showed uniform lymphocytic hyperplask; and in the bone marrow the normal structure was largely displaced by lymphocytes. After discussing the hematologic and other features of agranulocytosis, the author concludes that hie case was one of lymphatic leukemia, and that agranulocytic angina should be regarded as a syndrome rather than a clinical entity. There are four illustrations. [For a report by Burkens of a case in which lymphatic leukemia was apparently preceded by agranulocytosis, see Am. J. Cancer 16: abst. p. 499, 1932.1 F. CAVERS

Radiothorium in the Treatment of Leukemic Lymphadonosla, I. ZADEK. Radio- thorium bei leukamischer Lymphadenose, Folia haemat. 48: 39-66, 1932. The author refers to previously published reports on the effects of irradiation on the lympho- and hematopoietic tissues of experimental animals and poisoning in man by radioactive substances (see p. 654 above). Thorium-XI a compo- nent of radiothorium, has been tried, with fairly good palliative results, in leukemia. Radiothorium, with its half period of nearly two years as compared with less than four days for thorium-XI should be of greater value, used in inhibiting doses of diminishing strength, since leukemias are of medium radiosensitivity. A first dose equivalent to 200-300 electrostatic units, followed by injections of 200, 100, and 50 units respectively, has been given by others. The author deals in this paper with three cases of leukemic lymphadenosis. The first patient died two months after treatment (an unpromising case, complicated by pulmonary tuberculosis, lung abscess, and heart disease), the second in less than four months, the third a year after admission. In none of these cases could the author find any morphological changes attributable to the action of the radiothorium, except a slight reduction in the total leukocyte count. Comparison with his results in treating myeloses (Folia Haematologica 49: 115-147, 287-340, 1933) shows that lymphatic leukemic tissue is much more resistant than erythropoietic tissue. The author believes that, to be of benefit in lymphadenoses, the dosage of radiothorium would need to be so high aa to cause cachexia and fatal anemia; this conclusion is confirmed by animal experiments. Hence for practical purposes this method of treatment is unsuitable for lymphatic leukemia. [Information is rapidly accumulating which shows the great danger of adminis- tering such compounds under any circumstances.] F. CAVERS