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 EXAMPLES OE MYELOID TUMOE : 
 
 WITH 
 
 mtm mmmm wm \\m form of gfiowth, 
 
 By R* p. HOWARD, M D., 
 
 Prof» Clinical Medicine, McGill College, 6W. 
 (tlead before the Medical Students' Society of McGill College.) 
 
 Gentlemen, — The great progress which hns been maile in the patho- 
 logy ot' morbid growths, within the past few years, and which has rehulted 
 mainly from two causes, the employment of the microscope in the exam- 
 ination of morbid structures and the great attention which lias been paid to 
 clinical investigation,has tended to alter materially our modes of regarding 
 and classifying tumors. Formerly, and not very long ago, all tumors were 
 either malignant or benign ; and an individual specimen was placed in 
 either class, according to its naked-eye characters, and the result of its 
 removal. If it recurred either at the original site or re."" >tely fiom it, 
 it was called malignant, even though composed appatently of fibrous 
 tissue or cartilage. When the microscope began to be employed in 
 the examination of structure, and it was discovered that those growths 
 endowed with the greatest proclivity to recur and implicate parts far 
 removed from the primary seat of diser.se,generally contained an abundance 
 oi cells with large nuclei, it was inferred that certain cells of specific cha- 
 racter were the infallible test of malignancy, and cumors were pronounced 
 malignant or benign, according as they exhibited or not,the alleged specific 
 cells under the microscope. 
 
 More extended and accurate investigation, however, is now leading 
 pathologists to abandon the idea that there is one structural element — 
 a cell — always capable of recognition by the practised eye — which is 
 alone endowed with the fatal gift of malignancy, and to admit that 
 growths composed of other elements, as nuclei, fibres, cartilage cells, and 
 cells quite unlikt .he so-called "cancer-cells," may have most, if not all, the 
 attributes of malignancy- — such as rapid and enormous growth, tendency 
 to frequent recurrence both locally and romotely, aptness to ulcerate and 
 protrude, exhaustion of the vital powers, etc. Nay, even, that well marked 
 encephaioid tumors may exhibit no cells; but merely nuclei possessed of 
 no special characters. They are now recognising that the term malig- 
 nant is purely relative, — ihat there are degrees of malignancy, — that 
 some growths are highly so, others slightly so, and that between these 
 there are all grades of malignancy. Tiius there are growths which oiily 
 occasionally and exceptionally recur after removal ; others which habitu- 
 ally and repeatedly recur, though only or chiefly at the original site ; 
 
 ..^\ 
 
nthprs nrain which rocur both locally and remotely ; and yet others which 
 n* onv ™cu Sy and remotely, bnt infiltrate and absorb mto 
 S?eirolrolthe tissues in which they occur and the adjom.ng lex- 
 
 '" Our°£o*dsc i'rnot";:fB;,fBciently accurate and comprehensive to 
 enaWe n" to fif the rdlthe degrees of malignancy possessed by ll e 
 eS varieties of tumors-, h„. if we should «"7i; '° '^™:X f^ 
 nf morhifl (rrowth^ cla=^sified aiid arranged on that princip e, peiiiaps, uit 
 MZ^:^^Zt\:;^^^^^^ the tmth ?n its general outhue, though, of 
 course, it would not be accurate in all its details :— 
 
 Scale of tumors according to their degrees of malignancy. 
 Encephaloid " 
 Colloid 
 
 Malignant 
 
 . Scirrhous 
 I Osteoid 
 
 . Cancer. 
 
 locally) 
 
 Innocent. 
 
 1^ Epithelial 
 f Cartilaginous. 
 I Myeloid. 
 Semi-malignant (they recur ^ Malignant-fibrous. 
 
 locally and remotely) i Recurring-fibroid. 
 
 [ Fibro-plastic. 
 f Fibro-nucleated. ■ 
 Locally malignant (they recur J proliferous cysts containing vascular growths. 
 ' "~^ '" \ Glandular tumors. 
 
 Fibro-cellular. 
 Fibrous. . . 
 
 Proliferous cysts contammg cysts. 
 
 Barren cysts. 
 Osseous. 
 , Fatty, 
 
 You will perceive that I retain the fibro-plastic as a distinct form. 
 T do s^ because it is not quite certain whether the tumors included 
 in r tha^Si^nafion by LeU can all be assigned enhe^o t, 
 myeloid, recurring-horoid, fibro-cellular, or fibrous class, lo leter now 
 t? this table: the growths which occupy its extreme ends certj.n y 
 differ very widely from each other, so that we liave no hesitat.^ m 
 cSa aUy tumor innocent, and an encephaloid malignant ; still, the 
 severfl Vroups pass insensibly into each other, and tumors having 
 S vff s ruct^e, may be found occupying Pl-- ^^^V^.n d'the'T 
 class and the locally malignant, or in the semi-mahgnant and the ma- 
 
 ^?he\ransition of the semi-malignant into the malignant '^^-f^^^^- 
 trated by the cartilaginous tumor, which occasionally not only grows 
 wTth cn^at rapidity to°an enormous size, but recurs when removed, an I 
 Iipea^rs botl/ in the lymphatics and in remote organs, as the "ngs 
 Ephhelioma, on the other hand, placed amongst themalignant,haslit lie 
 Tendency to propagate itself, unless to contiguous parts ; it occasionally 
 does nof recvir when removed, and but rarely invades remote part«. 
 
 The fibro-plastic tumors placed at the lower end of the senn-ma gnant 
 group! are pLinlv intermediate between that group anti the locaUr"^; 
 Wnt- for although they now and then recur after removal it is ge- 
 Sly 'o^y at the original site, and but seldom in remote parts. 
 
 V 
 
3 
 
 Hespectincf the fibronijcloated, enough is not j'ct known to justify 
 their being placed elsewhere than in the locally malignant group ; but, 
 It is extremely probable, that, like the last two in the semi-malignant 
 group, they will he found now and then to invade parts remote from that 
 in which they first appear, and thus further corroborate the view I am 
 now advocating. 
 
 Lastly, on this topic, while fibrous, osseous tumors and proliferous 
 cysts, are generally quite benign or iimocent, sometimes they exhibit 
 some of the characters of malignancy, and thus come to occupy places 
 in two distinct gi'oups of the scale. 
 
 It must then be admitted, that, tumors like- all natural objects, do not 
 admit of a classifiraiion inherently and absolutely correct; for the mem- 
 bers of each group, by very imperceptible transitions, blend with the 
 groups placed next in the scale, whether above or below them, and the 
 chit'f utility of classifying them, is the practical convenience, resulting from 
 collectingthc individual varieties into groups, possessing several characters 
 in common. 
 
 I have made these (aw remarks on tumors, by way of preparing you for 
 «'ime of the peculiarities of an interesting variety of morbid growth, 
 wl'^ch has only of late years been recognized, and described as a distinct 
 variety. 
 
 Early in December last, my friend. Dr. Butler, of Waterloo, requested 
 me to examine with him a patient of his, the particulai-s of whose case ho 
 thus describes : — 
 
 •' L. II. K., farmer, aged 42 years, of sound constitution and temperate 
 habits, consulted me for disease of the right knee, in the early part of 
 last May. He informed me that in March, 1857, fourteen months pre- 
 viously, he had received a slight blow from a sleigh-tongue, upon the 
 external aspect of the knee, a little above the condyle. A s'Tight puffiness 
 at the spot was the only immediate result, and it was not until a few weeks 
 had elapsed that he began to experience slight pain at the injured part, 
 which, however, was not severe enough to prevent his pursuing his 
 usual avocations through the spring and summer. In early autumn, he 
 found it diflicult to walk upon an uneven surface without an increase of 
 pain and some lameness. On several occasions, an incautious step or 
 accidental blew on the limb, very much augmented the pain and lame- 
 ness- for a few days ; but this augmentation would subside and leave 
 him in his former condition. During the fall, and part of the winter, an 
 irregular practitioner exhausted his resources in vain attempts to cure 
 the disease. In February, 1858, Mr. K. once more injured his knee, by 
 slipping, and since then has been unable to leave his room or bear the 
 weight of his body upon the member. 
 
 I found the joint considerably swollen ; fluctuation perceptible, par- 
 ticularly above, on each side of the patella ; entire absence of pain on 
 moving the joint in every direction it was capable of, or on forcible 
 pressure of the articular surfaces against each otner ; no tenderness 
 except over a small spot on the external condyle of the femur ; he suf- 
 fered a pain Avhicli he describes as of a 'burning or scalding character 
 encircling the upper part of the knee-joint.' i he pain was not influ- 
 enced by the weather, and was most severe during the day. The treat. 
 
nicnt emhloyeJ consisted of local counter-irritants, blisters, tinctflre of 
 iodine, an issue; mercury, and iodide of potassium, in alterative dose« 
 for some lime. The joiut was put up in the manner recommended by 
 Scott and asain, immobility was secured by the d.^uble-inclmed plane. 
 At L the ?ain' was relieved completely. by t^^e ijsue. am, al houg^i 
 returned in the head of the femur m October last and wa? 
 aclorpLi-'d by gradual increase of the . sweP.ng it did no^ regjun 
 its previous degree. All means having faded to a est t_he 
 disease I now made an exploratory puncture of the jOnt 
 w itl a' fine trocar, and obtained chiefly a ^angumeous-looking fol- 
 Tov d by a tl n eti'aw-coloured fluid, a portion of which was forwarded 
 by letter to yourself, for microscopic examination ; bat you have intornied 
 
 '" Vubrc::sEt-rn' wffound M,-. K. in very good health for a p'erson 
 confined so long to the house (10 months); thin, but no much ema- 
 cUaed T ^ligbtly anxious-looking, but hopeful ; pulse rather re.p.en , 
 sml and quick; digestive functions well performed, and appetite faw 
 Tcmi^lh, and nothing abnormal discovered on physical examination ot 
 
 ''Ince October Inst, he has suffered rather severe pain in the head of 
 the femur or across U.e upper part of the knee, especially in the aft.r 
 noons but it has been easily alleviated by a small dose ot morphia, and 
 has never been of an intohrable or very severe character. 
 
 The rhrht knee presents a smooth uniform enlargement, extending 
 fron the head of the tibia upwards, say four inches on the femur It has 
 veiv much the contour seen in thickening of the synovial tnembrane of 
 his iS The integument of the pari is of the same colour as the rest of 
 le hub a few moderately large teins a.e visible beneath it; tVre is no 
 el ernes's a any point unless very firm pressure is made over the exter- 
 S condy e A somewhat elastie,%omewhat doughy sensation is expe- 
 Jfenced in handling this part, especially on each side of the pateda 
 Over the external condyle, the swelling is more yielding, and here two 
 Ssthict plates of bones can be felt, apparently formed in the substance of 
 ie exteff ^^^^^^^^ ligament, or in the thickened fibrous tissue of the 
 mrt Pres u -e on these osseous fragments easily forced them inwards, 
 ^^'.rnvpd that the lower one, situate at the lowest part of the outer 
 collvleti™^^^^^ the upper one, extending from the latter in 
 
 r di ec on of the external ligament, is long and narrow No distinct 
 flnctuattn present anywhere ; but it is somewhat simulated at this poi- 
 S^of heCe andihe ope'ning made by, the trocar is liere situa^d 
 The Datella does not float, and is but slightly moveable. The popW^a 
 ^te^f fi led up by a firm material. No pain whatever ^s expeiienced 
 ^ L, n.. no- the heel or forcibly rotating the tibia on the femur. The 
 wrpaSCflexed ol^he thi^gh, and admits of some movements of 
 fl ^ l^.n 1 extelon but not to any great extent; it has been kept in 
 SSposH on fo eral months. He^c-^not bear any weight on the toes 
 of the S!^t foot, and in raising the limb from the bed be grasps the leg 
 ir. hi« liquids to aid the pelvic and crural muscles. , . n -i^ ,. 
 
 CarelSmaiiiprtion proves the tumefaction to involve, chiefly, if not 
 excl'sivey Je^condyleland lower part of the shaft of the femur, and to 
 
nctiire of 
 ivo closes 
 iiided by 
 ed plane, 
 tliougli it 
 itid wa? 
 Dt regain 
 •rest the 
 be joint 
 >lving fol- 
 forwarded 
 J informed 
 
 r a person 
 ucb ema- 
 frequent, 
 letite fair ; 
 i nation of 
 
 16 head of 
 
 the aftt-r- 
 
 »rphia, and 
 
 extending 
 lur. It has 
 mbrane of 
 the rest of 
 tli«re is no 
 r the exter- 
 on is expe- 
 the patella 
 I here two 
 ubstanceof 
 ;sue of the 
 m inwards, 
 f the outer 
 le latter in 
 No distinct 
 at this por- 
 re situated, 
 le popliteal 
 expeiienced 
 emur. The 
 )vements of 
 )een kept in 
 
 on the toes 
 asps the leg 
 
 liefly, if not 
 jmur, and to 
 
 be really an enlargement of that bone. The probe passed tlirongh tlie 
 orifice made by the trocar, appears to enter the condyles of the femur, 
 and, at the depth of .3 inches, tou(!hes bare bone. Tiie diseased knee 
 njeasures 3 inches more than its fellow ; there is much wasting of the 
 thigh and leg. 
 
 In discussing the nature of the case wiih Dr. Butler, I agreed with him 
 that it was not an orilinary ease of chronic articular disease with ulcera- 
 tion of the caitilagesand disorganization of the joint, although thiMc was 
 probably some thickening of the synovial membrane ; and gave it rs my 
 opinion, that it was probably an instance of myeloid disease of the end o*' 
 the femur ; but admitted the possibility of its being malignant disea'^e. 
 
 My reasons for tlils opinion were the following : the blow received 
 from the sleigh-tongue was not on the joint, but a little above the outer 
 condyle) ; it was not immediately followed by swelling and tenderness of the 
 articulation, suggestive of synovitis ; nor, for some weeks, by pain at the 
 injured part. At no time throughout the case had the pain been severe, 
 as if the articulation were becoming disorganized ; the fluctuation ob- 
 Bevved when Dr. B. first took charge of the case, disappeared under 
 suitable treatment, but there was no corresponding improvement in 
 the other symptoms, and the enlargement continued to augment ; 
 although the disease had originated 21 months previously and had ren- 
 dered the leg useless and incapable of bearing any weight, the ordinary 
 symptoms of ulceration of the cartilages and caries of the articular 
 surfaces, were absent, and'had never been present ; the trocar had evacu- 
 ated chiefly blood and a thin straw-coloured fluid, very unlike pus ; the 
 enlargement, when seen by me, involved very plainly the condyles 
 and a portion of the shaft of the femur, rather than the knee joint ; it 
 was a circumscribed globular enlargement of the end of the bone, and 
 the outer part of the tumor contained moveable, yielding bony lamina;, a 
 symptom which I had before noticed in a case of myeloid disease of the 
 condyles of the femur. 
 
 Thej5e features indicated disease of the femur of the nature of a 
 morbid growth, with slight secondary implication of the synovial mem- 
 brane of the joint. 
 
 The circumstances which appeared to render it likely that the tumor 
 was not caicinomatous, were its comparatively slow growth ; the absence 
 of severe pain throughout his illness; the unimplicated state of the inte- 
 gument, glands and internal organs; his tolerably fair state of health, 
 without any distinct in lications_ of cachexia; the enlargement not ex- 
 tending along the bone so as to form an oval, elongated tumor, which is 
 the rule in carcimona of bone and osteoil cancer; and the non-existence 
 of malignant disease in his family. 
 
 Malignant disease being thus excluded, it remained chiefly to decide 
 between cartilaginous and myeloid tumor, for next to the carcinomatous, 
 these are far the most frequent varieties of tumor found involving the 
 condyles of the femur. It was not possible to say with positiveness, 
 which of these growths was present in this instance, as Iheir general 
 characters are very similar— but, inasmuch as cartilaginous tumors of long 
 bones, almost invariably begin on the outside ofthe bone and form 
 irregularly nodulated tumors, as they consequently must, very seldom 
 
6 
 
 ;l 
 
 indcpd, lidvo osseous plates emboddcrl, or sot as it were I'n a yielding 
 inc'inbraiie, forming tlicir exleiior — and wonid bo moio likely, when 
 
 f)iin(!tured, to be found dry, or to emit a tenacious jelly-like or synovial 
 ookiiig, ratluT than a sanjriiinoous lliiid, I tliought it highly probable 
 that wc ha<ltodo with a myeloid tumor. This species, Ix^oins almost ex(du- 
 sively in the cancellous tissue within the ends of long bones, and causes a 
 gradual expansion of the osseous walls into a smooth globular shell ; the 
 ossific matter may be at points deficient, and replaeed by a fibrous mem- 
 brane, the periosteum, thus giving rise to a sign which I am disposed to 
 regard as of much value as in indication of myeloid disease, viz : a distinct 
 yielding of the tumor's walls under pressure, and a sensation, as if thm 
 plates of bone, not unlike an egg-shell, yielded or oven i,"oke under the 
 fingers. Myeloid tumors, moreover, being highly vascular and contain- 
 ing chiefly a substance of the consistence of flesh or spleen, would not 
 only yield blood when punctured, but would permit a probe to be easily 
 passed into their centre without its impinging on hard, resisting bone or 
 cartilage. 
 
 An example of myeloid tumor of the condyles of the femur which I 
 had an apportunity of seeing in the General Hospital of this city, under 
 the care of my colleague. Dr. Scott, in the spring of 1854, also presented 
 the last three signs, and indeed, corresponded in almost every other fea- 
 ture with the case forming the subject of this ]>aper. 
 
 The patient was a tolerably healthy looking man, about 40 years of 
 age, Avho, for a considerable time (some two years I believe) had been 
 the subject of an affection of the lower end of the left femur, which had been 
 long and unsuccessfully treated as disease of the knee, in Glengarry, and 
 was then sent to this city for further advice 
 
 There was a smooth, uniform enJargement of the member above the 
 articulation ; this enlargement was most manifest over the external con- 
 dyle, at which part it was somewhat yielding and obscurely fluctuating ; 
 careful manipulation detected at the lower part of the external condyle 
 a thin shell of bone, which crackled under the fingers, and was continu- 
 ous with the more yielding wall of the enlargement higher up. The 
 day before the removal of the limb, an exploratory puncture was made, 
 when blood alone escaped, and the probe readily traversed the heart of 
 the tumor and touched its opposite Avail, whi(;h was formed by the internal 
 <!ondyle. The movements of the joint were very little impaired, and 
 not attended with pain. It proved to be a myeloid tumor, originating 
 wiiliin the condyles of the femur, and causing at first their expansion, 
 and ultimately the absorption of a ])ortion of the ontcr side of the ex- 
 ternal condyle — but not implicating the articulation. 
 
 This case instantly recurred to my recollection Avhen examining 
 Dr. Butler's patient, and infiuenced my decision very materially. Removal 
 of the limb above the tnmor was recommended, and a fortnight subse- 
 quently, the patient having consented, Dr. B. amputated at the centre 
 of the thigh, and kindly sent me the diseased parts for examination. 
 
 The integument covering the enlarged knee of natural color ; very 
 few moderately large veins being visible in it. The joint is much enlarged, 
 and lias a circumferance of IC inches on the level of the upper part of 
 the patella. The enlargement extends upwards to about the extreme 
 
 ; 
 
 
 
a yielding 
 koly, wlion 
 or synovial 
 ly probable 
 most ex(;lu- 
 tid causes a 
 • shell ; the 
 H'ous inem- 
 ilisposod to 
 : a distinct 
 , as if thm 
 ! under the 
 lid contain- 
 , would not 
 (> be easily 
 !ig bone or 
 
 ur which I 
 city, under 
 
 presented 
 ' other fea- 
 
 10 years of 
 ) had been 
 :}\ had been 
 igarry, and 
 
 : above the 
 ;tcrnal con- 
 luctuating ; 
 lal condyle 
 as continu- 
 [• np. The 
 '/vas made, 
 lie heart of 
 :,he internal 
 )airod, and 
 originating 
 expansion, 
 
 1 of the ex- 
 examining 
 r. Konioval 
 ight snb.<e- 
 
 the centre 
 nation, 
 olor ; very 
 h enlarged, 
 per part of 
 le extreme 
 
 limit of the reflection of the synovial membrane of the joint. Tlie ci ural 
 muscles are wasted and rather pale about the articuhition ; some portions 
 of .hem at their attachments lo the shaft, where it becomes continuous 
 with the tumor aie much altered in structure, being dense, indurated, 
 semi-transparent, and infiltrated with a serous fluid ; they cut as if they 
 had undcivone lardaceous degeneiation. At two or three points, vvheie 
 in contact with the anterior surface of the tumor, the muscle to the 
 depth of J^ to ^ an inch has been transformed into a pulpy detritus of 
 a pale brick color, all trace of fibre being lost. A good deal of very 
 dense fat in the popliteal space. On removing all tlie soft parts, a glo- 
 bular tumor is exposed, occupying the lower end of the femur, its con- 
 dyles, and a portion of the shaft. This tumor, of a reddish brown hue 
 on its anterior aspect, and a dark bluish colour on its posterior, is com- 
 posed almost completely of a thin shell of bone anteriorly, a thin, firm 
 membrane posteriorly^, with the healthy looking articular cartilage and 
 H layer of the adjacent osseous tissue forming its lower boundary. At 
 several points besides the posterior aspect, the bony shell is replaced by 
 membrane, and this is most remarkable over the lateral aspect of the 
 external condyle, where two moveable plates of bone, continuous with 
 the thickened periosteum, forms about a third part of the outer wall of the 
 tumor. The trocar had penetrated the tumor upon this aspect, and 
 the probe introduced during life had here entered the cavity of the tumor, 
 instead of the joint. The growth had not implicated the joint; ilie ar- 
 ticular surfaces of which are free of ulceration and caries; the syno.iai 
 membrane, however, is smnewhat thickened, and covered by a pinkish, 
 tolerably firm, though easily broken down exudation, which has produced 
 adhesion of the patella to the femur, and the other opposed surfaces form- 
 ing the articulation to each other. No fluid exists in the joint, indeed 
 there is no j)lace for any. 
 
 Circumference of the tumor above the condyles 12|- inches, around the 
 condyles, including the adherent patella, 12i inches. 
 
 A longitudinal section of tumor exposed the shaft of the fonmr termi- 
 nating abruptly, as though broken off, half an inch within the osteo-mem- 
 branous tumor. It now appears that the walls of the tumor are continuous 
 with the periosteum of the bone, and apnaiently formed by or covered 
 with it. Along the upper and anterior aspects of the internal half of 
 the tumor there, is unequally distributed bony matter, evidently con- 
 sisting of the expanded condyle, and perhaps of bone, newlv formed from 
 the inner surface of the periosteum; the latter, occupi('d the surface of the 
 tumor, and the former, the lower extremity (articular). Besides 
 three or four osseous laminic projecting inwards from the w;dls, the 
 contents consisted chiefly of a deep-red, sofi substance, generally of 
 consistence of soft butter, but interspersed with irregularly branched. 
 I lines of tougher and firmer consistence ; various shades of redness exist 
 I. in this material, and it is streaked here and there with opaque yellowish 
 .| whito lines and spots, so as to remind one of a hej'atized portion of lunfj 
 :| traversed here and there by bionclii. This material, save wlieie mettled 
 i| by whitish streaks, resembh s very much the spleen pulp in color and 
 ;| consistence when that organ is slightly softened. Besides this red ma- 
 '■; terial, tliere is another of the colour of the marroiv in the shaft, but softer ; 
 
riT 
 
 i| 
 
 it occupies a scrios of ovnl, cyst-liko cximmionB or ccIIh in tlio l)onc, 
 fonnini,' tlui nntero-siiperior aspoct of tlio tmnor. Tli<»o loculi in the 
 ('xp:ui.le<l l)ntiy portions of tlio tumor aris numerous, ami vary in siz.- from 
 those cjipahle of ho!(linj,'H jK-a, to one c.a\uhlt of liolding n l.fiuiam's (W 
 The largest one contains a mixture of the red and the whitish mjiterial. 
 the former greatly prepoiKK'raiini,'. Indeed, the oval glol.uhir arrange- 
 ment is remarkable throuijliout tlie tumor, and the laree central mass of 
 pulp, is itself egg-shape. 1, and mav he as easily turned out, leaving the 
 wall of the tumor free, as a kernel is out of a nut 
 
 The medullary canal of the femur for about one inch atid a lialf from the 
 cyst is filled with ossific, cum ellated tissue. 
 
 The red pulp, examined mic-roscopically, exhibited an abundance ot 
 large cells, enclosing numerous large oval nu(dei ; most of tho>e poly- 
 inu-leated ccdis weie circular or oval, and only two or three api)eaied to 
 have caudate processes ; in<leed, they resembled the mother cells 
 fi(TurGd by Lcbert (pla e xiv. figs 5 and 0), rather than those delineated 
 by Mr. Gray, Drs. Gull, Bristow, and others. In the white portions ot 
 the tumor, the many nucleated cells (contained fatty granules, as though 
 undergoing fatty degeneration. Many large cells also, contained nume- 
 rous pigment granules. Innumerable fusiform cells, or elongated nuclei, 
 were scattered throughout the tumor. 
 
 The term myeloid was proposed by Mr. Paget,* for a class 
 of tumors first described by M. Lebert in 1845, under the title iw- 
 menrs fibro-pldstiques on sarcomuteuses:'\ The latter pathologist included 
 under this head (growths whose histological structure consisted chictly ot 
 elongated fibre-cells, like those found in granulations, or contained inad- 
 diticm, " mothercells," i. e. cells containing several di.Minct nuclei, identical 
 in cliaract.T with those of the diploe and marrow of fcetal bones. I he 
 former pathologist regards growths composed chiefly of the many-nuc e- 
 nted cells as quite distinct in nature from those made up of elongated 
 fibre-cells, although, he admits that both these structures usually co exist 
 in the myeloid growth ; and to obviate objections, I have not, except in 
 one instance, ti.bulated any tumor which did not contain the poly-nuclo- 
 ated cells in sufiicicnt abundance to justify the application ot myeloid ; 
 the exceptional case however, in its clinical history and anatomical nakea- 
 eve characters admits of no other allocation. _ i ^ -i {• .i. 
 
 It is not my intention to furnish you with an account in detail ot the 
 hi6tory,-clinical, pathological and histological, of myeloid tumors— this 
 vou will find in the woik^ of the authors above mentioned, and in two 
 excellent papers, in the Medico-Chin.roical Transactions for 1856, and 
 Guy's Hospital Reports for 1857 ; the former by Mr. Henry Gray; the 
 
 latter by l>r. ^- ilks. . .- c e ,\... 
 I purpose merely giving the results of my examination of some ot the 
 features presented by 38 specimens of the disease recorded by competent 
 authorities. The table appended to this paper supplies the materials em- 
 ployed, and the sources whence they were derived. There are tour 
 alditioual cases tabulated separately, as some doubt exists as to whether 
 they were purely myeloid growths or not . 
 
 * Lectures on Surgical Pathology, American edition, p. 446. 
 + Physiologic Palhologiquc, luiiie 2, p. 120. 
 
9 
 
 tlio l)onc, 
 :iili ill the 
 [1 sizi' from 
 (ain's vasi' 
 I iiiiitoruil. 
 r {uriiiigc- 
 iil mass of 
 jiiviiig the 
 
 If from the 
 
 II n (Ian CO of 
 Llic^e poly- 
 ppeaiecl to 
 other cells 
 
 deliiioated 
 tortious of 
 
 aa tliough 
 ined mimc- 
 ited nuclei, 
 
 r a class 
 title " Tm- 
 is^t included 
 il chiefly of 
 ined in ad- 
 ei, identical 
 ones. The 
 lany-nucle- 
 f elongated 
 vUy CO exist 
 t, except in 
 poly-nuclo- 
 f myeloid ; 
 lica! naked- 
 
 etail of the 
 I mors — this 
 
 and in two 
 ■ 1856, and 
 
 Gray; the 
 
 some of the 
 f competent 
 alerials era- 
 re are four 
 i to whether 
 
 
 1. Myeloid tumors appear to oc «rwith about cr|ual frequciiry in both 
 sexes; thiiH. of the 38 cases, 15 v.^ro malen, 18 fcmak's, and in five the 
 sex is not stated. 
 
 2. An apparent exciting cause is mentioned in 10 instances; it is not 
 alluded to in 15, and is said t> he ahsi nt in 13. In the 10, an injuiy of 
 the part is the cause assigned, which is about ^th of the whole nuuibe'r, a 
 larger proportion than is assigned to injuries (jih) by Mr. I'aget in ilio 
 causation of cancer. The nature of tlie injury was in 7, either a blow 
 or fall, or succession of blows, and in the other 3, respectively, a sprain, a 
 strain, and a flight injury while swinging. 
 
 3. The ficcpjoncy of myeloid disease at various epochs of life was as 
 follows : 
 
 YEARS. 
 
 From 12 to 20— 9 cases. 
 
 20 to 30—14 " 
 
 30 to 40— 4 " 
 
 40 to no— 2 " 
 
 50 to (JO— " 
 
 60 to 70— " 
 
 70 to 74— 1 " 
 
 30 
 
 4. It is an interesting feature in the history of myeloid tumors of hone 
 as compared with cancerous, that the tbrmer occur chiefly before 40, 
 while the latter are almost as frequent after 40 ; thus, of the 3U cases of 
 myeloid tumor in which the ages are shewn, 2*7, i. e, 90 per cent were 
 under 40 ; 3, i. e 10 per cent were over 40. Of 54 cases of cancer of bone 
 (*) 33, /. ('.01 percent wore imder 40 ; 21, i. e. 40 per cent were over 40. 
 On the other hand, it is not a little singulai that cancer is of e(pial fiequency 
 with myeloid in early youth, say under 20 : thus, of 54 casiis of cancer, 21, 
 i. e. 30 per cent were under 20 ; of 30 cases of myeloid, 9 i. e. 30 per 
 cent were under 20. If the comparison be extended to the deeade be- 
 tween 20 and 30, it will be found that myeloid disease of bone becomes 
 much more frequent at that period of life than cancerous. Thus, of 30 
 cases of myeloid, 14, i. e. 47 per cent occurred between 20 and 30 
 while of 54 cases of cancer, only 11, t. e 20 per cent occurred between, 
 20 and 30. Hence, if such limited numbers may be relied on, it follows, 
 that if the patient be over 40, the chances that a tumor of a bone is can- 
 cer rather than myeloid are as 40 to 10 ; if between 20 and 30, the 
 chances are in favor of myeloid, as 47 to 20 ; but if under 20, they are 
 about equal. 
 
 5. The proclivity of the bones, especially of the long bones, and of 
 these, their articular extremities, to myeloid tumors is shown by the 
 table ; thus, in 34 of the 38 cases, the bones were the parts aftectod ; of 
 these, 25 were long bones, or 73 per cent ; and of the whole 25 the dis- 
 ease occupied the articular ends. 
 
 Even in the 4 cases in which osseous tissue was not involved, the growth 
 was .attached to the periosteum 3 times, and the dura-mater (analagous 
 to periosteum) once. 
 
 (*). Paget's Surg. Pathology, p. 55. 
 
10 
 
 It 
 
 II!! 
 
 The special sites of the tumors were as follows : — 
 
 Oondj'les of femur in 12 
 
 He-id of tibia in 7 
 
 Upper extremity of fibula in 2 
 
 Lower extremity of fibula in 1 
 
 Head of humerus in 2 
 
 Lower end of radius in 1 
 
 Superior maxilla in 4 
 
 Inferior maxilla in 2 
 
 Scapula ....in 1 
 
 Patella in 1 
 
 Vault skull in 1 
 
 Dura Mater in 1 
 
 About great toe in 1 
 
 Outside radiu3 at wrist in 1 
 
 Ptriostei'm of tibia near ankle in 1 
 
 38 
 
 In one instance, (c 28) the growth had extended from the femur into 
 the articulation and involved the pntoUa and tibia; and in another, (c 38), 
 the synovial cavity and space bet. een the articular surfaces of the fenuir 
 and tibia v;as occupied by the growth, and yet the cartilage covering 
 those surfaces was intact. Myeloid disease, like carcinomatous, is ex- 
 tremely litile pror to implicate cartihige. 
 
 6. Tiie irritation excited by the growth in the head of the bone may, 
 and frequently does excite inflammation in the contiguous articulation, 
 but this is of an adhesive, rather than of a suppurative and destructive 
 character. In the specimen now on the table, the cavity of the joint was 
 obliterate'] by tolerably firm adhesions. In one of Sir. B. I5rodie's cases, 
 (c 7), old adhesions were found between the articular siufaccs. The 
 circumstance that the inflammation of the joint whicli supervenes u|ion 
 myeloid disease of the articular extremity of a bone, is a'lhesivo rather 
 than suppui'ative, is not pecnliar to that growth, for it has been observed 
 to obtain in cancer invading the same locality, and is no doubt also the 
 rule in cartilaginous tumors. 
 
 7. The cases collected furnish no positive information as to the dura- 
 tion of life when myeloid tlisease is permitted to pursue its course without 
 surgical interference. Case 34, in which the growth engaged the dura- 
 mater, terminate'l fatally tivo months after the first manifesiation of the 
 head symj)toms; case 24, in which the cranial vault was the site of the 
 growth, closed with head symptoms three years after the first indications 
 of the disease; how long these patients might have lived, had not the 
 grr wths interfered with the functions of an organ essential to life, it is im- 
 possible to say ; case 39, bc-idos ueing of a doubtful nature, had its natural 
 course modified, probably much ai-celeraled by 35 tappings, G injections 
 with iodine, and 2 setons. 
 
 8. An examination of these cases however, proves that tne average 
 duration of life after removal of mycU>id tumors far exceeds its average 
 duration after reiiiovai of cancer. Mr. Paget assigns as the average du- 
 rati(jn of lite under these circumstances, 28 luonths tor medullary 
 and 49 months for scirrhous cancer. l)Ut of 21 persons who survived 
 the removal of myeloid tumors, and the duration of whose disease is 
 
n 
 
 in 12 
 ill 7 
 
 in 4 
 in 2 
 
 38 
 femur into 
 lier, (o 38), 
 ' the femur 
 c covering 
 )us, is ex- 
 bone may, 
 rticulation, 
 destructive 
 D joint was 
 lie's cases, 
 ices. Tlie 
 •encs upon 
 >ivG rather 
 II (.il)served 
 bt also the 
 
 > tlie dura- 
 'se without 
 1 tlie dura- 
 tion of the 
 site of the 
 iidii-ations 
 ul not the 
 fc, it isira- 
 its natural 
 injections 
 
 e average 
 ts average 
 i'craiii'e du- 
 mechdhiry 
 ) survived 
 disease is 
 
 I 
 
 had manifested'itself by svinnioms IFnw n,- I, i ° ' /i •-— 
 
 conti.^ed to live, is a ,Uo^ ^ AUu!'Xi:n. '^"^^^ '''' "^^^ ''''' 
 tif Z7f^'^T'^ moreover to observe, that tho cause of dea 
 
 lungs (37). 
 
 myeloid, Avas published in 
 of* 4.1 " ""v. vj,t,^oiLu lasi .January (c 37). About two vpira 
 
 o?r ibuh cr :' 'Ttr^'^""' '- '"■'•"^"•'^'^ <i^Jz g 
 
 n ■ i 1 . . ^'f ^ '^'••-''' three tumors on the stump, which on excision 
 .loved to be myeloK ; and at his death, whicli followed th 
 
 ihn fntv,-^.., • 'e 1 ' "'■",■ '" "^"-'"-"j ""icii luiiowca the removal of 
 
 orfoTr."'^ "'"'^V'^^^ lungswere each found occupied by t ree 
 or torn nj elo d tumors, the largest the size of the hea, t. 
 
 It IS s , ted whether the disease recurred or not, and in some of' these the 
 
 K" f ir: ?" ^''P"' '^^^"r" ^^ ''^'"-^^l ^f ^'- g-rowtiraudX " 
 poll ot the case, ai)pears ratlier ' ■ ^ - '^ 
 
 for 1 
 
 cation of each case : 
 No. of cases 
 
 « 1| years 
 
 Inter^iiil. 
 
 1 
 
 -'oath 
 
 2 
 
 Ik 
 
 G 
 
 (( 
 
 U 
 
 years 
 
 2 
 
 (< 
 
 2^ 
 
 11 
 
 3 
 
 a 
 
 4 
 
 ct 
 
 5 
 
 (( 
 
 6 
 
 a 
 
 7 
 
 ti 
 
 10 
 
 (( 
 
 18 
 
12 
 
 ! 
 
 ! -I 
 
 being 7 months in medullary cancer and 14 months (*) for scirrhous, 
 the coin|)araiive innocence of myeloid is proved by its non-recurrence, 
 after an average interval of 26 months. 
 
 11. That malignancy is but a comparative term, as remarked at the 
 coramencemoiut of this [taper, is shewn by the disease now under consi- 
 deration. In one instance, relali.d by a competent ol«erver, Dr. Wilks of 
 Guy's Hospital, a pure myeloid tumor recurred in the stump two years 
 after the ablation of the original disease, and similar pathological struc- 
 tures were found in the lungs; the disease in fact, re-appeared both 
 locally and remotely. The lymphatics were, however, not affected, the 
 patient exhibited no sigiis of cachexia, and his death was due to acute 
 pleurisy, (o 37), 
 
 Mr. Paget also, relates a case in which, while the microscopic and 
 naked-eye characters of the tumor were those of myeloid, it exhibited 
 some features of malignancy, for besides tlic presence of " four small 
 masses of similar substance in the lungs," a *' similar material was dif- 
 fused in o«e of the cervical (flmds (c 39). In this instance then, one 
 lymphatic gland was contaminated, as well as the lungs ; still, the patient 
 exhibited no cachexia, but was of " healthy appearance." 
 
 12. Our piesent knowledge of myeloid tumors not only proves that 
 malignancy is not peculiar to cancer, although both terms'are generally 
 regarded as equivalents in pathological meaning, but tends to show fur- 
 thur, (A) that the same growth may contain the comparatively innocent 
 myeloid cells and the so-called specific cancer cells, and, (B) that a tumor 
 apparently myeloid in structure, or, (C) mixed myeloid and fibro-iJastio, 
 may after removal be succeeded by genuine cancer both at the original 
 site and in the internal vicera. 
 
 (A) The same growth -nay contain " myeloid " and " cancer-cells." 
 A lad, astat 18, had his leg amputated for a growth from the hef,d of the 
 fibula, whicii, in its general appearance, resembled other myeloid tumors " ; 
 but " it contained a large amount of bone mixed with the soft material." 
 *' Much of the myeloid matter was of a milky white colour, and to the 
 naked eye resembled cancer. The microscope, however, showed true 
 myeloid cells, but at the same time some very large sinr/le nucleated cells, 
 elsewhere called " cancer cells" by the reporter. A "few months after, 
 the boy became paralysed, and growths, also containing myeloid and 
 cancer cells, were found in the spine and in the lungs. TJiis patient was 
 markedly cachectic (c 42). 
 
 (B.) 1 have said a *umor apparently myeloid may be followed after 
 removal by genuine cancer, both locally and remotely. 
 
 Mr. Paget records tlte history of a tumor of the mamma, which he 
 concluded after caretnl examination to be "a myeloid tumor, suppurated 
 or possibly mingled with cancer." Six months after its removal a tumor 
 re-appeared in the axilla, grew larjre, ulcerated, bled freely, and was 
 really open cancer (c 41). 
 
 (C.) A mixed fibro-plastic and myeloid tumor mav likewise be fol- 
 lowed by cancer. A remarkable case is related by Mr."^ Hutchinson of a 
 
 » (*)• This rate is obtained by calcuhition made from Mr. Paget's table at p. 
 o25 01 ins work, Amuricau edition. 
 
13 
 
 r scirrlioua, 
 i-recurience 
 
 rked at the 
 nder consi- 
 )r. Wilks of 
 D two years 
 Dgical struc- 
 leared both 
 iffected, the 
 le to acute 
 
 )scopic and 
 it exhibited 
 ' four small 
 al was dif- 
 ;e then, one 
 , the patient 
 
 proves that 
 re generally 
 ;o show fur- 
 ily innocent 
 hat a tumor 
 ibro-iJastic, 
 he original 
 
 mcer-cells." 
 heul of the 
 d tumors"; 
 t material." 
 and to the 
 lowed true 
 hated cells, 
 )ntlis after, 
 ',yehnd and 
 patient was 
 
 owed after 
 
 , which he 
 sup])u rated 
 t'al a tumor 
 J, an(' was 
 
 k'ise be fol- 
 liiison of a 
 
 3 table at p. 
 
 I 
 
 tumor consisting of fibro-piastic and mv I structures, tlie former 
 largely predominating however, and involv. Jie head of the humerus 
 the removal of which was succeeded in 10 > ks by genuine medullary 
 cancer, both at the site of the previous operation and in the lungs. The 
 lymphatic glands, although enlarged, contained no cells resembfinrr can- 
 cer cells (c 40.) This last example is a further illustration of the difficultv 
 of a rigidly accurate classification, for in the original tumor, two histolo- 
 gical elements, now considered quite distinct and different, the fibro- 
 plastic and the myeloid co-existed ; teaching us in fact, that tumors in 
 their structure are often compound, and are competent therefore to the 
 occupancy of one, two, or three locations in the scale of classification 
 according as one or other of their histological elements is regarded as 
 their essential characteristic. 
 
 12. If case 39, about whose real nature Mr. Paget expresses some doubt 
 (not thatit wanted the naked eye and microscopic characters of myeloid, 
 but that it differed from all that was ihen known of that form of tumor),' 
 be regarded as genuine myeloid, then there are two instances on record in 
 which that growth implicated the internal organs as well as the externa!, 
 and one in which a lymphatic gland in addUion was involved i.fi two' 
 out of 39 cases. 
 
 RECAPITULATION OP CONCLUSIONS RESPECTING MYELOID TUMORS. 
 
 1. They occur with about equal frequency in both sexes. 
 
 2. Local injury was the apparent exciting cause of the growths in 
 about one-fourth the entire number, and in 13 of the 38 cases no cause 
 could be assigned. 
 
 3. Myeloid tumors occur chiefly before 30 yeai-s of age, for 1Q per 
 cent of the cases were un .'r that age, and 90 per cent were under 40- 
 they may occur at as advanced an age as 74. ' 
 
 3. While myeloid and cancerous tumors are of about equal frequency 
 under 20, myeloid are more frequent than cancerous in the ratio of 47 
 to 20 at the decade between 20 and 30. 
 
 5. Tiie bones are of all parts of the body most prone to myeloid 
 growths ; in about |tlis of the cases it is the long bones which are im- 
 plicated ; and in perhaps all cases, the disease begins in and is confined to 
 the articular extremities of such bones. 
 
 6. The condyles of the femur is the part of the body most obnoxious 
 to these tumors, probably the head of the tibia next, and the superior 
 maxilla next. Several other localities exhibit about equal susceptibility 
 VIZ : the head of the humerus, the head of the fibula and the inferior 
 maxilla. 
 
 7. No bone is probably exempt. 
 
 _ 8. Of the soft parts, it is chiefly the fibrous tissues, and especially those 
 m proximity to bones and articulations, that are most liable to myeloid 
 growths ; but they have been ravely seen in the lungs, in the neck, in a 
 lymphatic gland, and in the mamma ; in the last site, it was probably 
 associated with cancer. 
 
 9. These growths very seldom extend into an articulation ; this event 
 having been noticed only twice in 25 cases, in which the disease occupied 
 f T articular extremity of long bones ; I'ven should the articulation be 
 eutered by the growth, the cartilages are not usually implicated. 
 
14 
 
 10. Secondary inflrunmation occasionally is excited in the contiguous 
 articulation, but it i of an adhesive, rather tlian a suppurative cliaracter. 
 
 11. Data are wanting to determine the average duration of life when 
 myeloid tumors are not interfered with. 
 
 12. The average duration of life after removal of myeloid tumors far 
 exceeds its average; duration after removal of cancerous ; a laro-e pro]->or- 
 tion of the su'ijec;s of the growth were alive five years and eighth months 
 sul)&eqiiently to the operation. 
 
 13. Oftwo dciths which followed removal of the tumor at the respec- 
 tive intervals of five and two years, the cause was accidental and not 
 connected with the disease. 
 
 14. So far as we know, pure myeloid disease exhibits little pronencss 
 to recur after removal, there being only one instance yet recorded of that 
 event (c 37) ; (*) but, then, in only half the cases collected is the subject of 
 recurrence mentioned, and in many others sufficient time had scarcely 
 elapsed to justify any opinion. 
 
 15. While medullary cancer recurs on the average in 1 months, 
 and scirrhous cancer in 14, myeloid tumor in 18 instances, had not re- 
 turned after an average interval" of 26 months, and in 12 of these or two- 
 thirds, the period of non-recurrence, was three years and five months. ^ 
 
 16. Myeloid may exceptionally recur as myeloid both locally and in 
 remote oigms; the lymphatics enjoying immunity, and there being no 
 cachexia. 
 
 17. It may o-exist in an external part, in the kings and in alynipha- 
 tic gland, and even prove fatal without the presence of constitutional 
 cachexia ( c89). 
 
 18. The same growth may comprise both myeloid cells and so-called 
 " cancer cells," although in general appearance resembling myeloid 
 tumors, and be succeeded by similar compound tumors in the lungs and 
 spine, with marked cachexia (c 42.) 
 
 19. A tumor apparently myeloid, even on microscopic examination, 
 may be followed after removal by genuine open cancer in the vicinity of 
 the original tumor (c 41). 
 
 20. A tumor composed chiefly of fibro-plastic structure and partly of 
 myeloid, may be attended with enlargement of the glands, and when 
 removed, be rapidly succeeded by cancer at the site of removal and in 
 the lungs, the glands though enlarged not being cancerous (c 40). 
 
 21. Of 42 examples of growths apparently myeloid, two of which, 
 however, probably contained cancer cells, and one fibro-plastic elements ; 
 there were five in which the growth either recurred after removal, or had 
 involved remote internal organs. 
 
 10 Bonaventure street, March 11th, 1859. 
 
 (*) I purposely have omitted some cases of myeloid disease of the maxilla 
 which re-appeared after removal, appareutly in consequence of having been 
 only partly excised. 
 
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