Miiiiiiiiliiili^^ II, ;ttltiUiUH»UUtiHintitl >irii ATLAS OF CLINICAL SURGERY WITH SPECIAL REFERENCE TO DIAGNOSIS AND TREATMENT FOR PRACTITIONERS AND STUDENTS BY Dr. Ph. Bockenheimer Professor of Surgery in the University of Berlin. ENGLISH ADAPTATION BY C. F. Marshall, M.D., F.R.C.S. Late Assistant Surgeon to the Hospital for Diseases of the Skin, London. 2SHitt) 150 Colored Jfigurcs From Models by F. Kolbow in the Pathoplastic Institute of Berlin. >*'*K>^; NEW YORK REBMAN COMPANY 1123 BROADWAY Copyright, 190S, bv REBMAN COMPANY New York Entered at Stationers' Hall, liondon, England All rights reserved Printed in A nierica Biomrdical Library WO 517 Preface Those who are acquainted with the history of medicine know that, even in ancient times, it was sought to represent pictures of diseases by the aid of plastic art. No wonder then that, at the present day, when medicine has made such great progress in all domains, we take advantage of all measures which may facilitate the study of morbid conditions. The rich material of von Bergviann's clinic, which has been placed at my disposal, renders it possible to give plastic representations of all surgical dis- eases which are suitable for reproduction in this way. The models were executed with the greatest skill by F. Kolbow in the pathoplastic institute at Berlin, and have proved of much value in the teaching of clinical surgery. The models have been reproduced by the four- color process, which gives a more natural appear- ance than can be obtained in reproduction by water colors. In this work clinical pictures have been repre- sented with a view to assist the practitioner in diag- nosis, and to give the student a survey of the more important surgical diseases. For this purpose, the malignant and benign tumors, a number of pyogenic, tuberculous and syphilitic conditions which are common in surgical practice have been figured and described, along with numerous other cases which belong to the domain of surgery. In the text, which represents the teaching of von Bergmann's school, all cases described have been iii 67.S7W under the author's observation. Diagnosis, differ- ential diagnosis, prognosis and treatment are dealt with from the modern standpoint. The author begs to acknowledge his indebtedness to his master, the late Professor von Bergmann, and thinks this can be expressed in no better way than by an endeavor to give a true exposition of his teaching, which will always remain a landmark in the science of surgery. Ph. Bockenheimer. Berlin. IV Translator's Preface With the exception of Lister, few surgeons have had more influence on the progress of surgical science than the late Professor von Bergviann. We are, therefore, much indebted to Professor Bockenheimer for placing before us the teaching of von Benjmann's school in a concise and practical form. The repro- ductions of Kolbow's models have been executed with remarkable skill, and give a most faithful and life-like representation of the various diseases. In this English adaptation I have followed the original text pretty closely. I have added a few paragraphs in brackets where they appeared to be useful. C. F. Marshall. 27 New Cavendish Street, London, W. Complete Index of Plates Plate Abscess, gununatoiis XCV Abscess, subcutaneous LXVII Acne rosacea — Rhinophyma LIV Acromegaly — llacromelia — Macroglossia CXX Actinomycosis, incipient XCII Actinomycosis, progressive XCIII Amputations, amniotic C'XIX Aneurism, arterial LXIV Angiosarcoma of skin XIX Anthrax — Malignant pustule XC Anthrax, necrosis XCI Arthritis, gonorrheal phlegmonous LXXXIX .\rthritis, gouty CXIII Arthritis, tuberculous fibrous — osseous anchy- losis C Arthritis, tuberculous fibrous — white tumor. ... CI Arthritis, tuberculous fungous — fibrous anchy- losis XCIX .\rthritis, tuberculous purulent C Atheromatous cyst — carcinoma of skin XII Bronchocele XXXIII Biu-ns CVIII Bum, X-ray CX Bursitis, prepatellar XXXI Carbuncle . LXX Carcinoma of breast — cancer en cuirasse X Carcinoma of breast — carcinomatous lymphan- gitis XI Carcinoma of breast — carcinomatous lymphoma V Carcinoma of breast — disseminations IX Carcinoma of brea.st — Paget's disease VIII Carcinoma of breast, ulcerated VI Carcinoma of face I Carcinoma of forehead I Carcinoma of leg after burn XIV Carcinoma of lip II Carcinoma of lip — lupus Ill Carcinoma of nipple VII Carcinoma of nose II Carcinoma of penis — leukoplakia XIII Carcinoma of skin in cicatri.x XV Carcinoma of skin after wart XV vii "igure Page 121 299 , 314 85 189 70 140 150 381, ,410 115 293 116 293 119 331 ,408 82 169 26 34,46 112 287 113 287 111 282 141 377 127 317, ,338 128 317; ,339 125 317, ,335 126 317, ,337 18 24 44 85 136 355 138 365 42 82 89 202 15 16 16 16 10 16 14 16 13 16 11 16 1 1 2 1 20 30 3 6 5 6 12 16 4 1 19 27 22 30 21 30 Plate Figure Carcinoma of tongue, incipient IV 8 Carcinoma of tongue, ulcerated — leukoplakia . . IV 9 Carcinoma and papilloma of tongue IV 7 Chancre of tongue, syphilitic XCIV 118 Chondromyxosarcoma — malignant exostosis. . . . XXVI 34 Cla\iis — purulent arthritis LXXIX 100 Contracture, aponeurotic (Dupuytren) XLVI 60 Contracture, ischaemic XLVIII 63 Contracture, tendinous (after whitlow) XLVII 61 Dactylitis tuberculotis — spina ventosa CIV 131 Dermoid XXXVI 48 Dermoid — phimosis XXXV 47 Dermoid, recurrent XXXV 46 Detachment of skin LVII 73 Dislocation with fracture of leg — Pseudarthrosis. LI 66 Duct, persistent omphalomesenteric CXVIII 147 Elephantiasis nervorum — Fibromata moUusca. . LIV 69 Elephantiasis of penis, Ij-mphangiectatic LV 71 Encephalocele, occipital — Rhachischisis CXIV 142 Enchondroma of hand XXXVII 50 Endothelioma of parotid — Mixed timaour XXX 40 Endothelioma of skin XXIX 39 Erysipelas, erj'thematous LXXI 90 Erysipelas, hemorrhagic bullous LXXII 91 Erj-sipeloid LXXIII 92 Fibro-adenoma of mamma, cystic XXVIII 37 Fil)rolipoma, pendulous subcutaneous XXXIX 52 Fibroma of tendon sheath XXXVII 49 Fistula, median of neck XLIV 57 Fistula, from foreign body XLIII 56 Frost-bite CIX 137 Furunculosis LXIX 88 Furimculus — Lj-mphangitis LXIX 87 Ganghon, carpal XXXI 41 Gangrene, carbolic CVII 135 Gangrene, diabetic — .Arteriosclerosis CXII 140 Gangrene, dry — Mummification CV 133 Gangrene, moist — Decubital ulcer CVI 134 Gangrene moist, of foot CIV 132 Gumma of the lip and nose XCV 120 Gumma of the tongue XCIV 119 Hallux valgus — hammer-toe — Arthrogenous contracture XLIX 64 Hemangioma LVIII 75 Hemangioma, cavernous, of tongue XXVII 36 Hemangioma, cavernous subcutaneous LXII 80 Hemangioma, cutaneous and subcutaneous tel- angiectases LXIII 81 Hemarthrosis — compression of ulnar nerve — neurogenous contracture XLVII 62 Hematoma, diffuse — Hemophilia LIX 77 Hemorrhoids — Fibromata ani XXXVIII 51 Hernia, congenital umbilical CXVIII 148 viii Page 6 6 6 299, 311 34,62 232 115 122 118 317. 343 92 92 92 148 132 381,404 139 142 381,383 99 77 74 204 208 211 69 104 96 110 109 360 196 196 80 354 370 345 350 317. 344 299.313 299, 312 126 152 66 166 168 120 156 102 406 .381 Plate Horn, cutaneous — Sebaceous adenoma XXIX Hygroma, multilocular XXXII Infection, generalized LXXXVI Keloid, after laparotomy XLV Keloid, after vaccination XLV Lipoma, diffuse subcutaneous XL Lipoma, symmetrical subcutaneous XLI Lj-mphadenitis, circumscribed suppurative. . . . XCII Lymphadenitis, diffuse (Bubo) LXXXVIII Lymphangioma, congenital multiple CXVII Lymphoma, tuberculous, of neck XCVIII LjTnphosarcoma of neck XVII Mastitis, purulent puerpural LXVIII Melanocarcinoma of skin, after wart XVI Melanosarcoma of skin — Sarcomatous lymphoma XX Myelocele — Pes varus CXV Myelocystocele — Mj^olipoma CXVI Ncevus, neuromatous — X'eurofibroma of skin. . . . LIII Nebvus, pigmented hairy LII Nsevus, vascular LIX Nseviis, warty — Carcinoma of skin XII CEdema. malignant — Gangrenous emphysema- tous phlegmon LXXXVII Osteomyelitis, chronic, of humerus LXXXIV Osteomyelitis of lower maxilla LXXXII Osteomyelitis, acute LXXXIII Osteomyelitis of tibia — X'ecrosis LXXXV Ostitis, giimmatous XCVI Othematoma LVIII Papilloma of skin, inflanmiatory XXXIV Papilloma of tongue IV Paronychia LXXVIII Perforating ulcer of foot — Raynaud's gangrene. CXI Periostitis, purulent alveolar — Parulis LXXXI Petechise and hemorrhage, by compression LXI Phlegmon of neck — Wooden phlegmon LXXX Phlegmon, progressive putrefactive LXXIX Rickets — Greenstick fracture L Sarcoma, epipharj'ngeal — malignant nasal polypus XVIII Sarcoma of fascia, ulcerated XXV Sarcoma, fungoid, of orbit XIX Sarcoma, giant celled — Epulis XXVII Sarcoma of humerus, peripheral XXIV Sarcoma of mamma, cystic XXII Sarcoma of mamma, ulcerated XXI Sarcoma of skin, multiple XXIII Skin-grafting XLII Suggillations and Suffusions — Subcutaneous and Hematoma LX Teratoma, monogerminal CXVII Thrombophlebitis, acute purulent LXVI Tongue, geographical (Marginate glossitis) XCIV ix Figure Page 38 72 43 84 108 261 59 113 58 113 53 104 54 104 114 292 110 278 145 381,397 124 317,334 24 34 86 192 23 32 ,39 28 34,48 143 381,388 144 381,388 68 136 67 134 76 155 17 24 109 274 106 244, 259 104 244, 255 105 244, 257 107 244, 260 122 299,315 74 150 45 90 6 6 98 228 139 367 103 241 79 164 102 237 101 234 65 128 25 34,42 33 34,60 27 34,46 35 34,64 32 34,55 30 34,49 29 34,49 31 34,52 55 108 78 160 146 381,401 84 186 117 298 Plate Tuberculosis of hand CIII Tuberculosis of testicle CII Ulcer, gummatous XCVII Ulcer, varicose — Elephantiasis — Pachydermia. . LVI Unguis incarnatus (Ingrowing toe-nail) LXXVIII Varix, cirsoid — Pes valgus LXV Whitlow, iiit«rdigital LXXVII Whitlow, osteal and articular LXXVI Whitlow, subcutaneous — Lymphangitis LXXV Whitlow, subepidermal LXXIV Whitlow, tendinous LXXVII Figure Page 130 317,342 129 317, 341 123 299 72 145 99 230 83 174 97 213,227 95 213, 224 94 213, 223 93 213, 222 96 213, 226 Bockenlieiiiier, Atlas. Tab. 1. E o U IE E c u Rehiiian roni|)anv. New-Vork Cutaneous Carcinoma CARCINOMA PLANUM FACIEI (o/ the Face) Plate I, Fig. 1. CARCINOMA FRONTIS {of the Forehead) Plate I, Fig. 2. CARCINOMA NASI {of the Nose) Plate n, Fig. 4. Cutaneous cancers of the face are of great im- portance because they constitute almost a tenth part of all cases of cancer {Gurlt, Heivxann). The nose, eyelids, cheeks, temples and forehead come in the first line, while the chin and ears are least affected. In youth, these tumors very seldom occur, and then originate in various ways from the basis of a Xero- derma pigmentosum (Kaposi). From the fortieth to the seventieth year the disease is common and develops from pre-existing warts, cutaneous horns, adenomata, dermoid or atheromatous cysts {H. Wolff), as well as from diseases which cause chronic irritation of the skin (erysipelas, eczema, tuberculous and syphilitic ulceration). In old country people the flat cutaneous carcinoma (Figs. 1 and 2) occurs very frequently, and can be traced to early wrinkling of the skin, uncleanliness and senile seborrhea, causing an accumulation of dirty scales on the skin. By scratching this epider- mic accumulation, superficial easily bleeding sores are formed, which, however, heal quickly so long as they are not cancerous. The Carcinoma planum faciei {von Schnh's "ulcus rodens") presents itself at first as a hard, flat, reddish nodule, which, when scratched or broken, 1 forms a flat ulcer with little tendency to heal. Of slow growth, and only attaining a conspicuous size after some years, it generally remains a long time unnoticed by the patient, especially as it causes no inconvenience. When it presents itself as a growing superficial ulceration, this generally has a circular form with hard, raised edges of overlapping thinned epidermis; while the floor of the ulcer is, for the most part, soft at first, and the whole growth is movable over the deeper structures. In the region of the chin especially there is a re- semblance to the syphilitic chancre or gumma, but the base of the cancerous ulcer is distinguished by manifold irregularities and fissures. Easily bleed- ing granulations alternate with more yellowish, fatty looking parts (Fig. 1). It is characteristic of these cutaneous carcinomata that plugs the size of a pin's head can be pressed from the yellow surface of the ulcer; microscopic examination shows that these consist of broken-down, fatty, cancer cells. The ulcer is often covered by a scab so that the diagnosis is only possible after its removal. As the tumor extends there appear radiating contractions of the surrounding skin and consequent deformity (of the eyelids, for example). The original circular shape is then often wanting, and the outline becomes irreg- ular (Fig. 2). At first superficial, the tumor may after some years extend to the deeper parts and cause extensive destruction; for instance, of the bones of the face (Fig. 4). This deep extension is especially seen in parts where the subcutaneous fatty tissue is not developed (the temples, bridge of the nose and zygomatic arch, Figs. 2 and 4). The deep growth is evident at the commencement in the slight mobility of the tumor over the subjacent structures. On account of the spontaneous cicatrization, which may take place at different parts of the ulcer or over its whole surface, although it is not perma- 2 nent, these growths were formerly wrongly placed in the group of benign tumors (canci'oid). Their mi- croscopic structure is in most cases that of squamous- celled, epithelial cancer, which by extension into the deep glandular regions may later on cause metas- tatic growths in the organs (Virchow). Differential Diagnosis. Carcinoma is distin- guished from papilloma or adenoma by its hard edges and the characters mentioned above. Treatment. Transient epidermization can gen- erally be (luickly obtained in small flat cutaneous carcinomas by aseptic and antiseptic dressings. A permanent healing is, however, not to be obtained in carcinoma by this means, nor by caustic pastes (Vienna paste, etc.), nor by treatment with X-rays or radium. Such healing is only deceptive, for the cancer extends deeply and gives rise to metastases; hence the only rational treatment of cancerous ulcers is early excision about one centimeter beyond the edge of the ulcer in the healthy tissue, and of sufficient depth. Infiltration anaesthesia should not be employed, for it obscures the limits of the tumor. Diseased glands, which can be recognized as small hard lumps, should always be removed. In excision no regard must be paid to adjacent parts (e.g. eyelids). The defect can be remedied by plastic surgery, especially by DieJJenbacfis methods. Recurrence seldom takes place in carcinoma planum after early excision. Fig. 1. Shows a flat cutaneous cancer in a typical situation on the face: still clear of the subjacent tis- sues. Cured by excision, and repair of the defect by a pedunculated flap from the left part of the forehead. The defect in the forehead was repaired by Thiersch's grafts. Fig. 2. Advanced carcinoma of the skin with 3 irregular borders. The growth has already extended to the bones. The upper eyelid and the ocular con- junctiva are also involved. This is a case of the rare form of cancer of the skin first described by von Bcrgmann, which in its early stages appears in the form of small multiple nodules and may there- fore be mistaken and treated for tuberculosis cutis (lupus). The raised, irregular, hard edges of the ulcer point to the correct diagnosis, which in doubt- ful cases should be cleared up by removal of a piece for examination. Previous treatment by the X-rays had caused a rapid extension of the carci- noma, so that the patient, on account of the very advanced local disease and the severe cachexia from organic metastases, came to the clinic in an inoper- able condition. Treatment of inoperable carcinoma: Antiseptic dressings with potassium permanganate and peroxide of hydrogen; later on, cauterization. Fig. 4. Cutaneous cancer with extensive deep growth. Destruction of the nose, both of the bony framework and of the ethmoid cells. This form of cancer in its early stage consists of subcutaneous nodules covered by unaltered skin. The skin gives way when the nodules break down and a very extensive and deep cancerous ulcer results. This may be mistaken for a gumma, but the latter is not so ragged and has a yellow core. (Cf. Fig. 120.) The presence of epithelial plugs is also characteris- tic of this form of carcinoma. Microscopical exam- ination and antisyphilitic treatment with iodide of potassium will decide the diagnosis in doubtful cases. The papillomatous forms (Fig. 4) which often give rise to deep cutaneous cancer, through their rapid growth and metastatic formations, must be regarded as extremely malignant tumors. The permanent results are generally favorable after extensive operations, which often involve re- moval of diseased bones (v. Bramann, Grosse). When carcinoma of the face extends through the dura mater, operation is not indicated, and the case must be treated according to the rules for inoperable cancer. In all extensive carcinomas of the face the patients may die from septic pneumonia when the destructive process reaches the buccal cavity. A special form of cancer arising in the deep parts of the corium as cancerous nodules constitutes what Krompecher described as basal-celled cancers. Ac- cording to Coenen these are not to be classed with endotheliomas, as formerly, for they arise from the basal cells of the sweat and sebaceous glaud epithe- lium, or from the epithelium of the hair follic'«s. In distinction to the other cutaneous cancers they do not become cornified, and were, therefore, classed hy Borst among the endotheliomas. Multiple carcinomas of the face have been noted by several observers {v. Bergmann, Coenen, Schim- melbitsch). Von Bergmann, in a case of carcinoma of the forehead, which after some years was followed by another in the floor of the mouth, was of opinion that these were separate, independent carcinomas, because metastases in the tongue and floor of the mouth are very rare, and there was a long time between the development of the two carcinomas. Carcinoma of the Mucous J Membranes CARCINOMA LABII INFERIORIS (o/ lower Lip) Plate II, Fig. 3. TUBERCULOSIS CUTIS (of the Skin) Plate III, Fig. 5. PAPILLOMA LINGUAE {of Tongue) Plate rV", Fig. 6. CARCINOMA ET PAPILLOMA LINGUAE {of Tongue) Plate IV. Fig. 7. CARCINOMA LINGUAE INCIPIENS {Incipient Carcinoma of Tongue) Plate IV. Fig. 8. CARCINOMA LINGUAE EXULCERATUM {Ulcerating Carcinoma of Tongue) LEUKOPLAKIA {Leukoplakia) Plate IV, Fig. 9. Cancers of the lips resemble cancers of the skin in their form and structure, for they are squamous- celled epitheliomas, and tend to cornification. They arise in the form of cauliflower-shaped, polypoid tumors on the mucous membrane of the lips, cheeks, and glans penis, or as deep ragged ulcers (lips and tongue), and appear in these principal forms in all mucous membranes covered with squamous epithe- lium. Carcinoma of the upper lip is very rare, but V. Bergmann has obsei'ved a case where a carci- noma of the upper lip developed within a few weeks after a cancer of the lower lip, in a symmetrical position. Carcinomas of the lower lip form 45.6 per cent, of all cancers of the face, nearly all occur- ring in the male sex. The action of tobacco must play a special role in the origin of cancel: of the lip, 6 Bockenheimer, Atlas. 'lali. U CO Rebman Company, New- York. for the patients, of both sexes, are mostly great smokers. Cancer of the lower lip often begins at the junc- tion of the skin with the red part of the lip, generally between the center of the lip and the angle of the mouth, as a small, hard nodule at first covered by mucous membrane. The mucous membrane soon becomes broken and the nodule grows, infiltrating the surrounding tissues rapidly, while the mucous membrane breaks down more and more and forms an ulcer. Antecedent diseases of the mucous mem- brane, such as tuberculosis and psoriasis (leuko- plakia) appear to predispose to carcinoma. The whole of the lower lip may be gradually destroyed (Fig. 3). Scabs and crusts form at several places on the ulcer, and when separated give rise to bleeding. While in its early stages the cancerous ulcer is recog- nized by its hard, raised edges and crateriform floor, the advanced cancer of the lip shows papillo- matous proliferations springing from the floor of the ulcer (Fig. 3). The more the carcinoma extends, the more it implicates the underlying bones and the mucous membrane of the cheeks and floor of the mouth, so that the bones and the buccal mucous membrane may be completely destroyed. The exu- dation of growing cancer of the lip gives rise to much cachexia, gastritis and enteritis, and the secretion may reach the lungs and cause death from septic pneumonia. In such inoperable forms the sub- maxillary and submental regions are usually filled with hard, fixed glands. Differential Diagnosis. Although these ad- vanced forms, which are often neglected, especially in country people, are unmistakable, there may be difficulty in the diagnosis of the early stage of the cancerous ulcer. The irregular, ragged surface of the carcinoma is in marked contrast to the smooth surface of primary syphilis, and the comedo-like 7 epithelial plugs which are characteristic of all squamous-celled epitheliomas can be extruded from it by pressure. The glands are affected very early in carcinoma, first in the submental region, and are usually, small, very hard and isolated, in contrast to the multiple glands in primary syphilis, which are not so hard and mostly situated at the bifurcation of the carotid. Isolated tuberculosis, or an ulcer extending from tuberculosis of the buccal mucous membrane or tongue, is very rare on the lip. It has in-egular edges which are not so raised and hard as those of cancer. The surface of the ulcer, which results from the breaking down of small tubercles, is of a reddish-gray color and bleeds very easily. It is usually covered with a single large scab. No plugs can be expressed from it. Glandular enlargement is soft and isolated. Ulcerated cavernoma (cavernous angioma) of the lip may have a cancerous appearance, but it usually occurs in children and is generally associated with other anomalies of the blood-vessels. The induration of fissures of the lips resulting from chronic eczema heals quickly under rational treatment, and is thus distinguished from carcinoma- tous induration. It is important to note that cancer of the lip occurs not only in old people but also soon after the thirtieth year. Treatment. All depends on early diagnosis, for the cuneiform excision of small tumors gives the best chance of a radical cure. In doubtful cases excision is to be preferred to antisyphilitic or antitubercu- lous treatment, so as to lose no time. In extensive growths, from one and one half to two centimeters of healthy tissue should be removed round the tumors, and the neighboring parts suspected of disease, such as bones and buccal mucous membrane, should also 8 Bockenheimer, Atlas. Tab. Ill Fie. 5. Carcinoma labii inferioris — Tuberculosis cutis. Rebman Company, New-York. be removed. The defect can be repaired by plastic operations, the best of which are Dieffcnbach'n or Jacsche's. Palpable glands should always be removed by separate incisions in the submental and submaxillary regions. The submaxillary gland which is often affected is best removed at the same time. By radical operation a permanent cure is possible even in extensive carcinomas. Fig. 3 shows a carcinoma involving the whole lower lip. Deep ulcerations alternate with papillo- matous outgrowths. In some parts there are scabs on the surface of the ulcers, in others isolated yellow epithelial plugs. The growth is hardly movable over the lower jaw, and is on the point of extending to the buccal mucous membrane. After free exci- sion of the tumor, removal of the enlarged glands in the submental and submaxillary regions, the exten- sive defect was repaired by double cheiloplasty {DiejfcnhacJi's operation) and a cure was obtained. Fig. 5 represents a large cancerous ulcer, originat- ing from tuberculosis of the skin, involving half the lower lip. The hard, raised edges of the ulcer divested of mucous membrane are characteristic. The floor of the ulcer is irregular and ragged and beset with yellowish epithelial plugs. Cancerous ulcers arising on the basis of tuberculosis of the skin have a great tendency to bleed. In contrast to the forms of hypertrophic lupus, which gives rise to soft, fungoid, slow-growing tumors, the hardness and rapid growth of the lupus-carcinoma is charac- teristic. Excision of the carcinoma, removal of the glands, and repair of the defect by DiefJenbacWs cheiloplasty led to a cure. Fig. 5 also shows a characteristic picture of differ- ent forms of cutaneous tuberculosis; lupus of the face. The disease appears most frequently in this situation and usually begins on the nose (tuberculosis 9 .of the nasal mucosa), and extends over the face in the form of a butterfly. The sharp, irregular outline on the forehead, neck, and behind the ears is charac- teristic. The disease begins with small reddish- brown nodules situated in the cutis giving rise to exfoliation of the epidermis (lupus exfoliativa) ; these become confluent and form flat, reddish-gray, easily bleeding ulcers (lupus exulcerans, which after healing leave radiating cicatrices, often after consid- erable destruction of tissue. (Fig. 5, ear.) After a time papillomatous proliferations may arise of soft and spongy consistence, especially about the ear (lupus hypertrophicus). These three forms are usu- ally present in the same patient (v. Bergmann). Treatment. In circumscribed forms excision of the skin with the diseased subcutaneous tissue is indicated, with repair of the defect by skin flaps. The diffuse forms are treated in v. Bergmanii's clinic by the sharp spoon {Volkmann). The diseased parts are scraped and the bleeding surface treated with Pacqueli7i's cautery or with hot air. Many sittings are often necessary in order to arrest the disease, and the patients often succumb from tuberculous disease of the internal organs, or relapsing facial erysipelas. Cancer of the buccal cavity occurs on the tongue, the floor of the mouth and the cheek. Cancer of the tongue (Figs. 7, 8 and 9) occurs almost exclusively in man (after the fortieth year), owing to the action of tobacco and alcohol. Antecedent lingual or buc- cal leucoplakia predisposes to buccal carcinoma; V. Bergmann finds it present in fifty per cent, of his cases of cancer of the tongue. Leucoplakia forms hard, white, opaline patches raised above the surface of the mucous membrane of the tongue, consisting of horny epithelium (hyperkeratosis). The surface, at first smooth, after a time becomes fissured, especially after excessive smoking, and the patches of leuco- 10 Bockenheinier, Atlas. lab. IV. Fig. 6. Papilloma linouae. Fig. 7. Carcinoma et Papilloma linguae. Fig. 8. Carcinoma linguae incipiens. Fig. 9. Carcinoma linguae cxiilccratum. I.euixoplakia. Rcbman Company, Ncw-\ork. plakia become clearly visible and at the same time take on deeper growth. Since carcinoma arises directly from these fissured patches of leucoplakia, which have absolutely nothing to do with syphilis,* removal of such large and fissured nodules should always be performed, especially as multiple carci- nomas of the buccal cavity have been observed under them. Microscopically, the direct transition from hyperkeratosis to carcinoma has not yet been con- clusively demonstrated. Besides leucoplakia, jagged carious molar teeth also act as exciting causes of cancer of the tongue, which explains the almost exclusive occurrence of cancer in the posterior part of the side of the tongue. The carcinoma appears in two forms, according as it arises from the superficial mucous membi'ane or from the glandular epithelium. The first form resembles the flat cutaneous car- cinoma and soon gives rise to a small ulcer with hard, raised edges (Fig. 7, right half) the fissured sur- face of which has a yellowish or dirty-brown appear- ance. Although the carcinoma is only superficial, the submaxillary glands are soon affected, owing to the abundant lymphatics of the tongue (Kuttner). The deep carcinomas form hard nodules over which the mucous membrane remains intact for a long time. After breaking down of the nodules and destruction of the mucous membrane, an extensive crateriform ulcer is formed with hard, irregular edges and deep fissures in the center. This often extends as far back as the epiglottis. Numerous epithelial plugs can be expressed from the floor of the ulcer, and often from the papillomatous proliferations. * Translator's Note — ^This statement is not in accordance with the teaching of Foumier and the majority of syphilologists, who regard buccal leucoplakia as almost exclusively of syphilitic origin. According to Foumier, cancer of the tongue is due to the combined effect of syphilis and tobacco. (See Foumier's Treatment and Pro- phylaxis of Syphihs, Rebman Company, New York.) 11 The patients suffer great pain from the irritation of free nerve-endings in the floor of the ichorous ulcer, and, in untreated eases, succumb usually within a year from glandular metastases extending along the carotid to the supra-clavicular region (Fig. 9). Early diagnosis is, therefore, of the great- est possible importance. Differential Diagnosis. The superficial carci- noma (Fig. 7) is recognized by the characteristic features of flat cutaneous carcinoma and differs from s^^hilitic chancre by its sharp, hard edges, the irregular floor of the ulcer with epithelial plugs, and the small, hard glands. As long as the flat carci- noma of the tongue is covered with mucous mem- brane it may in its earliest stages be confounded with papilloma (Fig. 6), especially in the rare cases where it lies more in the center of the dorsal surface of the tongue. Papillomas, however, generally appear as multiple, soft elevations the size of a pin's head, so that the surface of the tongue may appear furnished with small points, or may assume a lobulated form; or there may be fungiform sessile tumors, like stal- actites, which often form high projections and have a warty appearance (Fig. 7). That a flat carcinoma and a papilloma of this kind may occur independ- ently without microscopic transition into each other is shown by v. Bergmanrts case ("Handbook of Practical Surgery', III edition: Text-book of Sur- gery, II edition"). Small papillomata cause the patient hardly any inconvenience and can be re- moved with the sharp spoon or Pacquelhi s cautery. Larger papillomata should be excised (Fig. 7, left half). The diagnosis is difficult when, as in Fig. 8, a hard, carcinomatous nodule develops under a patch of leucoplakia. The irregular, deep, hard infiltra- tion and the rapid growth point to a commencing new growth, which should always be removed before it 12 breaks through, especially when there is leucoplakia over the nodule. Abscesses of the tongue, which result from injury by foreign bodies (steel pens, etc.), and form hard nodules in the substance of the tongue, are characterized by the early painfulness on pressure. Actinomycosis causes a more diffuse, wooden infiltration of the whole tongue and very soon interferes with its motion. (Abscess is treated by incision and actinomycosis by incision and scraping). The small carcinomatous ulcer of the edge of the tongue is liable to be confounded with ulcerations caused by the irritation of broken teeth (dental ulcers), especially when it is situated opposite a sharp tooth; however, the cancerous ulcer con- tinues to grow after removal of the offending tooth. Larger ulcerations which result from the breaking down of deep carcinoma may be confounded with gumma on superficial examination. The latter, however, is almost always situated in the center of the tongue or in its anterior part, and has the charac- teristic dirty-yellow, gummatous core, which can be removed without bleeding (Fig. 119), in distinction to the easily bleeding reddish-brown proliferations of carcinoma. Moreover, the pain radiating to the ear which is constantly present in large carcinomas, is absent in gumma; also the glandular metastases and the leucoplakia. The clinical picture of carcinoma is, therefore, so clear that antisyphilitic treatment for the purpose of diagnosis is not necessary. Excision for diagnosis, which is often inconclusive, is also to be disregarded (v. Bergmann). In cases where the diagnosis hesi- tates between carcinoma and the rarely occurring isolated tuberculosis, or between the still rarer sarcoma which is observed in young people at the tip of the tongue, complete excision should always be performed. 13 Treatment. Small carcinomas can be excised and the wound closed, after compression of the tongue by a ligature. Excision by Pacquelin's cautery and subsequent plugging may also be done. For large carcinoma a radical operation by section of the lower jaw is necessary (according to Sedilloi and Kocher in the middle line; according to v, Bergmann and Langenbeck, laterally) with subse- quent ligation of the lingual artery (cf. Bocken- heimer & Frohse's "Atlas of Typical Operations").* By this means not only can the tumor of the tongue be excised through healthy tissues as far as the epiglottis, but also the masses of glands which ex- tend from the submaxillary region to the ear can be removed. Even after extirpation of extensive portions of the tongue the patients, after a few months, can make themselves well understood. Permanent cures, are however, unfortunately rare, even after radical operations, in progressive cases of cancer of the tongue, especially when the lower jaw is involved and the glands have become fixed, so that some surgeons content themselves with the local treatment of carcinoma by caustics and cauter- ization. The treatment of cancer of the buccal cavity, which often arises on the basis of leucoplakia, in the same form and with the same symptoms, is carried out on the same principles. Fig. 6 represents a flat papilloma of the tongue which was removed with the sharp spoon. Fig. 7 shows on the right half of the tongue a superficially ulcerated carcinoma, while on the left half of the tongue there is an extensive papilloma. Both growths were removed by excision. Fig. 8 shows a deep carcinoma developing under a patch of leucoplakia; it is not yet ulcerated and is characterized by its hardness and irregular outline. This is exceptional in the center of the tongue. The ^Rebman Company, New York. 14 growth was removed by excision and subsequent suture. Fig. 9 represents the most common form of cancer of the tongue; a carcinomatous ulcer of the side of the tongue with extensive destruction, leucopla- kia and ghuidular metastases. After section of the lower jaw the growth was widely removed, the stump of the tongue sutured and the glands removed from the neck. 15 Glandular Carcinoma CARCINOMA MAMMAE (of Breast) LYMPHOMATA CARCINOMATOSA {Carcinomatous) Plate V. Fig. 10. CARCINOMA MAMMAE EXULCERATUM {Ulcerating Carcinovia of Breast) Plate VI, Fig. 11. CARCINOMA MAMMILLAE {of Nipple) Plate VII, Fig. 12. CARCINOMA MAMMAE (of Breast)— PAGETS DIS- EASE—ECZEMA CHRONICUM MAMMILLAE (Chronic Eczema of Nipple) Plate VIII, Fig. 13. CARCINOMA MAMMAE— DISSEMINATIONES (Disseminated Carcinoma of Breast) Plate IX, Fig. 14. CARCINOMA MAMMAE UTRIUSQUE(o/ both Breasts) —"CANCER EN CUIRASSE" Plate X, Fig. 15. CARCINOMA MAMMAE (of i?rfo*0— LYMPHANGITIS CARCINOMATOSA (Carcinomatous Lymphangitis) Plate XI, Fig. 16. Of the carcinomas of glandular organs those of the female mammary gland are among the most common (they take the third place). They show a typical unrestricted epithelial proliferation in their origin and development. Observations made on cancer of the breast, therefore, have manifold bear- ings on carcinoma of other organs. A division into soft, many-celled, rapidly growing tumors of which the medullary cancers represent the most malignant, and slow-growing scirrhous forms with few cells, is of clinical importance. The exciting causes include inflammatory irrita- tion, puerperal interstitial mastitis, eczema of the nipple, antecedent benign tumors (fibro-adenoma, 16 Bockcnheimer, Atlas. Tab. V. Fi^. 10. Carcinoma inainiiiac — L}-mph()mata carciiiomatosa. Bockenheimer, Atlas. Tab. VI. o t/. Ktbman Company, New-York. cysts) injuries, mechanical irritation, frequent par- turition with prolonged suckling ot" infants. Cancer of the breast is attributed by the public to injuries (blows), but these are often too recent to be accepted as an etiological factor, considering the slow growth of the carcinoma. It is a remarkable fact that of sterile women only 10 per cent, have cancer of the breast. In 10 per cent, of the cases there is said to be a hereditary tendency. Women are most often affected at the menopause (fortieth to fifty-fifth years), and come to the sui'geon with nodules in the breast which have been hitherto painless and are only accidentally observed. These nodules very soon form a malignant growth of hard consistency and irregular surface. The most important sign of a malignant new growth is the absence of any demarcation or encapsulation. The tumor cannot, like all benign tumors, be separated from the mammary tissue and moved freely, but is fixed immovably in the glandular tissue, with ill- defined boundaries, and is anchored in the meshes of the mammary tissue by numerous offshoots. The nodules, which at first appear harmless, thus soon show their malignity. ^Accompanied by lan- cinating pains in the thorax, upper arm and shoulder, the tumor sends its destructive offshoots in all direc- tions into the neighboring tissues, without limit or restraint, and reaching the surface adheres to the skin and causes retraction and fixation of the nip- ple. Finally, it gives rise to a hard inflammatory infiltration of the whole of the overlying skin. At the same time the tumor extends deeply and soon infil- trates the lymphatics beneath the pectoralis major muscle and also the regional lymphatic vessels and glands of the axilla (Fig. 10), which are usually affected about a year after the formation of the nodules in the breast, and take the form of hard, solid, painless nodules, which are often difficult to 17 feel in corpulent women. Extensive glandular af- fection gives rise to radiating pain and oedema of the arm (supra-clavicular glands). Although the cancer usually arises as a single nodule, there are cases in which several nodules develop simultaneously (Fig. 10) and extend through the whole breast to the axilla (Fig. 10). The prognosis is unfavorable in these cases, and in disease of both breasts (Fig. 15). The disease is very frequently situated in the up- per and outer quadrant of the breast, especially on the left side. The tumors situated in the outer half of the mamma towards the axilla, wrongly called paramammary carcinomas, are really glandular can- cers, for they originate in the offshoots of the mamma which extend towards the clavicle, sternum, axilla and twelfth rib in the form of long, thin cords. Cancer of the breast, like all cancers rich in cells (acinous, tubular), grows rapidly, especially during pregnancy, and causes destruction of the skin. A cancerous ulcer results, characterized like cutaneous carcinoma by its hard, raised, fixed borders, crateri- form base and sanious discharge. A hard infiltra- tion develops round the tumor which is usually fixed to the thorax. Small nodular thickenings of the ad- jacent unbroken skin sometimes constitute the first sign of commencing general cutaneous dissemination (Fig. 11). In this way the whole mamma may be transformed into a large ulcer (Fig. 15). In other cases a tumor is gradually developed involving the whole breast without breaking through externally. The skin, however, may be infiltrated and the redress may be mistaken for inflammatory infiltration (Figs. 14 and 16). These leathery infil- trating forms of breast cancer finally envelop the whole mammary region like a cuirass (Fig. 15). In the infiltrated skin these often appear small, pin-point disseminations of the carcinoma (Fig. 15, right side), which by confluence give rise to a nodu- lar infiltration of the whole thorax (Fig. 14). 18 Bockenheimer, Atlas. Tab. VII. PifT. 12. Carcinoma mammillae. Kcbnan Company, New-York. In cancers which are poor in cells (scirrhous) the mammary gland is often diminished in size by shrinking, and the skin becomes puckered over the tumor by cicatricial contraction (Fig. 10). Differential Diagnosis. Ulcerated cancers of the breast and those with hard, raised infiltration are difficult to mistake, but small tumors in the sub- stance of the breast have to be diagnosed from inter- stitial mastitis, benign tumors (fibro-adenomas, cysts and mixed tumors) and abscesses, in which there is frequently deceptive induration. The age of the pa- tient, the continuous growth of the nodules, the appearance of hard, lymphatic glands in the axilla, and the frequent occurrence of emaciation and cachexia even in small cancers assist in the diagnosis, which in doubtful cases can be established by exci- sion of a piece for examination. Sarcoma occurs at an earlier age in the form of soft tumors extending to the skin, and presents a fairly typical clinical pic- ture which should not be confounded with carcinoma (Figs. 29 and 30). The glands are generally unaf- fected in sarcoma. Treatment. Radical excision of the whole breast and its processes as early as possible, with removal of the pectoralis major and in some cases also the pectoralis minor, and complete removal of the axillary glands is necessary for a permanent cure. In V. Bergmann's clinic there were 29.79 per cent, permanent cures out of 1,000 cases, i.e. free from recurrence three years after the operation. Recur- rence is much less common in the axillary glands than locally. If of small extent they can be treated by excision, if larger by the X-rays (Fig. 15). All cases with extensive dissemination in the skin (Fig. 14), diffuse infiltrating cancer, "cancer en cuirasse" (Figs. 15 and 16) are unsuitable for opera- 19 tion. In cases where the supra-clavicular glands are extensively affected, permanent cures are hardly ever obtained, even after radical operations including sec- tion of the clavicle and ligation of the axillary vein; so that it is best to abandon the operation. Also tumors which are adherent to the ribs, and fixed glandular tumors extending to the axilla are unsuitable for operation, for the recurrence generally takes place before the patient has recovered from the operation. Operation is also contra-indicated in cases of severe cachexia, in the atrophic slow-growing forms met with in old people, in cases with metastatic growths in the lung, liver and bones (often leading to sponta- neous fracture of the neck of the femur.) In the region of the head metastatic carcinomas are sometimes inoperable. Owing to their circumscribed encapsuled formation with soft contents they may be confounded with atheromatous cysts. According to Schimvielbusch they arise in this form through em- bolism of cancer cells, and thus form encapsuled freely movable nodules. [The first brain tumor operated upon was an en- capsulated metastatic carcinoma resulting from a mammary cancer.] In cases of inoperable carcinoma the X-rays may lead to epidermization, especially in the ulcerated forms, after previous removal of the ulcerated parts. In discharging cancers powdered charcoal or chlo- ride of zinc may be used locally, and high doses of morphia internally. Cases hitherto reported as cured by X-rays are fallacious. No doubt a carcinomatous nodule may disintegrate and disappear under the action of the X-rays, but there is always a further growth in other parts — glands and internal organs. As regards cas- tration for advanced mammary carcinoma in women, further experience is required. Doyen's serum treatment of cancer has so far given no results. 20 Fig. 10 shows an acinous carcinoma forming sev- eral nodules in the breast, already infiltrating the skin. The axillary glands form hard, fixed, indolent nodular swellings, and nodules can be easily traced in the form of a rosary from the mammary gland to the axilla. The nipple is retracted and fixed, and the whole breast is diminished in size. Operation was performed in the usual way. The patient was already emaciated. Fig. 11. A single cancerous nodule in a male breast. The skin has broken down and shows a cancerous ulcer with hard, raised, jagged edges, which has destroyed the nipple. The floor of the ulcer is irregular and the whole tumor is fixed to the pectoral muscle. At the edge of the ulcer the skin is radially contracted and shows isolated cancerous nodules. The axillary glands are hard, visible and hardly movable. In spite of the small size of the tumor there was already cachexia. After removal of the mamma with the pectoralis major and the axil- lary glands the wound, which could not be com- pletely closed by suture, was repaired by Thiersch's grafts. Cancer of the male breast (about 1 per cent, of all mammary carcinomas according to Schuchardt) gen- erally arises as a small, hard nodule (scirrhous) in the neighborhood of the nipple and giv'es rise to a typical cancerous ulcer. The tumor occurs between the fortieth and seventieth years. Heredity appears to be frequent. Occasionally cancer of the breast is seen in husband and wife. Fig. 12 shows a very rare case of carcinoma arising from the nipple (squamous-celled epithelioma). This is more common in men than in women. It com- mences as a hard infiltration of the nipple, in the same way as commencing carcinoma of the navel. The nipple is much retracted and the whole areola is transformed into a rigid wall. A cancerous ulcer soon develops which destroys the nipple and the 21 whole areola. At first there is no connection between this cutaneous cancer and the mammary gland. The treatment consists in early extirpation of the mammilla with the subjacent mammary tissue, by means of an oval incision with subsequent suture. Recurrence is rare after early treatment. In doubt- ful cases with induration of the mammilla excision should always be performed. Fig. 13. Paget's disease, or chronic eczema of the nipple, which is refractory to all treatment. The eczema begins on the nipple, gradually extends to the areola and surrounding skin and assumes the form of eczema madidans pustulosum. Retraction of the nipple and dragging pains are caused by the presence of carcinoma under the nipple (cylinder- epithelioma), which at first has no connection with the nipple but later on may become attached to it. The mammary gland in this case shows hard infil- tration round a nodule. In the normal parts of the skin there are small dimples. Obstinate eczema of the nipple accompanied by a tumor in the breast, with infiltration of the axillary glands and early cachexia, make the diagnosis clear and indicate removal of the whole mammary gland with the axil- lary glands. In cases of chronic eczema of the nip- ple resisting all treatment, excision of the mammilla is advisable. Out of 884 cases of mammary carci- noma in V. Bergvianns clinic there were only seven typical cases of Paget's disease. Two of the author's cases showed cancer of the mammary gland without connection with the eczematous nipple. According to Scliamhacher and Ribbert this affec- tion is an inti"a-epidermoidal carcinoma which gives rise to secondary chronic eczema, an hypothesis which does not explain all cases, and is yet to be proved by microscopic examination. Fig. 14. This is a case of tubular carcinoma (Billroth) with cutaneous dissemination which has 22 Bockenlieimer, Atlas. Tab. Vill. Fig. 13. Carcinoma mammae — Paget Disease — Eczema clironicum mammillae. Rcbman Company, New- York. Bockenheimer, Atlas. Fitr. 14. Carcinoma iiiaiiimae - Disseniinatioiies. iian Company, New-York. Bockenheiiner, Atlas. Tab. \. U lan Pnmmrn- V»w-V'<-.irb w Bockenheimcr, Atlas. Fig. 16. Carcinoma mammae. - Lymphangitis carcinomatosa. extended in all directions and spread over the thorax. The development of nodules in the skin occurs early. These appear at first as punctiform, bluish, glisten- ing elevations, which increase in number and size and coalesce, forming a kind of cuirass inclosing the thorax in a rigid mass. (Cancer en cuirasse, Panzer- krebs). These cases are inoperable. Fig. 15. This is a case of inoperable cancer, en cuirasse, in which both mammae are affected with carcinoma. On the one side there has been a recur- rence of the growth in the scar soon after operation, where a soft, fungous, easily bleeding ulcer presents itself. In the surrounding skin there are several isolated nodules. The left mammary gland is in- volved in a hard, immovable, carcinomatous infiltra- tion. The transmigration of a carcinoma from one side to the other is possibly explained by the per- sistence of congenital lymphatics. Fig. 16. At first sight this appears to be a pyo- genic inflammation. However, the bluish color, the retraction of the nipple, the hard, immovable breast forming a large tumor, and the extensive metastases in the axillary and supra-clavicular glands lead to a diagnosis of carcinoma. J^olkmcuin has named this very rare form of cancer — mastitis carcinomatosa. That we have here to deal with an affection of the lymphatics (lymphangitis carcinomatosa) is shown by the punctiform red spots between the two breasts, the larger punctiform or circular spots below the clavicle and the changes in the region of the neck. The latter is of a blue color and the seat of hard infiltration which is not inflammatory but due to plugging of the lymphatics with cancer cells, and consecutive oedema. The three last plates (Figs. 14, 15 and 16) show the terrible effects of advanced cancer of the breast, so that the necessity for the earliest possible diag- nosis and radical removal by operation must once more be urged. 23 Naevus Carcinoma Plate XII, Fig. 17. ATHEROMA— CARCmOMA (Sebaceous) Plate XIII, Fig. 18. Fig. 17. Carcinoma of the scalp is very rare and usually arises on the basis of old scars, ulcers, warts, atheroma (sebaceous cysts) and moles. Pigmentary nsevi, which are congenital or appear soon after birth, when they appear as warty formations, belong to the class of benign tumors. Occurring over the whole body, they were included by v. Recklinghausen among diseases of nerves. While the growth of the naevus ceases with the growth of the body, changes occur in later years which may take the form of papilloma, sarcoma, carcinoma or malignant melan- oma. In the case represented in Fig. 17, a rapidly growing tumor arose from a congenital naevus in the thirty-seventh year; the cutaneous covering soon disappeared and the tumor was separated by deep fissures into cauliflower growths. The ulcerated sur- face is covered with sanious secretion, so that macro- scopic examination often does not decide whether it is a case of ulcerated carcinoma or sarcoma. That it is a malignant growth is shown by the rapid growth of the tumor, which in a short time extends over and destroys the whole nsevus; the early adhe- sion to the bones; the regional glandular metastases in the form of hard, slightly movable nodules behind the ear, and the cachexia of the patient. On account of the glandular metastases which soon extend along the large vessels from the neck to the supra-clavicular 24 u I p < 5 3 O o > 2 in region, the case is presumed to be a carcinoma of the scalp on the basis of a na?vus (pigmentary carci- noma), but there remains the possibiHty that micro- scopic examination may show it to be a pigmentary sarcoma. Treatment. This consists in extirpation of the tumor and the rest of the naevus, repair by a plastic operation, and removal of the diseased glands. In large nsevi of the head and face a portion of the nsevus can, in some situations, be removed by an elliptical incision and subsequent suture {DieJJen- hach). Owing to the elasticity of the skin of the head large nsevi can often be removed without re- pair by plastic operation. As soon as changes of any kind appear in a naevus, especially in advanced age, it is important to remove it as soon as possible. It is best to remove all pigmentary nsevi because fatal malignant melanomatous growths so often develop even from the smallest pigmentary spots. Fig. 18. Along with multiple sebaceous cysts scattered over the whole scalp, is a carcinoma origi- nating from one of the cysts. The sebaceous cysts, commencing as small yellowish nodules in the skin, slowly grow into large tumors with a broad base and smooth surface. The cysts are fixed to the skin but easily movable over the subjacent bone, and have a doughy consistence often resembling fluctuation. If this mobility of the cyst over the subjacent tissues ceases and the originally soft tumor becomes a hard nodule with an irregular rough surface, malignant degeneration is to be suspected; apart fi'om the occurrence of calcification in its walls, in which, moreover, the spherical smooth surface is generally preserved. This suspicion becomes a certainty when the skin gives way and there appears a rapidly growing nodular tumor characterized by multiple lobulation and secreting a fetid discharge. These carcinomas resemble in many ways the formation 25 of a discharging sarcoma (Fig. 33), and often cause severe pain owing to inflammation round the tumor. Cachexia occurs early, and the patients are usually of advanced age. The diagnosis of carcinoma depends on the hard multiple glandular enlargement, which affects the whole nape of the neck. This usually occurs later and is not so hard in sarcoma. Treatment. This consists in extirpation of the carcinoma, and involves removal of part of the exter- nal table of the skull on account of the tumor being fixed to it. The extensive space left by removal of the tumor can be sutured after making two long lateral incisions over both ears and undermining of the scalp. The spaces left by the lateral incisions can be repaired by Thiersch's grafts. The glands in the nape of the neck must also be removed. On account of the early appearance of glandular metastases the excision of especially indurated seba- ceous cysts is indicated. Moreover, as there is always a possibility of malignant degeneration, it is advisable to remove every sebaceous cyst by dissecting it out, so as to avoid recurrence. 26 Bockenheimer, Atlas. Fio;. IQ. Carcinoma penis — Leukoplai