ABSTRACT OF A Lecture ON THE NATURE OF CANCER AND GENERAL CLASSIFICATION OF CANCEROUS DISEASES.

JULY 29, 1893. down to the cauda equina, producing a tumour in that spot,4 and Dr. Moxonreports an epithelioma of the trachea, minute fragments of which had been inhaled ; with the result that minute epithcliomatous foci developed at the extremities of the smallest air tubes. The ease with which the cancer patient under suitable conditions inoculates him or herself singularly ON contrasts with the entire absence of any authentic case of AND cancer inoculation upon another individual ; an event for NATURE OF which the great prevalence of uterine cancer affords special OF facility. It may be further compared with the extreme difficulties of purposive cancer inoculation amongst the lower DISEASES.1 animals. By HERBERT SNOW, M.D. LOND. &C., Xldll1’lÛ classification of the cancers.-Taking the tissue SURGEON TO THE CANCER HOSPITAL. origin as a natural basis of classification nine primary genera of cancer demand recognition. These are : (1) epithelioma derived from epidermis or from non-specialised as ]}eflnitio-n of ea1tCe1’.-The various diseases known epithelium ; (2) carcinoma, from the specialised epithelioid ’"malignant" or "cancerous," more briefly as "cancer," cells of secreting glands ; (3) sarcoma, from the fixed-cell constitute a large group of morbid conditions in which cell elements of the connective tissues ; (4) lympho-carcinoma, elements normal to the body are found to multiply luxuriantly from the lymphoid or adenoid tissues, specially from those and to prey upon the healthy tissues, eventually destroying which constitute the lymph glands; (5) cylindroma, from the life of the individual. The cells or nuclei which have tubular gland follicles in the stomach and intestines ; (6) rodent ulcer-the cancer of short hair follicles,-from undergone this profound modification appear to have now the cells of the outer root sheath ; (7) endotheliom or become independent organisms-parasites, or rather autosites. cancer of serous membranes, primary probably All malignant lesions comply with this definition ; their phe- from the endothelium of the stomata; (8) myogerminal nomena, clinical and pathological, differ in details, but sarcoma, from the nuclei of non-striated muscle ; uniformly agree in kind, the variations depending mainly on (9) blastoma (from (aros, germ), vestigial cancer derived the character and functions of the particular cells attacked from unobliterated foetal residua-a new group correspondtheory of Cohnheim. Some of these by the diseased process. There are strong reasons for regard- ing to the inclusion further subdivision into species. Thus the genera require ing this peculiar change as one, of reversionary character, of carcinomata of the female mamma present two typesdevolution in place of evolution ; the cell elements of the chronic and acute. The former constitutes the familiar xrticular tissue attacked reverting to a primitive, amoebiform scirrhus ; the latter soft or encephaloid cancer. Sarcomata show two corresponding structural and clinical condition once universal throughout the germ. the more chronic consist wholly of spindle Evidencesof tkis autositic reversion. -The parenchyma of all variations; cells sarcoma); the more rapidly progres(spindle-celled cancerous growths can be traced by microscopic examination to healthy cell elements, and in a specimen so investigated sive also largely consist of spindle cells in bands or in the incipient stage the transformation process is very strands, but mixed with a number of round or ovoid cells evident. In section from small spindle-celled sarcoma deve- which appear to be the free nuclei of the former. The latter are mixed-celled sarcomata. Certain tumours of the same loped on the sheath of the flexor tendon of a man’s thumb, the staff. shaped nuclei of the fibrous tissue were shown under- class further contain giant corpuscles, closely resembling the named elements of tuberculous lesions. These going transformation into the malignant spindle-cells of the littlesimilarly bodies seem to be small masses of fibrine, entangling sarcoma. Whatever the cell species attacked by this " cancer numerous ; but their real nature is still obscure. process" the new cells are found to be enormously increased They haveleucocytes been termed "myeloids," from a supposed analogy in number, and by them the healthy tissues around are to the myelo-plax of marrow. They have, however, no known a remarkeroded. the latter Further, develop being actively relation to that tissue, and the growths in which they occur do able infectivity. Some are transplanted by mechanical agency- not differ from spindle sarcomata of the ordinary type. to blood or distant regions, In clinically lymph-currents ù>ual y by work on the "Reappearance of Cancer" is recorded a my where they grew actively and gave rise to secondary tumours. case affecting the mamma which ran a particularly acute With active growth, death and decay are necessarily " course. Glioma "is a word applied to several distinct forms concomitant, the sum total of the two contrasted pro- of tumour developed in nerve tissue. Those attacking the cesses giving rise to the outward and visible signs of disease. Progressive erosion by new cells which have infantile retina are vestigial cancers, pertaining to the class become infective is the essential badge of all the cancers. blastoma. Of so-called gliomata in the brain or spinal cord The phenomenon known as "auto-inoculation,"in some of elderly adults, some are derived from the delicate conspecies common, in others exceptional, affords collateral nective-tissue neuroglia ; others from the ganglion cells, as evidence tending in the same direction. Malignant tumours originally pointed out by Virchow."Alveolar sarcoma" is an in the ovary or broad ligament assume ordinarily a cystic ambiguous title generally applied to tumours of endothelial ’character; the cysts have gelatinous contents and are prone origin. Psammomata are calcified endotheliomata, probably to rupture into the peritoneal cavity. The jelly is due to a often vestigial, and non-malignant. Of the exuberant masses " mucoid degeneration of the parenchyma ; still active cells of round or ovoid cells recorded as "round-celled sarcoma as in not seldom found the are of mamma, glandular survive therein, and these are now strewn widely about the some, and are really encephaloid carcinomata ; others, as in serous membrane. They take root as grafts, each pro- origin, the abdominal cavity, are derived from lymphoid tissue, and ceeding to develop into a gelatinous quasi-cystic tumour should rank with lympho-carcinoma ; a third section, freresembling the parent. Such cases are described as " colloid cancer" ; the secondary grafts are usually very nume- quent in the kidneys of children, in the palatine or pharyngeal of the adult, own a congenital inclusion source, and rous, Again, to take a more common cancer species, patients regions No new growth can be accurately are properly blastomata. from white dying lingual epithelioma commonly display little islets of morbid epithelium on the soft palate and pharynx, referred to the group of the true sarcomata unless it possess the which, if time allow, progress into typical epithelial sores. distinctive badge of malignant spindle cells, ranged more or In the bladder, also, the condition is often found. More ex- less in bands. The cancers of the lymphoid tissues, hitherto termed "lympho-sarcoma," but which, in order not further to ceptional instances have been reported by numerous writers. abuse the well-worn term ’’ sarcoma," I prefer to call lymphoDr. Cayley2 met with a cylindroma of the rectum which had must not be confounded with the pyrexial carcinomata," the perforated posterior wall of the vagina and had produced disease or lymphadenoma. The former is a true Hodgkin’s on the anterior wall. Mr. describes 3 a De caragraft Morgan in a woman’s breast, which had similarly attacked the cancer, primarily local, attacking generally a lymph gland cinoma inner aspect of the corresponding elbow kept in contact with it ; (compound lymph follicle), and involving progressive erosion he records another instance in which cells from a growth in the of the fibrous stroma by the new cells, which undergo wide diseba1l gained access to the subarachnoid fluid and drifted semination. The latter, also termed "lymphadenoma," is an obscure general febrile malady involving a multiple synchronous

ABSTRACT OF

A Lecture

THE

GENERAL CANCER CANCEROUS CLASSIFICATION

derived

---

1

Delivered at the Cancer Hospital on Feb. 10th, 1893. 2 Pathological Transactions, vol. xvii. 3 The Origin of Cancer.

No. 3648.

4

Transactions, vol. xviii. Pathological 5

Ibid., vol. E

xx.

DR. H. SNOW ON THE NATURE OF CANCER.

236

throughout the body, with destruc- D’Arcy Power." The retinal glioma of infancy similar ; it has nothing in common with needs differentiation from the cancerous diseases (general sarcomata, more or less pigmented), which attack the eye’r;. malignant tumours. in disease has adult life. Its age-limit appears to be twelve years::: form of cancerous hardly - /c-Mco?K.—This yet received full recognition from English pathologists. In may commence in utero ; both eyes may be synchronous;v most of the reported cases the uterus was the site ; the ’, attacked. Tumours of the soft palate,12 of the parotid &e.. neoplasm probably occurs occasionally elsewhere, but is then I, furnish another section of the blastomata. The latter are confounded with sarcoma. An ordinary benign myoma has important as showing that the malignant reversion may here often long preceded the cancer symptoms, seeming to be delayed till advanced age; whereas in the ovaries, kidney;. undergo cancer reversion. An instance is elaborately recorded bladder and adrenals the patient is almost invariably youthful. by Dr. David Finlay;it had been preceded for fifteen years The thymus is a vestigial organ, whose remains frequently by a hard quiescent tumour. Microscopically the new develop malignancy; 14 the lesions are often polymorphic. growth consists of two areas, each with distinct features, one About the spinal cord and medulla are found tumour; of a spindle-celled structure, the other of minute round reproducing the structural characters of intestinal canee: cells or nuclei, lymphoid in appearance and betraying no (cylindroma), the central nervous system and alimentary tendency to organisation. The drawing exhibited shows two canal having both arisen from a primitive U-shaped tube, portions of one of the tumours termed by Mr. Lawson Tait Uneffaced traces of the six obsolete foetal canals—practical’v "soft cedematous myxoma," which he kindly gave me an sequestrated portions of bowel--often prove the source ot opportunity of examining ; it recurred after removal. Other quasi-malignant new growths. Such obsolete rudiments as the examples have been reported under the same designation pineal and pituitary bodies are occasionally the site of tumolU by this surgeon, also by Mr. J. Hutchinson,7 and by Mr. develepment. In some of these cases the cancerous nature Callender.s See further Schroeder’s account in Ziemssen’s of the lesion would seem to have escaped recognition only Encyclopaedia; he terms the condition "sarcoma of the because life has been quickly terminated by local pressure. parenchyma of the uterus." As an illustration of cancer effects before the emission of metastases. When malignant phenomena supervene in a tumour arising reversion the sequence upon a long-antecedent benign myxoma from any fcetal remnant they seem to do so spontaneously, is highly significant. TAe,ne7v gr01Jp of blastomata.-A definite differentiation of in virtue of some inherent reversionary force. The best illustration of the principle is afforded by the rhabdo-myomata cancers of the vestigial group, on which I have ventured to confer the title" blastoma," is demanded by the existence of the kidney ; rapidly growing cancers, containing sarcoma of an obscure section of cancer cases, numerically very small elements blended with striped muscle fibre, sometimes with in proportion to the rest, which conspicuously differ from the various other heterogeneous tissues ; and usually fatal wi’hin latter in histological composition and generally also in the two years after birth. This characteristic affords a verp period of life at which they appear, and which can be traced important distinction between most of the vestigial blastomata to some partially obliterated foetal organ or else to some per- and cancer of the ordinary type in adults. For in the lattei sistent cells of the "blasts " concerned in the development no predisposing congenital element can be discovered ; and the of the embryo. Such foetal remains may persist throughout previous operation of a more or less extraneous exciting cause life in a perfectly innocuous form, others constitute palpable is always evident if duly sought. The clinical characteristic tumours without any malignant attribute. A substantial which stamp a tumour as of the blastoma order are sometimes proportion, however, after a term of existence in a quiescent an obvious congenital origin, as when the disease has comstate, suddenly increase, and unless surgically dealt with menced in utero ; development from an obsolete foetal organ, prove fatal, with all the symptoms of true cancer. Nearly such as the thymus, pineal and pituitary bodies, parovarium, all the malignant lesions of childhood and early youth belong coccygeal body or other relic of primitive intestine, &c.: to this congenital division. The group of organs which are simultaneous appearance in bilateral structures, as in both the most conspicuous offenders in this respect are those derived kidneys, or both retinae ; occurrence in early childhood from the Wolffian bod-y with the Mullerian ducts and germinal without obvious cause, especially when in one of the epithelium; such are the kidneys, uterine appendages, testes, derivatives of the Wolfflan body. The histological and vesiculas seminales, epididymis, prostate, vas deferens and microscopic characters of neoplasms ranking in the group cortical portion of the adrenals. Ovarian dermoid cysts are vary considerably. The most common and most salient characteristic is polymorphism, a curious and complex mix. a familiar class of tumours ; but it is not so well known that they are either actual or potential cancers, prone to emit ture of the most dissimilar and unrelated tissues ; of carcinospindle secondary metastases, and when ruptured into the peritoneal matous or epithelial cells, with the embryonic cysts lined by cubicar cavity to generate auto-inoculative grafts : very likely also elements of sarcoma; of tubules or to recur after removal. Various examples are cited by epithelium, with areas of diffuse cell infiltration; of glanMr. Bland Sutton in his valuable work on " Surgical Diseases dular acini or crypts, with tissues of the connective order, of the Ovaries and Fallopian Tubes." Perhaps the most in- bone, cartilage, fat. Thus the cartilage common in parotid structive case is one by Dr. Fraenkel.9 A woman aged thirty- tumours proves their congenital parentage, being developed from remains of the structure known by the name of Meckei: seven fell and ruptured an abdominal tumour, which had been noticed for two years ; there was subsequent peri- so cartilage and even true bone are occasional constituents of formations in the mamma, scrotum, rectum tonitis and rapid increase in size. Eventually the cyst obscure tumour Some of the blastomata may seem not microscopicallyto &c. was found to have been a dermoid, grafts from which had taken root over nearly the whole peritoneal surface and differ from ordinary malignant lesions ; thus they have hitheni. were growing luxuriantly as pedunculated masses. Some been classed as sarcomata, especially as "round-celkc of the smaller contained fine hairs. Mr. Bland Sutton pro- sarcoma," as "columnar-celled epithelioma," as "ade poses the name I I o6phoroma " for these congenital ovarian mata," " angeio-sarcomata," " chondro-myxo-sarcomata. The bewi1der lesions, and significantly points out that their degree of organi- as cysts or sarcomata, pure and simple &c. sation varies with the age which the individual has attained, variety of names testifies to the obscurity of their structure, being most embryonic in early infancy; whilst towards as well as to the need of differentiation as a special group. puberty the new tissue tends to "assume an alveolar arrange- The polymorphism is usually apparent upon microscopicaila A similar devolution tendency is shown by the examining sections from different parts of the growth:!!l ment." derivatives of the male Wolfflan body. Dr. Bertram Windle 10 reaches its acme in the "mixed embryonic tumour" ci has demonstrated the congenital source of " many, if not Cornil and Ranvier, which is composed of embryonic conmost," of the malignant new growths found in the kidney nective-tissue, cartilage, striped muscle, bone, tubes lined’!? during early life. In 11 of his 41 cases the tumours con- cylindrical epithelium, lobules of pavement epithelium M" tained striped muscle (rhabdo-myoma) ; the remainder cysts. differed from the ordinary sarcomata of adults in their Seconda1’Y cance1’ varieties due to modifieations, its?tal4 mixed structure. So also the bladder tumours of young generative, iib one or other of the ]J1’eceding.-(a) Co, children contrast with those of the adult in their com- loid or gelatiniform cancer is produced by a transforn:.. plex histological composition ; they may contain such tion of carcinoma or cylindroma into a mucoid heterogeneous elements as striped muscle and cartilage. See cases by Messrs. Hurry Fenwick, F. A. Southam and 11 Pathological Transactions, vol. xxxix. cirrhosis of lymph glands tion of their parenchyma

12

6 7

Wiener Medicinische Wochenschrift, 1883, p. 865. Journal of Anatomy and Physiology, vol. xviii., p. 166.

9 10

Pathological Transactions. vol. xxxiv. Ibid., vol. viii. 8 Ibid., vol. ix.

One hundred

cases

1886. Hospital Reports, 13 14

See

by

Mr.

Stephen Paget: St. Bartholomew’s

Mr. Jacobson: Guy’s Hospital Reports, vol. xxvi. M. Letulle: Archives Générales de Medecin

eight cases by December, 1890.

MR. F. BOWREMAN JESSETT ON CANCER OF THE UTERUS.

phons jelly;

it is thus

practically

a

disease within

ai

stimulus

applied immediately to

237 the

cells,

or

else of

some

disuse: the carcinomatous form attacks the mammainterference with the nerve forces which normally control and ovary; the cylindromatous, the stomach or intestines. their nutrition and functions. a mucoid change, precisely similar (b) Xaoiua resultsinfrom cell elements derived from connective to the preceding,

Why cancer can hardley be, due to a micro-organisim.-Considerations which render this theory, now much in fashion, tissue (c) Chloroma is a very rare degenerative modifica- so improbable as to be well nigh impossible are as follows : tion also of sarcoma tissue ; it is seen only in young children 1. A parallel is supposed to exist between certain phenomena snJ in sarcomata on the skull or facial bones ; the masses occurring microscopically in the cells and the coccidial disease 3If of a peculiar greenish-yellow colour. (d) Melanotic cancer which attacks the liver of rabbits. Clinical evidence negatives, s the product of cells which secrete melanine. It has been however, any such theoretical analogy. The coccidial lesion of dfferentiated by myself 15 into true melanotic sarcoma, the rabbit’s bile ducts infests young rabbits, which may whichis almost wholly restricted to the connective tissue of spontaneously recover; cancer attacks the elderly or old, very the eyeball, and into melanotic epithelioid cancer, which rarely the young, and no spontaneous cure ever happens. - springs from the pigmented cells of the Malpighian rete and 2. Very conspicuous differences are found between every thus attacks the integument. (e) Osteoid sarcoma, in which form of disease hitherto associated with a micro-organism, the spindle-celled tissue of a periosteal sarcoma undergoes and cancer. Leprosy and tubercle always lay under strong suspicion of contagion for centuries before the discovery of partial organisation into bone. Obscure forms of cancer: quasi-cancerous lesions. -There the bacilli. Malarious fevers attack numerous persons exyet remains a section of neoplasms which cannot be grouped posed to similar conditions of soil and climate Cancer with the preceding and must be placed in a special residuary bears no relation to soil or to any climatic condition whatclass. The most remarkable is the rare thyroid cancer ever, although it is an appanage of civilisation. It is non-conwhich attacks the thyroid body, infects the bone marrow tagious, for no large number of individuals suiTer at the same and gives rise to numerous metastases, chiefly on the time and in the same locality. 3. The consideration which bones, of tissue exactly simulating the structure of the goes furthest to negative the hypothesis of cancer causation thyroid body. The plexiform sarcoma of Billroth and the by an extraneous micro-organism is the fact that the seconalveolar sarcoma of other writers may be referred to the dary metastases always involve a reproduction not merely of group of endotheliomata. Kaposi and Duhring’s diseases the particular cells concerned, but of their original arrange(xeroderma pigmentosum and granuloma fungoides) are con- i ment and functional characters. The parent tissue in which ditions of congenital lesion on the skin, which is highly the cancer process began is thus exactly mimicked by all the irritable and prone to injury by external agencies. As the secondary deposits far and near. The familiar breast consequence of this hyper-sensibility, multiple epitheliomatons scirrhus, producing multiple nodules in the subcutaneous conulcers in the one case, sarcomatous tumours in the other, nective tissue, in each copies exactly the acinar structure of stake their appearance. Cysts with fluid contents, developed the mammary parenchyma. The metastases of a rectal in organs which are becoming obsolete, become associated cylindroma, frequent in the liver, reproduce the follicular ’lVith cancer symptoms in one form or another. Most com- composition of the primary lesion, developed from Liebermonly intra-cystic vegetations sprout from their walls ; such kuhn’s follicles. Pigment-secreting cells in melanotic cancer may be composed of embryonic connective tissue (sarco- continue to secrete melanine throughout all the very nume,matous), or more frequently of glandular epithelium, rous visceral offshoots of that widely disseminated species. the wide meshes of a fibrous No known micro-organism can effect anything in the least colnmnaj’ in shape and stroma. In this latter carcinomatous form there is also resembling this. The bacilli of tubercle or leprosy stimulate diffuse infiltration of the surrounding parts. Clinically the to proliferation the cell elements of the tissues amidst which cases hardly differ from carcinoma of the ordinary type. they arrive, but do not transport cells, which retain their They have been reported as duct cancers " ; but as the functional endowments and original mode of distribution, cysts in question are often dilated acini rather than bodily from one region to another. ducts the term is objectionable. The mammary tumours, known as "cystic"or "adeno-fibromata,"appear in later life and are primarily benign. They eventually, like new in the female and like growth every simple cysts, breast undergoing devolution, become associated with malignancy. Cheloid is an overgrowth of scar tissue, also ON primarily benign, but prone as age advances to a sarcomatons reversion. The "keloid"" of Alibert was such a THE OF tumour developed from some minute scar previously AND overlooked. Causes of cancer.-With the exception of the blastomata, VAGINAL OF ancerous diseases are almost wholly restricted to old or or on the other to on the one individuals hand, organs THE UTERUS.1 elderly tissues similarly past their prime, decrepit and enfeebled. Organs which have fulfilled their purpose in the animal BY F. BOWREMAN JESSETT, F.R.C.S. SURGEON TO THE CANCER HOSPITAL, BROMPTON. economy and are passing into an obsolete devolution stage are the most common prey of cancer ; such are the female breasts after the age of thirty-eightand the uterus from thesame period GENTLEMEN,-A distinguished American physician, Dr. or from one slightly earlier. All malignant lesions, with the in his Presidential Address delivered at the meeting Jackson, same reservation, are consecutive to a special exciting cause, of the American Gynaecological Society held at Brooklyn in which may be direct or indirect, and which also varies with the tissue attacked by the cancer process. In those of direct 1891, took occasion to allude to certain abuses which had causation the peccant cells are found to have been injured crept into the practice of gynaecology. One of these was the or irritated by external agencies, applied immediately to alarming extent and frequency to which, through the benethem; the traumatism may be transient and sudden, or it ficial but seductive agency of antiseptics, surgeons have been may be of continuous character. Epithelioma of mucous membranes is consequent on long-continued friction : 11-5 per tempted to resort to dangerous and mutilating operations on That such abuses have existed cent. of carcinomata in the mamma follow a blow or fall. the sexual organs of women. Sarcomata are generated by a blow, strain, or sprain, involv- in the past there can be no doubt, but I believe that the time ing probably some rupture of fibres ; lympho-carcinomata has now arrived when gynaecologists have discovered that own a like source. The indirect mode of cancer origin is most conspicuously much may be done without having recourse to such radical illatrated by the history of the common cervical uterine measures as some, especially some of the continental tarcinoma, and also by the remaining 88-5 per cent. of breast gynascologists, have thought to be necessary. I allude in cases, in which the sole immediate antecedents are neurotic- this paper to the wholesale performance of vaginal hysterectrouble, laborious and harassing occupations, any tomy ; this operation has been performed on the Continent e g., mental exhaustive illness &c. It would thus appcar that the proliferation of malignancy may be the consequence of a not only for cancer of the uterus but also for uterine dis:

lining

An Address

RESULTS THE OPERATIONS OF VAGINAL HYSTERECTOMY SUPRAAMPUTATION THE CERVIX FOR CANCER OF ENG.,

of

15

Vide THE LANCET, Oct. 15th, 1892.

1 Presidential Address delivered before the Members of theBritish

CrynæcologicalSocietyonFeb.9th,1893.