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casily have been removed by the knife or ligature, but which, owing to its concealed position, was in these cases attended with a series of phenomena, which during life it seemed impossible to refer to anything else than a really malignant new formation.

In

Just the same is the case with the much-discussed cauliflower-tumours, as they are seen on the surface of the genital organs, both in man and woman. In men, these papillary tumours, which proceed from the prepuce and surround the corona glandis, are for the most part covered by a very thick layer of epidermis, so that, when they ulcerate, they yield but a very trifling amount of secretion. In women on the contrary, the tumour, being seated on the neck of the uterus-a very vascular part, provided with a thin stratum of epithelium, and naturally beset with a thick layer of numerous and large papilla-for the most part very early occasions abundant transudations and occasionally hæmorrhagical exudations of a fluid, like water in which raw meat has been soaked, or really red and bloody. these cases there frequently exist doubts as to the nature of the disease. I myself was present when a very renowned surgeon came to Dieffenbach's operating room, just as that operator had amputated a penis on account of a (c carcinoma❞—and when the stranger afterwards declared it to have been a simple condyloma. On the other hand I have examined cases, in which growths of this sort had been doctored about for years as if they had been syphilitic condylomata, because the external appearance is so extremely analogous, and it is so extremely difficult to discover a criterion by which it can be accurately determined whether the formation only involves the surface, or whether it is complicated with disease of the subjacent tissue. There are certainly at the present time very many anatomists and surgeons who entertain the notion that cells may grow on the surface

exactly similar to those which are usually only found in the interior of diseased organs-that, for example, a villous tumour must be termed cancerous, if it is covered over with cancer-cells as with an epithelium, without any development of cancerous matter having shewn itself in the interior of the villi. In fact, villi, which are very delicate and scarcely contain enough connective tissue to envelop the vessels that run up in them, are sometimes met with, enclosed in a thick layer of cells which, from the irregularity of their form, the size of their nuclei, and their own large dimensions, present rather the character of cancer than that of epithelium. But I must confess that I have not as yet been able to convince myself that cancer-cells are able to arise upon the free surfaces of membranes, and that they can be produced simply from epithelium; on the contrary, I believe from all that I have seen, that a very strict line of demarcation must be drawn between the cases, where masses of cells, however abundant and curiously shaped they may be, are found seated upon a basis-tissue in itself unaltered, and those, where the cells have been formed in the parenchyma of the parts themselves.

The pathological importance of a papillary tumour is, at least as far as I know, determined by the condition of its basis-substance, or by that of the parenchyma of the villi themselves; and a formation can only be pronounced to be cancroid or carcinoma when, in addition to the growth on the surface, the peculiar degenerations which characterize these two kinds of tumours, take place also in the deeper layers or in the villi themselves. I think, therefore, that all these external differences of form can only serve to distinguish different species of the same genus of tumours, but by no means different tumours, from one another. There are connective-tissue [fibrous] tumours of the surface, which manifest themselves in the

1

PAPILLARY TUMOURS.

471

form of simple tubera (Knoten'), others which shew themselves in the form of warts and papillary tumours. In just the same manner, there are cancerous formations

and cancroid formations which may assume this form, and others again, which do not do so.

With reference to the relation of form and nature, there is a question of really cardinal importance, concerning which, in the interest of mankind, a certain degree of unanimity ought soon to be arrived at, namely, what

Fig. 139. Vertical section through a commencing cauliflower growth (cancroid) of the neck of the uterus. On the still unchanged surface the tolerably large papillæ of the os uteri are seen invested by a homogeneous, stratified layer of epithelium. The disease begins first on the other side of the mucous membrane in the real parenchyma of the cervix, where large, roundish or irregular, scattered groups of cells (contained in alveoli) are disseminated throughout the tissue. 150 diameters.

1 The term Knoten (Engl. knot, Lat. tuber) having reference rather to the form, than to the size of a tumour, is used in this work as a designation for all sorts of tuberiform tumours, even the largest.-Trans.

is properly to be understood by the term tubercle. The same difficulties which I have just described to you, are again encountered in the case of tubercle in a still higher degree. The old writers introduced the name tubercle merely to express an external form. Everything was called a tubercle which manifested itself in the shape of a small knot. It is, as you are no doubt aware, by no means so very long since this term was employed in the most loose manner. Carcinomatous and scirrhous tubercles were talked about, scrofulous and syphilitic tubercles were distinguished from one another, and these terms are still preserved in France. Cancer too, you know, in old times was not by any means exclusively employed to designate a real tumour, but noma (cancer aquaticus) was considered to have as much right to the appellation as a chancre (cancer syphiliticus).

Now in the course of the present century endeavours have been made gradually to exchange these somewhat superficial views for more accurate conceptions, and here also it is to Laennec especially that credit is due for having sought for precise denominations. Still he himself in his turn has been the cause of this matter's having fallen into a state of nearly irremediable confusion. For, as you no doubt recollect, he asserted that tubercle presented itself in the lungs under two different aspects, the so-called tubercular infiltration, and tubercular granulation. Now, inasmuch as infiltration signifies something completely at variance with the old notion of tubercle, since it does not at all imply the presence of small knots (Knötchen), but expresses an equable pervasion of the whole parenchyma, a track was hereby opened, in following which the old idea of tubercle has more and more been departed from. As soon as the infiltration of tubercle had once been created and the form of the neoplasm had thereby been abandoned, the infiltration was generally, as being more extensive and therefore more instructive, taken as the basis of subsequent

descriptions, and attempts were made to find out in what respects it really agreed with the other, previously known, forms of tubercle. It was in this way, that the cheesy stage of tubercle came to be gradually adopted as the common generic characteristic of all tuberculous products, not merely as the principal aid in diagnosis, but as the starting-point for the interpretation of the process in general. It was in this way, in particular, that the idea came to be entertained, that tubercles could arise simply by any exudation's losing its watery constituents, growing thick, turbid, opaque, cheesy, and remaining in this condition.

The term, tubercle-corpuscles (corpuscules tuberculeux), which is, you know, still in very frequent use, has reference to just this cheesy stage, and the accurate description which Lebert has given of them amounts to this-that they are formations which correspond with none of the known organic forms, and are neither cells, nor nuclei, nor anything else of an analogous nature, but appear in the form of little, roundish, solid corpuscles, which frequently have particles of fat scattered through them (Fig. 64). But if the development of these corpuscles be investigated, it is easy to convince oneself that, wherever they occur, they arise out of previous organic morphological elements, and that they are not by any means the first bungling products, unfortunate essays, of organization, but that they were once well-grown elements, which by an unhappy chance were early checked in their development and early succumbed to a process of shrivelling. You may with certainty assume that, where you meet with a largish corpuscle of this description, a cell had previously existed, and where you find a small one, there once had been a nucleus, enclosed perhaps within a cell.

Upon examining the point which has been the leading one in the doctrine of tuberculosis recently advanced, namely tubercular infiltration of the lungs, we readily