SPINDLE-CELL SARCOMA AND EPITHELIOMA; A REPORT OF CASES. BY W. BLAIR STEWART, A.M., M.D., Lecturer on Therapeutic! ; late Instructor in' Practice of Medi- cine in the Mkdico-Chirurgical College, of Philadelphia. RHPRINT FROM American Medico-Surgical Bulletin, September i, 1894. TO CONTRIBUTORS. Contributions of Original Thought anJ Experiences, on Medical and Surgical Topics, are desired ny the AMERICAN MEiflOO-BURtilCAL BULLETIN on the following conditions: 1. —Authors of Scientific Papers or Clinical Reports accepted by us will receive—according to their own preference expressed with each communication, either: a;—A n uni tier of Rkprints of their article in neat pamphlet form (pocket size); or, b:—Instead of thealiove, an Equivalent vnlue therefor in Cash. 2. —All contribuiious are received only on the express understanding: a:—Thai they have not been printed anywhere, nor communicated to any other journal. b:~-That, If they have been read anywhere to an audience, this fact be stated in full detail by a note on the manuscript. Contributors will servo their own interest by heeding the following suggestions Write Concisely and Clearly« What we desire to print, and what professional men liketo read, is information, not verbiage. An article will stand lietter chances of acceptance, and of being widely read and copied and discussed, the fewer its words are, in proportion to the facts or ideas it emlsidies. Of course, a thought too thinly clad must suffer. Use, therefore, cheerfully, as many words as ap,>ear needed to convey your meaning,—but no more. It. is not to be expected that every Medical or Surgica. paper should be a mere array of statistical data, hospital records, tabulated figures, or graphic summaries; some room must be allowed to theory, or even conjecture, in its proper place ; but the true aim of theory should never he fett out of sight,—which is, to lead to fact; to a rule or result of practice.—And it should he likewise borne in mind that the Reader will attach little weight to mere generalizing statements (such as, that a certain rem- edy, procedure, or line of treatment has uniformly proved successful, etc.);—to lie convinced, he wants to see positive evidence- recorded in clinical detail of cases: con- ditions found, courses pursued, and results achieved Aim at Fact. however, that a communication you may tie inclined to make would tie devoid oi value because you have but little time to sjiend on writing it! If your thought tie a gisxi one to yourself and forvoui patients* benefit, it will be (spiallv so to your colleagues and their practice, and will be worth communicating. It need not come in the garb of«n elaborate Scientific treatise; a simple “ Letter to the Editor” will often lie just as acceptable. Do Not Fear, Some Rules of Order we should I’lte to have our esteemed Contributor* comply with *I)o not write on both sides of the sheet. Write as legibly as you conveniently can ( names especially so). Leave a liberal margin on the sheet, or space between the lines. ( ('"lose writing is not conducive to correct tyisigraphv; ami what you save in writing material has to be expended a thousand-fold by us in eyesight lalsir, and expense for printer’s corrections.) AddressP O. Rox,2.’>35, New York city. Editor American Medico-Surgical Bulletin. SPINDLE-CELL SARCOMA AND EPITHELIOMA; A REPORT OF CASES. BY W. BLAIR STEWART, A.M., M.D., Lecturer on Therapeutics ; late Instructor in Practice of Medi- cine in the Mbdico-Chirurgical College, of Philadelphia. REPRINT FROM American Medico-Surgical Bulletin, September I, 1894. SPINDLE-CELL SARCOMA AND EPITHELIOMA; A REPORT OF CASES. By W. BLAIR STEWART, A.M., M.D., Lecturer on Therapeutics; late Instructor in Practice of Med- icine in the Mkdico-Chirurgical College of Philadelphia. IN the fall of 1893, Dr. E. Harley Buck- land, dentist, was consulted by a little girl of seven years for her teeth. At that time his attention was attracted by a small growth on her lower jaw, exter- nally,/and which presented the following very interesting history. Mary Francis M., aged seven years, bom of healthy parents and free from hereditary taint, suffered considerably with tooth-ache in her lower, right, temporary, second bi- cuspid, which was considerably decayed. In the spring of 1893, it grew worse and, as shown later, became abscessed at the root and presented itself as a swelling on the side of the face. The family physician was consulted, and he, thinking it was an or- dinary boil, ordered a poultice applied ex- ternally. The lump softened and opened spontaneously with a free discharge of pus which continued some time. The tooth was afterward drawn, and the pus cavity dost d. From that time on a small pimple developed and gradually increased in size until the time it was examined by Dr. Buck- land. He called me into his office and to- gether we examined the growth. It was situated on the lower border of the inferior- maxilla, anterior to the facial artery about one-half inch. It was about the size of a 3 small cherry; dark in color and looked as if it were filled with venous blood; no pulsa- tion; little or no soreness or pain; was itchy at times; the surrounding skin was slightly blushed; small waxy white scales sur- rounded the base; no apparent lymphatic in- volvement; physical signs on the inside Mary K. M.—Photograph taken July il, 1894. of the mouth were negative; general health was fair but there was slight anaemia. Immediate operation was advised, but not acted on. The growth gradually increased in size, and, under the advice of another phy- sician, it was opened by him and several 4 small spiculae of bone were removed. No improvement resulted; they consulted us again, and on November ii, 1893, at eleven a.m., Dr. Buckland and myself, assisted by Dr. Andrew Lindsay, placed her under ether and operated for the removal of the growth. I made my first incision about one line an- terior to the facial artery and carried it in an ellipse wide of the growth and dissected down to the bone where it was firmly ad- herent. A small sinus was detected in the in- ferior maxilla and around it considerable soft, spongy, dead bone. The periosteum was removed wide of the decayed area, and a section of the bone was removed with the dental engine and a good sharp bur and bone scraper. Wound was cleansed with bichloride; a drainage suture was placed in the bottom of the wound and the whole closed with black silk sutures and dressed with powdered aristol. Little or no discharge resulted, and on November 26 the little patient was declared cured. She was given syrup of hydriodic acid, in ten drop doses, three times daily for three months and made a speedy recovery. A decayed tooth was subsequently removed to prevent a possible involvement later. At this time, August 1, 1894, the scar looks entirely healthy, and there is not the least indication of a return. The child is in perfect health. The specimen removed was given to Prof. E. B. Sangkee for examina- tion, and he writes as follows: “The speci- men you sent is a fibro-sarcoma of the spindle cell variety. More toward the fibro- ma than the sarcoma type, however.” This case is one of unusual interest and is unique from the history and aetiology, and affords an important lesson in all tumors, 5 growths, and inflammations in the vicinity of the teeth. In all probability the growth would never have resulted had the tooth been extracted in the first instance. It also shows that a semi-malignant growth can develop in a perfectly healthy child without any hereditary predisposition. Sarcoma is primarily a disease of young children and adults, and will spread rapidly according to type and anatomical location. It spreads through the circulatory system, and does not depend upon the lymphatics for its dissemination. The blood supply of every sarcoma is rather profuse, and the blood vessels tend to degenerate and break easily. In this case the bluish appearance of the growth was due both to ruptured ves- sels and a free venous supply. It is still a question in my own mind whether the growth involving the bone was simple m type or whether it was an ostto-sarcoma. No part of the bone was examined micro- scopically. It is altogether probable that the bone had not taken on any sarcoma- tous condition, or there would have been some manifestation of a secondary return by this time. It is extremely important in these cases to sacrifice plenty of sound tis- sue in order that every trace of the disease may be excised. The earlier the operation can be performed the greater the chances of recovery and its elimination. If the inferior maxilla were involved wilh sarcoma, no- thing short of one half or complete excision would be beneficial or permanent in its re- sults. The vascularity of bone is such that in a short time it will be wholly infiltrated with the disease, and the only cure is its complete removal. It is a surgeon’s duty to consider the subject of the scar, but, in an 6 o-deo- or fibro-sarcoma or true cancer, life is of primary and the scar of secondary im- portance. It is said that one never profits except by actual experience, and my next case illus- trates what conservative surgery will do in a primary operation. May the same mis- take never occur to me again ! Mrs. H. R. T., nearly eighty years of age, noticed a small itchy pimple on the back of her left hand which gave her but slight annoyance for some weeks. She used all sorts of home remedies which kind neighbors advised, but the pimple grew in size until she could not wear her glove. At times she experienced sharp pains. She consulted me on July 25, 1891, and the growth was diagnosed as an epithelioma, in its first stages, without lymphatic involve- ment. On August 26, the growth was re- moved under local anaesthesia with cocaine. The tendons on the back of the hand were not exposed during the operation and, un- fortunately, the incision was carried rather near the growth. It healed rapidly but soon assumed a suspicious appearance, and another small growth developed in the cen- ter of the scar. Dr. Ernest Laplace saw it with me on September 20, and advised a second op- eration. On the twentieth of the same month, assisted by Dr. Buckland, I removed the growth again under cocaine ana?sthesia, but took especial pains to make my incision one-half inch beyond the supposed diseased area and dissected away all of the areolar tissue between the extensor tendons, and cauterized the bottom of the wound with nitric acid, introduced black silk sutures and dressed with aristol and iodoform. The 7 wound healed readily and little or no ad- hesion took place between the tendons and the skin. At this writing, three years later, there has not been the least indication of a return and I consider her cured. No sec- ondary involvement is discoverable and the general health is very good. A close microscopical examination showed that the growth was a true epithelioma. Here are two cases, both in their mcipi- ency,—one in a child and the other in an adult; both were of a malignant character; both were recognized early; were operated upon at once and were cured. There is never anything to be gained by waiting for growths to develop themselves, and it is rare that you are justified in cutting away one portion of a growth to determine its real character. There is often great danger in this from various points. It is possible that you may get a part of the growth which will not show the malignant elements: you may startup an active inflammation which would contra-indicate active operation in many cases; you will lose that much valu- able time. When the removal of some in- ternal organ such as the uterus is involved, such a course may be justifiable. All sus- picious growths, independent of location, should receive immediate attention and be removed if practicable. Such cases as the ones detailed would rapidly assume a fatal type and infiltrate all surrounding tissues and lymphatics if not operated upon quite early. Atlantic City, N. J.; N. Carolina and Pacific ave9. 8 SEVENTH YEAR. $2.00 per year. American Medieo=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the 1st and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N. Y. EDITORIAL 5TAFF. WILLIAM HENRY PORTER, M.D., Chief Editor. FREDERICK PETERSON, M.D., Associate Editor. WILLIAM FANKHAUSER, M.D., Materia'Medica arid Therapeutics. ADOLPH ZEH, M.D.. Pathology and General Medicine. WILLIAM C. GUTH, M.D., Pathology and Genera' Medicine. GEORGE G. VAN SCHA1CK, M.D., Pathology and Clinical Medicine. W. TRAVH GIBB, M.D., Gynaecology. T. S. SOUTHWORTH, M.D., Paediatrics. WILLIAM OLIVER MOORE, M.D., Ophthalmology and Otology. ADOLPH BVRON, M I)., Disea=e« ot Children. HENRY F. OUAt KF.NBi »S, M.D., General Medicine. T. HALSTF.D MYERS, M.D., Orthopapdic Surgery. GEORGE THOMAS J ACKSON, M.D., Dermatologv. WILLIAM B. COLEY, M.D.. General Surgery. JAMES F.. NEWCOMB. M.D., Laryngology. GEORGE K. SWINBURNE, M.D., Genito-Urinarv Surgery. SAMUEL LLOYD, M.D., Surgery. I. RIDDLE GOFFE, M.D., Obstetrics, Gynaecology Paediatrics. HENRY T. BROOKS. M.D., Bacteriology. JOHN WINTERS BRANNAN, M.D., Neurology and Psychiatry. IRA VAN GIESON, M.D., Pathology of Nervous System. LEWIS A. CONNER, M.D., Neurology. ALBERT WARREN FERRIS, M.D., Neurology. PEARCE BAILEY, M.D., Neurology. MORION R. PECK, M.D., Neurology. LOUIS HE1TZM ANN. M.D.. General Medicine and Pathology. DANIEL B. HARDENRERGH, M.D., Obstetrics and Gynaecology. Ol'PO H. SCHUL1ZF, M.D., Obstetrics and Gynaecology. . JOHN HOCH. M.D., Gen ral Medicine. HOWELL T. PERSHING, M.D., Neurology. THOMAS PECK PROUT, M D., Psychiatry.