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Related post: operative danger, and the part removed may be un-
wisely selected so that the area in which there is
beginning malignant degeneration is not revealed.
The suture of the infiltrated tissue may be difficult
and the danger of hemorrhage, infection, or leak-
age considerable, and no matter how carefully this
examination is made, the condition as to remote
metastasis is not always proved. In such a case I
reverse the usual procedure and select an enlarged
lymph node or other apparent secondary growth as
*Read before the Philadelphia Pathological Society, March 28, 1912.
giving the most valuable information. Here we
find focalized the essence of malignancy. With
an accessible primary growth, near the sur-
face of the body, the excision of a por-
tion of tissue for examination may involve
some risk of hemorrhage and of the dis-
semination of malignancy, while the tissue re-
moved is often so necrotic or so infiltrated that the
diagnosis is uncertain. At the present time, I have
under my care a patient with a growth upon the
tongue from which microscopic sections have been
obtained, and have been examined by two well
known professors of pathology; and each has given
a different diagnosis. In this case a third and later
examination made from a bit of enlarged gland in
the neck, not only indicates the condition, but to
some degree shows the extent of the metastasis and Buy Wellbutrin Sr Online
other features.
My contention, therefore, is this, that when su-
perficial or subcutaneous nodules appear in patients
who are suspected of harboring Buy Wellbutrin Sr a malignant tumor,
that often the most direct way in Wellbutrin Sr Online which the diag-
nosis may be ascertained and the conditions of
metastasis proved, is by cocainizing the area and,
by a very slight operation, removing a part or all
of the nodule and subjecting it to microscopical ex-
amination. In this way one avoids the dangers that
may attend the removal of tissue from the primary
growth, and may absolutely prove the condition of
inoperable metastasis. Obviously, superficial sec-
ondary growths are far from being invariable, yet
if careful search is made, superficial metastatic
manifestations will be found more frequently than
is often suspected.
Some years ago a patient applied to me for loss
of power in the right thumb; a few days later the
entire arm became weak; vomiting without nausea
occurred, and secondary headache developed. On
shaving the man's scalp preparatory to operation, a
number of reddish papules, two or three millimetres
in diameter, were observed upon the scalp over the
left motor area. A craniotomy was done, a subcor-
tical sarcoma excised from the motor region, and
later an examination of one of these scalp nodules
showed it to be a metastatic sarcoma. Had I but
simply excised one of these cutaneous nodules, and
examined it, it would have proved the nature of the
patient's motor lesion, and a very useless operation
might have been avoided, for a generalized sarco-
matosis soon developed. In this Purchase Wellbutrin Sr case, the first me-
tastases were, as often happens, in the skin over
the primary lesion. Recently, I saw a patient suf-
fering from severe abdominal pain, weakness, and
some emaciation. The most thorough examination
Copyright, 1913, by A. R. Elliott Publishing Company.
no
VANDEGRIFT: EDEMA OF LIDS.
[New York
Medical Journal.
by a very capable internist revealed no cause for
the condition. The abdominal and rectal examina-
tions were negative, and an examination of the gas-
tric contents, urine, stools, and blood gave no clue
to the nature of the disease. Finally, the patient
was admitted to the hospital for an exploratory ab-
dominal section. There was found a Generic Wellbutrin Sr subcutaneous
nodule, about one centimetre in diameter, near the
eighth costochondral junction on the left side. The
patient considered this unimportant, but said that
it had been present only two or three weeks. An
exploratory section showed a small carcinoma of
the sigmoid bound down in the hollow of the ileum,
and diffuse small metastatic peritoneal growths.
The examination of the nodule from the chest wall,
and of a minute mesenteric nodule showed the char-
acteristic alveoli of an adenocarcinoma. In this
patient, had we simply excised the subcutaneous Order Wellbutrin Sr
nodule under local anethesia, the patient might have
been spared the useless abdominal operation and
the necessity of hospital treatment.
The metastasis may also direct the method of
surgical attack. Thus a middle aged man, with a
large firm mass in the left hypochondrium, was re-
ferred to the hospital after very careful study by
an internist for a presumable growth of the left
kidney. The situation of Purchase Wellbutrin Sr Online the growth and the study
of the secretions suggested that the man did not
have what otherwise would have seemed probable,
that is, a carcinoma of the stomach. In this case,
were the condition inflammatory or a tumor of the
kidney, a lumbar and probably extraperitoneal in-
cifion would have been desirable, while, were the
growth one of the stomach, a median abdominal
section would have been necessary to obtain the
best access. Instead of incising over the growth,
however, we first removed, under cocaine anesthe-
sis, a firm, rather nodular lymphatic enlargement
above the left clavicle, and the man was able to
leave the hospital shortly afterward with a proved
diagnosis of "carcinoma of the stomach, inoperable,
and with distinct metastatic growths."
In carcinoma of the liver or peritoneum, metas-
tasis may occur along the Buy Cheap Wellbutrin Sr round Order Wellbutrin Sr Online ligament and a
secondary subcutaneous nodule be found at the um-
bilicus. In carcinoma of the breast but little atten-
tion is often given to the very characteristic metas-
tatic skin eruptions. The bluish Cheap Wellbutrin Sr or scarlet macules,
or the dusky reddish papules that occur in the skin
overlying a carcinoma, all may have their malig-
nant nature proved by the removal of an involved
bit of skin. This type of metastasis almost invari-
ably indicates a hopeless and inoperable form of
carcinoma.
At times the metastatic nodule is discovered ac-
cidentally, and enables one to forecast the patient's
future. As an example, some years ago, a patient
was sent to this city from a distant point, to be
operated upon for appendicitis. In the removal of
the appendix a firm, enlarged mesenteric gland was
felt and removed. To my surprise, on microscopical
examination, the picture of a secondary growth,

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