Chapter XXXVIII: , is, nevertheless, practically a cyst of congenital (2)

Recognition of angiomas is not difficult unless they are deeply concealed. The effect of intermitting pressure, the emptying and refilling, and the distinction between arterial and venous growths by the result of alternating pressure and relaxation, either above or below the growth, with discoloration of the skin, and, in the larger growths, audible murmur, leave little doubt of the character of the growth.

When such growths are small they may be dealt with by electrolysis, the needles from both poles being introduced, or that from the negative, the positive being applied upon some neighboring portion of the body. The effect of the electric current is to determine coagulation of the blood in the tissues acted upon, and this is followed by organization of thrombus, conversion of vascular into cicatricial tissue, shrinkage, and possible eventual disappearance of the mass. Radical excision under an anesthetic should be made, dissecting out the mass, securing bleeding vessels, and reuniting the parts by sutures, with the expectation of securing primary union. This is the quickest and in many cases the least disfiguring method. Old methods of ligation of surrounding vessels or the subcutaneous ligature are now practically discarded. The injection methods as formerly practised, especially the use of iron salts in solution, are severely condemned, as death is liable to occur. With electrolysis and excision the surgeon has nearly all the measures which he will need to practise for the medical treatment of angiomas.

Lymphangioma of lip; macrocheilia. (Neisser.)]

=Lymphangioma.=--Lymphangiomas are tumors composed of lymph vessels and bear resemblance to the tumors above considered. They may be divided into three varieties:

1. =The Lymphatic Nevus.=--The lymphatic nevus is composed mostly of lymphatics nearly normal in size, and occasionally colored red by the presence of bloodvessels. When pricked, pure lymph or blood-stained lymph, will flow. They are usually small, and are noticed during childhood. They may occur anywhere upon the surface of the body or in the mouth, generally in connection with the tongue, where they may appear as large papillæ involving a portion or all of the dorsum. When the lymphatic structures of the tongue are thus enlarged and involved the condition is known as _macroglossia_, and consists of enlargement of the organ, sometimes to a degree not permitting its retention in the mouth, but leading to its constant protrusion (Fig. 81).

2. =Cavernous Lymphangioma.=--Cavernous lymphangioma corresponds to cavernous angioma, and is a condition in which the lymph vessels become positively cavernous and sacculated.

3. =Lymph Cysts.=--Lymph cysts are the still more aggravated form which lymphatic dilatation may attain, and are usually encapsulated, complicated with more or less tense tissue, and produce a condition of the parts, especially about the scrotum and labia, to which the term _elephantiasis_ is often applied (Fig. 83).

The question of _congenital occlusion or dilatation of lymph channels_ is one which has been made the subject of large separate monographs (especially by Busey). Numerous tumors, essentially of lymph-vascular origin, are found upon the lips, in the neck, and elsewhere, which grow slowly, are more or less elastic and spongy upon pressure, are frequently covered with skin, from which hair grows most luxuriantly, and in which pigment or papillomatous structures are dispersed. These tumors are called _cavernous tumors_, are of slow growth, and undergo spontaneous involution, but usually require surgical relief. They are often confounded with branchiogenic and other congenital cysts of the neck.

=Treatment.=--The treatment for the smaller lymphatic tumors is simple, but here electricity is less to be relied upon and excision is more urgently demanded. Electrolysis will cause coagulation of blood, but not of lymph--at least not to nearly the same extent; consequently its usefulness is restricted to blood-vascular tumors. Excision, then, is the best remedy. When this is impracticable much can be done by galvanopuncture or ignipuncture, the cicatricial contraction following multiple punctures leading to reduction in size of the affected part. The enlargement of the tongue spoken of above as macroglossia may be treated by ignipuncture or by electrolysis, if necessary under an anesthetic, the effect of the electric current here being not to produce coagulation, but apparently absorption of fibrous tissue and changes which come slowly rather than by obliterative processes.

Congenital lymphangioma. (Original.)]

Lymphangioma of lower extremity. (Original.)]

5. =Tumors of Nerve Elements.=

=Glioma.=--Glioma is a malignant tumor developing directly from actual nerve structure or that of the original nerve elements, and is clinically allied to the sarcomas. It arises from the neuroglia, and hence is confined to the central and peripheral nervous system, mainly the former. It is most common in the brain, the cord, and in connection with the optic nerve and fundus of the eye. It is often extremely vascular, the vessels being sacculated, and is usually met with in solitary form. When near the surface of the cortex such a tumor may appear like a great convolution (Virchow). In the basal portions of the brain it may attain considerable size. In the cord it is rare, usually limited to the cervical region. In the orbit and eye it may produce marked exophthalmos. It is more frequent in the young than in the aged.

Glioma is an exceedingly malignant form of tumor, and operation is rarely performed sufficiently early to more than prolong life. Dissemination by continuity is the rule rather than metastasis. It kills usually by its pressure effect on the nerve centres.

=Neuroma.=--True neuromas spring from the structures of nerve trunks, which trunks may also be the site of other tumors, mainly fibromas and sarcomas, with which neuromas may be easily confounded. The most common nerve tumor is the _neurofibroma_, which grows from the structure of a nerve sheath, its long axis usually coinciding with that of the nerve trunk. Tumors of this class vary greatly in size, are often multiple, and in other instances affect nearly all the nerves in the body. They are extremely liable to _myxomatous degeneration_, which will account for many of the instances reported as _myxoneuroma_, etc. They attack cranial and spinal nerves alike, and no nerve or nerve root in the body is exempt. The sensory nerves appear more liable to attack than the motor. The nerve least often attacked is the optic. They are not rare upon the roots of the spinal nerves, in which location they may attain to such size as to press upon the cord and induce paraplegia. Multiple neuromas are often associated with molluscum fibrosum (_q. v._). There is an instance on record in which 1600 of these tumors were found after careful dissection of the neuroskeleton, and another in which at least 2000 were found, 60 of them involving the pneumogastric trunks and their branches.

Plexiform neuroma, dissected free from all adherent tissues. (Lexer.)]

Plexiform neuroma of chest wall in a young child. Illustrating its gross external resemblance to lymphangioma. (Lexer.)]

=Plexiform Neuroma.=--Plexiform neuroma is relatively rare. This is a type of nerve tumor in which all the branches of a given nerve which are distributed to a particular area become enlarged and elongated, the overlying skin being stretched and thin. Such a tumor seems like a loose bag containing a number of vermiform bodies, resembling the sensation given when palpating a varicocele. On section each of the affected nerves reveals a quantity of myxomatous tissue replacing the nerve sheath. They are in large measure congenital. The skin overlying a plexiform neuroma will frequently be found to be pigmented, variously altered in thickness, and covered with fine hair. These growths have been frequently _mistaken for lymphangioma_ (Figs. 84 and 85).

=Malignant Neuroma.=--Malignant neuroma (so called) will generally be found to be a true sarcoma of nerve structures, usually of the spindle-cell variety. _Traumatic neuroma_ is often seen in amputation stumps, where the terminations of the divided nerves become bulbous, attaining the size of cherry stones, the tumors being composed of a mixture of connective tissues and nerve fiber, from which in time the true nerve structure usually recedes or vanishes. They form when suppuration has been profuse or healing long delayed, and when sufficient care has not been exercised to prevent entangling of the nerve ends in the scar of the wound. They give rise to much pain, and often necessitate re-amputation. The bulbous enlargement is the result of prolonged irritation in a nerve, and has been noted around various foreign bodies.

True neuroma is innocent in tendency, though often painful. It is the sarcoma of nerve tissue which produces signs of malignancy. A true neuroma which causes unendurable pain should, when accessible, be removed. It is sometimes possible to separate the tumor mass from the balance of the nerve trunk, and thus to remove it without excision of the nerve. At other times it is impossible to avoid division and ensuing paralysis. Divided nerve ends should be brought together by catgut suture, by which means it may be possible to avoid permanent loss of function. Nerve grafting is also resorted to for repairing such defects. Removal of painful neuromas due to injuries to the head has more than once been the means of curing traumatic epilepsy.

6. =Tumors Derived from Epithelium.=

These tumors consist of specific epithelial elements supported and more or less bound together by a vascular connective-tissue stroma. The only apparent exception to this statement is tumor of dental tissue. The teeth are positively modified and petrified or calcified epithelial products.

=Odontoma.=--The odontomas are tumors composed of one or more of the dental tissues, arising either from tooth changes or teeth in process of development. They may be divided, according to Sutton, as follows:

1. =Epithelial Odontomas.=--These are provided with a capsule, and present usually as a series of cysts separated by thin septa, containing mucoid fluid, while the growing portions have a reddish tint not unlike sarcoma. They are most frequent about the twentieth year of life, but may occur at any age. They probably arise from persistent remains of the epithelium of the original enamel organs.

2. =Follicular Odontomas.=--These are often called “dentigerous cysts.” They arise in connection with permanent teeth, and especially with the molars, sometimes attaining great size and producing conspicuous deformity. The tumor consists of a wall representing the expanded tooth follicle, and a cavity containing viscid fluid, with some part of an imperfectly developed tooth, occasionally loose and more or less displaced in location. The cyst wall always contains calcareous material. These tumors rarely suppurate. They occur also in animals.

3. =Fibrous Odontomas.=--These consist of condensed connective tissue in a developing tooth, presenting as a tumor with a firm outer wall and a loose inner texture, blending at the root of the tooth with the dental papilla and indistinguishable from it. The developing tooth thus becomes enclosed within the capsule before it protrudes from the gum. These tumors are most common in ruminants, being often multiple.

4. =Cementoma.=--A tumor of fibrous character whose capsule has ossified or calcified, the developing tooth thus becoming embedded in a mass of dental cementum. These tumors occur most frequently in horses.

5. =Compound Follicular Odontomas.=--These are tumors containing a number of masses of cementum resembling small teeth, or even amounting to well-formed but ill-shaped teeth composed of all three dental elements. In such a tumor teeth may be found in great numbers. They occur in the human subject as well as in animals.

6. =Radicular Odontomas.=--These are tumors which arise after the crown of the tooth has been completed and while its roots are yet in process of formation. The crown, being unalterable enamel, does not enter into the composition of these growths, which then consists of dentine and cementum in varying proportions. They are rare in man, but frequent in other animals, and often multiple.

7. =Composite Odontomas.=--These are hard tumors, bearing little or no resemblance in shape to normal teeth, occurring in the jaws, consisting of a conglomeration of enamel, dentine, and cementum, presenting abnormal growth of all the elements of the tooth germ. So far this tumor has only been found in man.

Little is said about the _odontomas_ in general surgical literature. These tumors, as they grow, are often regarded as due to necrosed bone or to unerupted teeth, while fibrous odontomas have been often regarded as myeloid sarcomas. No tumor of the jaw, especially in young people, should lead to excision of the jaw until it has been demonstrated that the tumor is not one of the above forms. When diagnosticated as true odontoma its complete removal is all that is necessary.

=Papilloma, or Fibro-epithelioma.=--The type of papilloma is this common wart, consisting of a central stem of fibrous tissue and bloodvessels covered by epithelial projections and proliferations. Papillomas are usually _sessile_ and _villous_.

1. =Warts.=[14]--These are sessile papillomas, most common on the _skin_, often seen on mucous surfaces, and occurring sometimes singly, often in crops. They are exceedingly common about the _perineum_, where skin and mucous membrane meet, and are regarded as due to the irritation of specific discharges. The papillomas occurring about the genitalia are known as _condylomas_. The growths in these instances are frequently so luxuriant and proliferative that they assume fungoid shape, and are called _mulberry growths_. Warts grow slowly or rapidly according to circumstances. Warty growths may attain enormous size and become vascular. Late in life they are frequently the starting points of epithelial ingrowths, and then become true epitheliomas--_i. e._, cancer. Warty growths sometimes line the buccal cavity and complicate cases of _macroglossa_. They occur also in the _larynx_, and when situated near the glottis may cause dyspnea and fatal obstruction to respiration. It is claimed by some that cutaneous warts will disappear with continued small internal dosage of Fowler’s solution. (See Plate XXI.)

[14] Warts are by many pathologists considered as mere evidences
of hypertrophy from persistent irritation. They are here retained
among the tumors lest too much violence be done to formerly received
notions.

Papilloma of the bladder.]

2. =Villous Papillomas.=--These are met with most commonly in the _bladder_, occasionally in the pelvis of the _kidney_. They are identical with chorionic villi, and occur most often singly. It frequently happens that long, fine tufts are detached and carried away with the escaping urine. Another form of villous growth arises from the choroid plexuses of the lateral ventricles in the brain. These may grow and attain a size sufficient to produce disturbance (Fig. 86).

3. =Intracystic Villous Growths.=--These are seen, for example, in mammary cysts. These, of course, are lined with epithelium, which acts here as it does in other localities, and proliferates more or less rapidly under unknown circumstances. In dealing with paroöphoritic cysts the presence of these growths has also been alluded to.

4. =Ovarian Papilloma.=--There is a form of ovarian papilloma which partakes of the nature of a malignant tumor, in that separated particles seem to attach themselves to peritoneal surfaces, where they grow luxuriantly. Either this is an expression of parasitism or infectivity, or else of the implantation of tumors, which, to the writer’s mind, constitutes a strong argument for the parasitism of cancer. After abdominal section, with removal of the original focus, these growths often disappear. This affords a parallel to the instances of cure of tuberculous peritonitis after the same procedure.

Photographic Reproduction of Papilloma. Low power. (Gaylord.)]

5. =Cutaneous Horns.=--These are also epithelial outgrowths, and are met with in four varieties (Sutton):

(_a_) _Sebaceous horns_, quite common, arising by protrusion of contents of a sebaceous cyst through a rupture in its wall or through its duct, with consequent desiccation by exposure to the air, while fresh material is consequently added at the basis so long as sebaceous secretion continues. These growths soften when soaked in weak liquor potassæ.

(_b_) _Warty horns_, structurally identical with the above, but growing from warts instead of from sebaceous cysts. Both these forms are often found about the head. Cutaneous horns are also met with in ovarian dermoids. They are common in the lower animals and may attain large size.

(_c_) _Horns growing from cicatrices_, especially of bones, are rare, but a cornified condition of the cicatrix itself, with formation of scales resembling those from horns, is not uncommon.

(_d_) _Nail horns_ are simply overgrown nails, occurring on the digits and toes of bedridden patients who never walk (Fig. 87).

Nail horns. (Original.)]

=Treatment.=--All these forms of epithelial outgrowth call for radical removal, which implies complete extirpation of the membrane or tissue from which the growth occurs, after which, if effected, there is no recurrence. If some be left there is tendency to recedive.

=Mucous Polyp.=--Similar papillary and often pedunculated epithelial tumors frequently hang or project from the mucous membrane--_e. g._, the rectum. The pedicle really projects from the submucosa. Between the layers of the overgrown mucosa are found altered glands. So long as the growth of these polyps is toward the exposed surface they are innocent and wellnigh harmless, unless they attain fair size; but so soon as they grow inward and the boundary of the submucosa is transgressed they assume malignant aspects at once. Such transformation is by no means rare, and constitutes a strong argument for their prompt removal.

=Goitre; Struma.=--Pathologically the various enlargements of the thyroid known as goitre or struma constitute essential neoplasms. (See chapter on Regional Surgery of the Neck.) In this condition either the epithelial or the connective tissue may be primarily at fault.

1. =Struma Parenchymatosa Nodosa.=--This includes also the _colloid_ and the _cystic_ varieties, and refers to an enormous overproduction of the epithelial elements (parenchyma) in distended alveoli, where they often undergo colloid softening. So marked are these changes in numerous instances that multiple cysts (minute or large) result. The collective volume of such altered tissue may be very large.

2. =Struma Fibrosa.=--This presents itself in the way of dense enlargement of the thyroid, the stroma being the tissue now involved, even to the extent of causing much of the alveolar structure to disappear or become obliterated. In this condition calcification is common, and calcareous concretions or patches are often found.

Even benign tumors of the thyroid show occasionally a tendency to metastases. Cases are on record of benign goitre causing general metastases, and even of metastasis without noticeable thyroid enlargement. These occur most often in the bones, less frequently in the lungs and other organs. They are more common when the goitre has undergone colloid changes. The reasons for these changes are unknown.

In either form hemorrhages are common, with their resulting blood cysts or their solid residue, in which case pigment is usually found. Both forms are often accompanied by enlargement of the vessels, and sometimes these become enormously dilated and constitute an almost insuperable obstacle to successful removal. (See Thyroidectomy.)

=Ovarian Cystoma.=--The cystomas of the ovarian region assume two types: (1) Glandular cystoma, and (2) papillary cystoma.

1. =Glandular Cystoma.=--The _glandular_ type produces the multilocular forms, with numerous small and large cavities, filled with fluid which varies in color and appearance within wide limits, having usually the consistency of mucus or thin pus, and containing a small number of cylindrical epithelial cells. The cyst wall may contain tubular glandlike structures reaching into the surrounding connective tissue.

2. =Papillary Cystoma.=--The _papillary_ type presents projections into cavities of papillomatous outgrowths from their walls, which are covered by cylindrical epithelium, which latter also lines the cavities. It is most common in the parovarium.

It is rare to find a pure type of either variety; both forms are usually blended. Malignant transformation, of the latter type especially, occurs easily and insidiously, and explains many disappointments in result.

=Adenoma and Fibro-adenoma.=--Adenoma is a tumor whose type is the _normal secreting gland_, from which it differs in being an abnormal outgrowth or product, but particularly in that it has _no power of producing the secretion peculiar to the gland tissue_ or type from which it grows. The adenomas occur for the most part as circumscribed tumors in the _mammæ_, _parotid_, _thyroid_, _liver_, and in the _mucous membranes_ of the bowels and the uterus. They may be single or multiple; in the intestine they are usually multiple. In certain locations (_e. g._, the mammæ) they attain enormous dimensions, and in the ovary tumors of this character may be met with weighing forty or fifty pounds. The true adenoma shows no tendency to infection of neighboring lymphatics, and gives rise to no secondary deposit, and when it causes death it is usually because of size or pressure upon important organs. It displays a marked tendency to cystic alteration, while the relative proportion of epithelium and connective tissue or stroma varies within wide limits. In some cases, in which the former is small in amount, the preponderance of the latter has caused the use of the term _adenosarcoma_, which is really a misleading name.

The _distinction_ between _adenoma_ and true _carcinoma_ is in some respects but slight, and this fact will account for the conversion which many innocent gland tumors seem to undergo from one into the other. As soon as the epithelial cells lose their regularity of disposition and collect in groups, or make their way outside of the acini into the tissues, then the change from the benign to the malignant tumor has begun, and the entire clinical aspect of the case has altered. This change may be the result of external irritation, of such tissue changes as pregnancy and lactation, or of the undefined changes which advancing years seem to produce. (See Plate XXII, Fig. 2.)

Adenoma occurs in the _breast_ as _cystic adenoma_ or _fibro-adenoma_. The former often attains large size, is encapsulated, the acini are much dilated, while from the walls of the epithelium-lined cavities frequently project papillomatous processes, forming what are called _intracystic_ growths. Cystic adenomas grow slowly, produce atrophy of mammary tissue by pressure, occur after puberty until the menopause, and rarely give rise to pain until they become large. As they grow they distort the breast until it may become pendulous. When the growth of connective tissue, peculiar to the tumor in that it is rich in nuclei, forms well-marked partitions between alveoli, the growth is called _pericanalicular adenofibroma_, which may assume a tubular or an acinose type. When the alveoli and ducts are themselves invaded by ingrowth of this tissue, then we have the _intracanalicular adenofibroma_, which constitutes a growth sometimes bordering on the malignant. When the arrangement of epithelial cells in the acini and ducts becomes irregular and atypical, then malignant transformation has begun.

FIG. 1

Fibromyoma of Uterus. (Low power.)

FIG. 2

Fibro-adenoma of Breast. (Low power.)]

FIG. 1

Epithelial Pearl Formation in Squamous Epithelioma. (Middle power.)

FIG. 2

Malignant Adenoma of Rectum. (Middle power.)]

_Fibro-adenoma_ occurs also in the breast as a small tumor, encapsulated, usually superficially placed, movable in its site, often multiple; most common between the twentieth and thirtieth years of life; often painful, especially during menstruation; tender upon pressure. Both forms may occur in _young men_. A form of fibro-adenoma in which fibrous tissue is greatly in excess, which never attains great size, is common in the breasts of unmarried women. It gives rise to much pain and distress, but is clinically not malignant. (See Plate XXII, Fig. 2.)

Adenoma occurs frequently in sebaceous glands as:

1. =Sebaceous Cysts.=--Sebaceous cysts are generally known as _wens_. These tumors commonly begin as retention cysts, the ducts of the sebaceous glands becoming occluded. But in many cases there is no occlusion of the ducts, and their secretion may be easily expressed. They occur wherever sebaceous glands abound, but especially upon the scalp. They are usually multiple, vary greatly in size, are easily movable over the bone, and are intimately related to the skin, while the duct orifice is frequently recognized by a black spot, after removing which sebum can be expressed. These cyst-adenomas are encapsulated, and can be easily shelled out of their matrices, save when inflamed, in which case they are often astonishingly adherent. Their contents consist of pultaceous debris resembling old epithelial scales, fat, cholesterin, etc. The contents of these cysts are very prone to decompose, and they become as offensive as anything with which the surgeon has to deal. Putrefaction may be independent of inflammation or coincident with it. When irritated these gland cysts become inflamed and may suppurate, suppuration being tantamount to cure by spontaneous processes. They may also ulcerate, without suppurating, and form foul-smelling ulcers, or give rise to cutaneous horns.

Multiple atheromatous cysts (wens). (Lexer.)]

2. =Sebaceous Adenomas.=--These arise from the sebaceous glands, which are lobulated, like those about the nose and ear. Adenomas from this source are extremely liable to ulceration, may undergo calcification, and are often mistaken for epithelioma because of the fungous ulcerations to which they give rise.

3. =Adenocarcinoma.=--Sutton has also described an adenocarcinoma of the peculiar sebaceous glands named after Tyson. These are found particularly at the base of the prepuce, this form of tumor being rare. Adenomas arising from the _mucous glands_, which are usually transformed into cysts, are also known, as well as other gland tumors springing from the glands of Bartholin, Cowper, etc. (See Plate XXIII, Fig. 2, and Plate XXIV.)

_Pituitary adenomas_ are either analogous to struma or belong to the mixed tumors of dermoid or teratomatous type.

_Prostatic adenoma_ is in large degree fibromyoma of that body, with more or less hypertrophy of its glandular structures. Minute cystic alterations may occur also, as well as growth resembling intracanalicular fibro-adenoma.

Adenoma is occasionally observed in the _salivary glands_, where it is usually encapsulated, and may undergo cystic changes. It has been observed in the liver and pancreas. In the former its pseudo-ducts often contain inspissated material of bile-green tint.

The lesions of the _kidney_ referred to as cystadenoma are now grouped among the teratomas, and are described under that heading. They present interesting examples of mixed tumors.

In the _testis_, as in the _ovary_, epithelial tumors frequently present themselves, but they partake less often of the type of pure adenoma, and incline rather to that already described under Ovarian Cystoma. Even in the paradidymis tumors of this same character are found, with cystic or even papillary alterations.

In the _mucous membrane_ of the _stomach_ and _bowels_ adenoma usually presents as an ovoid tumor, attaining such size as to give rise to mechanical obstruction either by pressure or by traction. Adenoma of the pyloric region is a repetition in structure of the pyloric glands. In the _rectum_ it presents usually as a polypoid outgrowth, often seen in young children. Such tumors are generally small, and when solitary they often hang by a distinct stalk.

Similar polypoid tumors present in the cervical canal of the _uterus_, where are also found sessile and racemose tumors, all of which are structural repetitions of the glands met with in the cervix uteri. Adenoma of the uterine cavity is seldom seen; it is also rare in the _Fallopian tube_, but occasionally presents as a dendritic outgrowth from the mucous membrane distending the tube.

=Epithelioma.=--Epithelioma is common, especially where there is transition from one kind of epithelium to another, and, of all other localities, particularly where skin and mucous membrane meet--_e. g._, the lips, the vulva, and the anus. Epithelioma differs from papilloma in that the former is no longer limited by basement membrane, but passes beyond it into the underlying connective tissue and presents _down_--rather than _up_--growth. Characteristic of epithelioma are the so-called _cell nests_ or _pearly bodies_, where there seems to be a tendency to globular arrangement of cells with such condensation or alteration that they lose their ability to take stains, and appear as a more or less lustrous mass, showing off by contrast among the standard surrounding tissue. On this account they are often called _pearly bodies_. Recognition of these is tantamount to diagnosis of epithelium. (See Plate XXIII.)

This form of neoplasm is essentially the same, no matter what its clinical varieties. These comprise a _wart-like_ growth or nodule, which quickly becomes an ulcer with elevated edges, ulceration being due to necrosis of cells farthest from the periphery; or, again, the disease may start as an _ulcerated fissure_, ulceration and infiltration keeping pace, in which case there is a sharply defined ulcer with undermined edges. A third variety, often seen upon the lips, comprises a _projecting mass_, with more or less horny surface. In nearly all of these, however, the characteristic cell nests with their onion-like arrangements of cells will be found.

Epithelioma, especially when exposed to the air or to surface irritation, quickly _ulcerates_ and tends to involve all the surrounding tissues, while occasionally the distinctive cells proliferate so rapidly as to give the ulcer more or less of a bursal or a _cauliflower-like_ arrangement. From such a surface there is a constant discharge of foul-smelling detritus or of sloughs. Even bone cannot resist its progressive invasion and slowly disintegrates before the advancing mass. Cartilage is resistant, and usually preserves its integrity. In other words, the tendency of epithelioma is toward constant encroachment and infiltration, and toward a fatal termination from hemorrhage by ulceration, from septic infection, exhaustion, or other accidents. The wart-like forms run the slowest course of all, but even here the malignant tendency is most evident.

=Lymph-node Infection.=--A striking characteristic of epitheliomas is the _invasion of the adjoining lymph nodes_, which attain a size disproportionate and bearing no necessary relation to that of the primary growth. This constitutes one of the most serious complications of the condition. This lymphatic invasion partakes of the malignant character of the disease, and from every focus of this character infiltration and destruction proceed. Infected nodes also show an early tendency to central degeneration and to spurious cyst formation. When the overlying skin becomes involved we have extensive sloughing and the conversion into large malignant ulcers. Dissemination to a distance (_i. e._, _metastasis_) is rare in epithelioma--much more so than in carcinoma. (See Plate XXV, Fig. 2.)

About the mouth epithelioma is not common before the thirty-fifth year, though I have seen it on the lip of a twenty-year-old woman. It is vastly more common in men than in women, and more frequent on the lower than the upper _lip_. In the _tongue_ it seldom occurs before the fortieth year. It seems to be more common both on the lip and tongue in men with bad teeth and in confirmed smokers, thus giving rise to the view often held that it is purely a matter of irritation. It may, however, be due to contact infection should it be regarded as of parasitic origin. In one-fifth of the cases of epithelioma of the tongue there are preceding lesions, usually described as _leukoplakia_ or _ichthyosis_ of the tongue--conditions characterized by epithelial reduplication and the formation of dense plaques or scales. These lesions are usually regarded as precancerous conditions. (See Plate XXVI.)

FIG. 1

Primary Papillary Adenocarcinoma of the Kidney. (One-half original size.) (Gaylord.)

FIG. 2

_Papillary growth into tubule_

Section of the Primary Growth. (Gaylord.)]

FIG. 1

Carcinoma developing in a Thrombus in the Portal Vein. (Middle power.) (Gaylord.)

FIG. 2

Metastasis of Squamous Epithelioma in a Lymph Node. Pearl Formation. (Middle Power.)]

FIG. 1

Epithelioma of Tongue. Enlarged three diameters.

FIG. 2

Paget’s Disease of the Nipple. Enlarged two diameters.

Photographs from hardened unstained specimens.]

The disease often starts near the stump of a _carious tooth_, in which case infiltration and erosion begin promptly and progress rapidly. Epithelioma of the _tongue_ has been known to follow along the obliterated track of the thyrolingual duct, and in this way to bring about a perforating ulcer.

Epithelioma of the _esophagus_ is a common cause of stricture of this passage-way. It leads to ulceration, and usually to perforation into the trachea or some other cavity or passage (_i. e._, a bloodvessel). In the _larynx_ the disease is well known, and gives rise to intense and finally fatal symptoms, but has been dealt with successfully by radical operations for extirpation of the entire organ. (See Chapter XLI.)

Epithelioma of forehead and eyelid. (Neisser.)]

Epithelioma of lip. (Neisser.)]

Occurring upon the _scrotum_, epithelioma has been called _chimney-sweeper’s cancer_, or _soot-warts_, and has been ascribed to the irritation of foreign material. Ulceration and infection of the inguinal nodes usually proceed rapidly and disastrously. It is believed also that tar and paraffin may produce similar irritation, and _paraffin cancer_ has been described by various writers. It usually occurs upon the scrotum.

The skin lesions which precede the formation of paraffin cancer resemble those seen in chimney-sweeper’s cancer. The skin becomes dry, thickened, parchment-like, while the openings of the sebaceous glands become obstructed by the tar or other material, producing acne-like lesions. Warty outgrowths then occur, and these become the seat of malignant ulceration. In chimney-sweeper’s cancer the scrotum is usually first affected in a chronic dermatitis, to which warty outgrowths succeed, these enlarging and growing downward as ulceration takes place.

About the external genitalia epithelioma is not uncommon, particularly in and about the _prepuce_. Such a degree of phimosis as leads to retention of smegma is certainly a predisposing cause, not only in man but in the lower animals. Epithelioma of the _vulva_ has been described under the name _esthiomène_, and requires to be recognized and dealt with promptly if the surgeon should attempt a radical cure. In the _vagina_ and about the _cervix uteri_ it is common, a large proportion of cases of cancer of the uterus being essentially epitheliomas of the cervix.

In and about _scars_ and upon _granulating ulcers_ epithelioma is quite common. One danger to which a chronic ulcer is always exposed is that of epitheliomatous transformation. These growths also attack _lupus scars_, or even any tissues actively involved in the lupoid process. This is particularly true between the fortieth and sixtieth years of life.

Among the viscera the _gall-bladder_ is probably more often involved in distinct epitheliomatous changes than any other. It presents as a uniform thickening, and causes augmentation in size, so that a distinct tumor projects from beneath the liver. In this location dessemination is rare.

Epithelioma is to be regarded as having an essential malignant tendency. Its treatment demands early removal of diseased parts and complete extirpation of involved lymph nodes. It is only the small and incipient growths which should be attacked by such destructive agencies as cancer pastes or the electrolytic current.

=Rodent Ulcers.=--Under the name of _rodent ulcers_, _lupus exedens_, _noli-me-tangere_, etc., writers, mostly English, have described a variety of epithelioma, met especially upon the face, to which a separate classification has usually been assigned. Until recently it has been generally regarded as a local ulceration, distinct from cancer. In some text-books it is described as _lupus exedens_. It is preceded usually by a nodular condition of the skin, vascular, breaking down into a regular ulceration, but little elevated, the base of the ulcer deeply excavated, with a striking disproportion between ulceration and new-growth. In this particular variety infiltration seems to be continuously in advance of the rodent process, the former being excessive, the latter but slight. This variety of epithelioma rarely produces lymphatic involvement; the discharge is slight, the pain complained of inconsiderable. Occasionally it entirely alters its aspect, and may present features of the conventional epitheliomatous type.

FIG. 92

Rodent ulcer. (Original.)]

The development of cancer in lupus areas is now of sufficiently frequent occurrence to demand attention. Whether the epithelium which gives rise to it is to be accounted for by Cohnheim’s hypothesis, as having been cut off in the course of healing and become a cell rest to subsequently undergo malignant degeneration, is not yet settled. It has been suggested that curettage might cause fragments of epidermis to be loosened and then entangled in the cicatrix, and thus be responsible for subsequent malignant changes. When lupus thus degenerates it assumes usually the papillomatous form, which rarely involves lymph nodes, while the change which follows _x_-ray treatment often succeeds a hyperkeratosis and rapidly involves gland structure.

_Rodent ulcer_ allies itself with the type of tubular epithelioma springing from the outer sheath of the hair follicle, sending out cylindrical processes which freely blend with one another. It is to be regarded as an equally malignant type of ulceration with other cancerous ulcers, and demands the same thorough and radical measures for its relief as do other forms of epithelioma. It is perhaps the most favorable one with which to deal, because of the usual freedom from involvement of deep lymphatics. No distinctive measures are necessary for its relief--only those which are thorough.

=Carcinoma.=--Carcinoma is a tumor _springing from preëxisting gland tissue_, which it more or less closely resembles in type, save that the _structural similarity is incomplete_, the epithelial cells now collecting in irregular clusters, or filling the acini and obstructing the ducts, or bursting beyond the basement membrane and invading the surrounding tissues. They frequently so fill the ducts as to appear in columnar arrangement when seen under the microscope, and this has given rise to the use of a term so vague as to have no place in pathology--_i. e._, _cylindroma_. Carcinomas may arise from any of the secreting glands, but more commonly from some than from others. They have _no capsules_. They _infiltrate_ the surrounding tissues, _usually involve the lymphatics early_, are liable to _spread to the superficial tissues_ and to _ulcerate_, and to _undergo various degenerative changes_. Nearly all cancerous tumors abound in lymphatics, which will explain the rapidity with which the lymph nodes become infected, as well as the tendency to dissemination, which is characteristic of these growths. Dissemination leads to so-called secondary or _metastatic_ growths, which may make their appearance in any organ or tissue, even in the bones, where they give rise to changes of texture that make spontaneous fracture easy. It is characteristic of carcinoma that the metastatic tumors which it may produce will reproduce almost perfectly the type of the primary tumor whence the embolic fragments which have produced them spring. The amount of dissemination varies exceedingly: it may even become so marked and widespread as to produce a condition analogous to that met with in miliary tuberculosis--_miliary carcinosis_. A similar condition, much more rare, is seen in dissemination of sarcoma, and is known as _miliary sarcomatosis_. A constantly spreading cancerous infiltration of the superficial tissues, which is noted most often after mammary cancer, is described under the form of _cancer en cuirasse_, or _jacket_ or _corset cancer_. Instances will be seen in which this infiltration of the surrounding structures has extended nearly or even completely around the thorax. It gives rise to a brawny induration which is unyielding, and is studded here and there by nodules that tend to ulcerate, to fungate, and to bleed easily. It is perhaps the most hopeless form of cancerous disease.

The older writers have constituted two or three clinically distinct forms of carcinoma, based mainly upon the relative hardness or softness of the tumor and the invaded tissues. The term _scirrhus_ is thus applied to a tumor in which connective tissue preponderates and epithelial cells are relatively deficient. On the other hand, the term _encephaloid_ has been applied to a tumor in which the connective tissue seems barely sufficient to hold the mass together, while the epithelial cells are in vast preponderance. These are all tumors of the round epithelial-cell type, and these distinctions are of clinical interest, yet have no great pathological import, save that in a general way the greater the proportion of epithelial elements the sooner will life be terminated by destructive processes. In other words, _the more the tumor may partake of the encephaloid type the worse the prognosis_ or the shorter the probable duration of life. Again, these tumors pursue a varying clinical course. In those tumors, particularly of the scirrhus type, where the connective tissue largely preponderates, there is often an eventual reduction in the size of the part involved, and such reduction of vascularity and of nutritive activity that the rate of growth is thereby perceptibly checked. The so-called atrophying cancers of the breast are the best examples of this type of cancerous disease. Here the volume of the gland is diminished rather than augmented, and the disease may last for a number of years. It is questionable whether it is well to operate.

The so-called _colloid forms_ of cancer are simply the expression of pathological changes occurring in growths of more distinct type. Thus colloid softening may occur in any tumor in which cancer cells predominate, and the so-called colloid cancers of the peritoneum, the ovary, etc., are either examples of such alterations or are possibly endotheliomas arising in these locations. The term _villous cancer_, with other terms like it, should be expunged from all scientific literature, unless these terms are used in purely adjective and clinical sense, for they imply nothing accurate as to histological structure, and are often misleading and inaccurate.

Carcinoma is most common in the following regions:

In the _breast_ it appears particularly in two forms:

1. _Acinous Cancer_; and

2. _Duct Cancer_.

1. =Acinous Carcinoma.=--Acinous carcinoma is usually of the scirrhus type. It may arise at any portion of the breast, and if anywhere near the nipple it will cause _retraction_ of that prominence, which is always pathognomonic; elsewhere it leads to puckering and adhesion of the overlying skin. These tumors infiltrate widely, especially along the connective-tissue stroma and the fibrous tissue which intersperses the fat of the breast. They are usually firm and sometimes exceedingly dense. A form of scirrhus known as _atrophying scirrhus_ consists largely of strands of fibrous tissue, injected here and there with epithelial cells. It is the slowest in growing of all the forms of cancer, and by its contraction tends to reduce rather than augment the size of the mamma.

Acinous cancer is rare before the age of thirty, most common between forty and fifty. It occurs in women in all conditions of life, married and single, but is rarely noted in the male breast. The most dangerous form is that which appears _during lactation_. Ordinarily its progress is slow. As it augments in volume it infiltrates the surrounding tissues, becomes adherent to the pectoral fascia, infiltrates the muscle fibers, and finally attaches itself to the periosteum of the ribs. The infiltrated tissues tend to shrink rather than to increase in volume. _Lymphatic injection_ occurs early in this form, and is a pathognomonic sign. It occurs mostly in the axillary lymphatic nodes, but may often be detected in the neck above the clavicle. When the skin is involved there is a tendency toward ulceration and fungoid condition. This is preceded by the purplish appearance of the tense skin. (See Plate XXVII.)

“Pig-skin” appearance of cancerous breast.]

_Pain is an uncertain_ and _variable_ feature. It is important to emphasize this fact, as many of these conditions have been lightly regarded because of freedom from pain. Pain is not a constant phenomenon in cancer. On the other hand, it is sometimes intense, either localized or radiating and referred to distant points. Pain is particularly noticed in cases which assume the form of cancer _en cuirasse_. Secondary deposits in viscera frequently occur, particularly in the abdominal organs and the lungs; but any organ may be the seat of secondary infection, and this is found occasionally in the bone-marrow, not alone of the sternum or ribs, but of distant bones, and is called _marrow injection_. As the result of cancerous affection of serous membranes effusions of fluid frequently take place, as in the pleura, peritoneum, and pericardium, and this fluid is often blood-stained.

In consequence of pressure upon the venous trunks in the axilla there is often a swelling of the arm upon the affected side, dropsical in character, known as _lymphatic edema_. The arm grows heavy, the patient loses control of it, and the skin may become so distended by effusion as to cause the limb to resemble a cast. This is due not alone to pressure upon the veins but to involvement of the lymphatics, and upon careful examination positive dilatation of the lymphatic vessels may be noted. Pain is a usual accompaniment of this form of edema.

2. =Duct Carcinoma.=--This appears especially about the time of the menopause, when glandular structure has disappeared and only ducts remain. It is common, without reference to cancer in these instances, to find cystic dilatation of numerous ducts, which vary in size from a mustard seed to that of a cherry. These are referred to by Sutton and others as _involution cysts_. They are filled with mucoid material and have a bluish tint. They occur usually upon the under surface of the gland. Such cystic breasts are common, and when appearing in diffused form may be easily mistaken for cancer. Pain is not frequent. _This condition is certainly a precancerous stage_, since the dilated ducts are often the starting points of cancer, and occasionally of papillomatous or villous outgrowths from their walls.

_Duct cancer_ implies the form which arises in these dilated ducts, most commonly in the terminal branches, appearing ordinarily as a single tumor, but sometimes as a mass of separate nodules. _Intracystic_ and _intracanalicular_ growths of this character are often found. When assuming the truly cancerous phases they may be spoken of as _duct cancers_, otherwise as _duct papillomas_. They have generally been referred to as _intracanalicular fibromas_. Duct cancers are less tense than the preceding variety, and when situated near the surface often discolor the skin. It is from these cases that there is seen a more or less abundant discharge of fluid resembling _bloody milk_. These tumors grow slowly, lymphatic involvement is late, and in general they present the least malignant forms of breast cancer.

FIG. 1

Scirrhus Carcinoma of Breast. (Middle power.)

FIG. 2

Soft Infiltration Carcinoma of Breast, showing Stroma. (Mallory’s connective-tissue stain.)]

_Carcinoma of sebaceous glands_ is by all means most common in those specialized glands named after Tyson, occurring about the prepuce. They give rise to the usual forms of cancer in this locality.

Carcinoma in the _prostate_ is not common, and is usually confined to old men. Infiltration proceeds around the base of the bladder at the same time and binds the pelvic viscera together. The pelvic lymphatics become early infected and dissemination is frequent. (See Prostatic Hypertrophy.)

Recurring carcinoma of male breast. (Original.)]

Carcinoma in the _salivary glands_ is not common; it is more frequent in the parotid region, occurring at middle life, growing rapidly, infiltrating surrounding parts, and tending to ulceration.

Carcinoma of the _liver_ varies in its arrangement and appearance. Sometimes it appears in the form of nodules; at other times, as a more diffuse malignant infiltration by cells relatively abundant in number, so that the clinical aspects of the case conform rather to the encephaloid or medullary type.

Carcinoma of the _kidney_ was formerly described as encephaloid, meaning thereby simply a malignant tumor of soft structure. It is probable that a large proportion of these tumors were sarcomas. Nevertheless, true carcinoma of the kidney is possible.

Carcinoma of the _ovary_ may originate as such, or be the result of a transformation from an ovarian cystoma (see above). No better illustration can be offered of the infectivity of cancer cells (be the secret of this infectivity what it may) than the rapid dissemination of cancer throughout the peritoneal cavity, which sometimes follows the removal of an apparently non-malignant tumor which is undergoing this change.

On the other hand, in the _testicle_ such tumors are common--more so than sarcomas. It is likely that many of them arise from the paradidymis.

Carcinoma of the _stomach_ is a frequent disease. It involves the tubular glands, especially in the pyloric region, and conforms to them in type. After involving the mucosa it spreads to the entire coats of the stomach and infiltrates adjacent structures, while the mesenteric lymphatics are usually early and notably involved. Were it possible to recognize this involvement early in the course of the disease diagnosis of pyloric cancer and operative interference would be much more common and hopeful. Secondary involvement is generally in the adjoining viscera, but may be seen at a distance. Miliary carcinosis has been noted after pyloric cancer. This form usually occurs between the fortieth and sixtieth years of life, the duration of the disease not being long.

In the _intestine_, and particularly in the _rectum_, carcinoma proceeds also from the mucous glands, and tends constantly to extend at its periphery and involve the entire lumen of the bowel. It seems to be inseparable from a tendency to contraction of the gut and consequent annular stricture. Ulceration, favored by surface irritation and infection, occurs almost always early. Above the rectum it usually occurs in the neighborhood of the sigmoid flexure. Cripps has observed that when cancer of the rectum spreads downward and involves the _anus_, it loses its typical glandular character and assumes the type of epithelioma, or squamous-cell cancer. In these cases the pelvic and mesenteric lymphatics are infiltrated and metastatic affections are common.

Carcinoma may appear in any portion of the _uterus_, but is more common in the lower than in the upper half. It assumes the type of the cervical glands, spreads rapidly, infiltrates widely, ulcerates early, and disseminates frequently. By extension of ulceration the formation of urinary and of fecal fistulæ is common. Pyosalpinx and hydrosalpinx are also favored, while the spread of the disease is, in fact, more common when it involves the cervix than when it involves the uterine fundus.

=Malignant Chorion Epithelioma.=--This has also been called _deciduoma malignum_, a malignant growth of chorionic epithelium. Inasmuch as this tumor also includes a syncytial layer it has been known as _syncytioma_. Such tumors usually contain elements derived from both layers of the chorion. They follow pregnancy, generally within a few months, and are often preceded or accompanied by a _hydatidiform mole_. This growth constitutes a malignant neoplasm. It pertains to ulcerating uterine growths characterized by early extensive metastasis, which prove fatal. It has been shown that similar growths occur not only in the uterus but also in the testicle, and thus the scope of the term has been much enlarged. In its biology it resembles the sarcoma; in its histology, the carcinoma. It is more malignant than any other known growth. (See Plate XXVIII.)

Occurring within the uterus its most important clinical feature is a tendency to frequent and alarming hemorrhage. When occurring about the testicle this trouble rapidly becomes fungoid, bleeding easily and excessively, the lungs being among the first organs to show metastasis, which takes place through the blood as well as the lymphatic vessels, for the cells of these growths seem to penetrate the capillaries. By the time a diagnosis is made a case is likely to be too far advanced to admit of radical treatment. If scrapings could be examined early, shreds of syncytioma would be found, and it might be possible that a complete hysterectomy would be of use.

Metastatic nodules consist mostly of round, dark masses presenting a more or less pronounced fibrous structure. These are generally found in the lungs and cerebrum, where the vessels are large and the tissues soft. There is usually a sharp contrast between such a tumor and the surrounding tissues. The time which elapses between delivery and the appearance of the growth is from three to ten weeks. The tumor rapidly spreads to the upper portion of the vagina. The trouble probably begins some time before delivery.

The latest tendency among pathologists is to refer a growth of this kind to the teratomas. In women this tumor is particularly a teratoid growth, some cells of the fecundated ovum giving rise to neoplasms, while the ovum itself thus derived may misdevelop into a hydatidiform mole. The tumor may be properly regarded as consisting in effect of fetal cells; it is built up of these cells, without bloodvessels and connective tissue, and so belongs to a class by itself. Occurring in women it is almost always a consequence of pregnancy; occurring in the testicle or in the ovary it should be regarded as proceeding from ectodermal cells. For their treatment the earliest and most radical measures only will suffice.

=Suprarenal Epithelioma; Hypernephroma.=--Grawitz has distinctly established the right of these tumors to separate consideration, for he first determined their origin and identity. Hypernephroma is a tumor, found mainly in the kidney, composed of adrenal rests, or bits of accessory suprarenal tissue imprisoned within the renal capsule. Their minute structure is often that of the adrenals, with a tendency toward the type of perithelioma. They have hitherto been considered examples of sarcoma of the kidney, but are to be abruptly distinguished from it in most instances. Tumors of this character have also been found within the capsule of the liver and along the spermatic artery. In the kidney the tumor portion is usually distinct from the renal tissue; it is often enclosed within a sort of capsule, and rarely connects with the pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely escapes by the ureter. Hypernephroma is delicate in structure, and its vessels give way readily. After this has happened a true hematoma may result. (See Plate XXVIII.)

Similar neoplasms form in the adrenals themselves. These tumors vary in degree of malignancy, some of them scarcely deserving the designation malignant. They may be met at any age, but are more common in adult life. Before removal they are not to be differentiated from other tumors of the kidney. Their cells manifest this peculiarity in that they contain a notable percentage of glycogen. It should also be added that even in true sarcoma of the kidney proliferating adrenal elements may be found.

FIG. 1

Hypernephroma Renalis. (Medium magnification.)

FIG. 2

Chorion Epithelioma.]

GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.