In the eyelids one occasionally meets with cystic dilatations of the

lacrymal ducts. These are known as _dacryopic cysts_ or _dacryops_.

Fistulas result when they are opened through the skin, and if meddled

with at all they should be radically extirpated.[13]

[13] In the treatment of cysts, as of many abscesses (_e. g._,

those of the gland of Bartholin), it will be of advantage to empty

the cavity through a small trocar or needle and then to fill it

with melted paraffin, as suggested by Pozzi. When it has thus been

distended it can be dissected out with much more deliberation and

more easily than would be otherwise possible.

=Pseudocysts.=--In his elaborate work on tumors Sutton has made

a distinct classification of pseudocysts, which lack some of the

characteristics of genuine cysts, yet, nevertheless, are entitled to

consideration in this place. Among these are included _intestinal

diverticula_ and _vesical diverticula_, in either of which instances

hernial protrusions of the mucous membrane through the outer coating

of the bowel or of the bladder occur, thus forming pouches. These are

common in the bowel, rare in the bladder; especially in the former

locality they are often multiple. This condition is often referred to

as _sacculation_, and sacculation of the bladder may even be confounded

with true urachus cyst. They are of little consequence so long as

foreign materials, such as feces, urinary calculi, etc., do not lodge

in them. But they occasionally cause serious trouble. Diverticula have

been mistaken for appendices, while diverticula from the bladder have

been encountered in hernia operations.

_Pharyngeal diverticula_ give rise to rare but most interesting tumors.

It is well known that the branchial clefts, which in early fetal life

connect with the pharynx, are sometimes not completely closed, and that

a portion of one may persist abnormally, giving rise to a condition

known as the _pouch of Rathke_. There may also occur sacculation of the

pharyngeal wall where it joins the esophagus, or hernial protrusions,

especially in Rosenmüller’s fossa.

Cystic dilatation of Rathke’s pouch occurs near the upper part of the

pharynx, and may attain the size of a marble. Hernial pouches are

seldom mistaken for cysts, and are of importance mainly because of

the fact that food or other foreign material gathers and lodges in

them. Most of the other cystic abnormalities of the pharynx pertain

to dermoids, and will be considered shortly. In a general way, these

pharyngeal tumors have been grouped as _pharyngoceles_.

Similarly in the _esophagus and trachea hernial protrusions_ occur, and

lesions closely resembling retention cysts may be seen.

_Synovial cysts_ (_i. e._, those containing synovial fluid) may arise

(1) by protrusion of synovial sheaths, (2) by distention of bursæ

in the vicinity of joints, or (3) by hernial protrusions of joint

membranes. They are often met with in connection with the larger

joints, more particularly about the knee. In this way tumors as large

as goose-eggs may be formed, while their location may be so shifted

that they present themselves in perplexing ways. To that form produced

by hernial protrusion of the lining of a tendon sheath has been given

the name _ganglion_.

The simple ganglion is frequently seen on the back of the wrist, and,

while it is always connected with the tendon sheath, it undoubtedly

often connects with the synovial membrane of the carpal joints. The

compound ganglion, so called, is a much more serious and extensive

affair, being one which has prolongations in two or more directions,

and containing peculiar bodies, known as _melon-seed bodies_, which

appear to be fibrinous concretions worn round and smooth by attrition.

These are present sometimes in enormous numbers. (See Tuberculosis of

Synovial Structures, Chapter IX.)

_Bursæ_ are normal in many well-known situations in the body, but may

undergo cystic dilatation and become annoying tumors. In many other

places, under the influence of friction or mechanical irritation, there

develop bursæ which are known as adventitious. These are sometimes

subtendinous, and may communicate alike with joint sheaths and tendon

sheaths. These are true cysts of new formation not developed from a

pre-existing cavity.

They are largely the effect of peculiar occupation, as in housemaids

and carpet-layers there are formed frequently _prepatellar bursæ_,

while miners get them upon the elbow, porters upon the shoulder,

plasterers upon the forearm, etc. In the same way, by the pressure of

ill-fitting boots, an adventitious bursa is developed over the expanded

head of the first metacarpal bone, thus forming a condition known as

_bunion_.

=Neural Cysts.=--This term has been applied by Sutton to pseudocystic

dilatation of certain cavities found in the brain and central nervous

system. _Hydrocephalus_ is in one sense a pseudocyst of this variety.

Corresponding to it in fetal life is _hydramnios_. Hydrocele or

cystic dilatation of the fourth ventricle is well known. _Cranial

meningoceles_, which are hernial protrusions of brain membranes,

are also pseudocysts, to be included in this category. They will be

considered in Chapter XXXVI. _Cephalhematoma_ may be also included in

the same way. _Spina bifida_, a condition which will be described in

Chapter XXXVIII, is, nevertheless, practically a cyst of congenital

origin involving the spinal meninges. One form of spina bifida is

constituted by cystic dilatation of the central canal of the spinal

cord, and produces _syringomyelocele_. These conditions will be treated

more fully in their appropriate places.

Sutton has rendered a great service by showing that the brain and

spinal cord are evolved from a segment of the primary intestines, and

that the _intestinal canal and the neural canal communicate in fetal

life_ at their _lower terminations_; while it has been shown by several

that in the earlier forms of mammalian life they were also connected by

their _anterior terminations_. It is in this way that certain complex

tumors of the sacral and coccygeal region are to be explained. So also

is the collection of lymphoid tissue in the vault of the pharynx, known

as _Luschka’s tonsil_, and in the coccygeal region, known as _Luschka’s

gland_, it being a curious and instructive fact that lymphoid tissue

of this character is always met with in the neighborhood of obsolete

canals.

=Hydatid Cysts.=--These cysts are the indirect product of the eggs

of the Tænia echinococcus, a form of tape-worm which infests the

alimentary canal of dogs. The eggs reach in some direct or indirect way

the food or water taken into the human stomach and are there hatched;

the young animals migrate through vessel walls and are deposited in

some tissue or organ where the cyst later develops. These cysts have a

thick, elastic wall, with a lining containing cells, involuntary muscle

fibers, and a water-vascular system. After such a cyst has attained

the size of an inch or more, small vesicles, or “brood capsules,”

begin to develop, which present at one point a retractable head,

with scolices so arranged in crown form as to produce sucking disks.

According to the date at which the cyst is opened appearances will

differ. Sometimes a large cavity will be filled with multiple “daughter

cysts,” and sometimes these will have disappeared, so that the cyst

fluid contains nothing distinctive. After having ceased to develop,

hydatids frequently undergo atrophy and even become calcified; the

characteristic hooklets are the last of the distinctive features to

disappear.

These growths may be rapid, even to the point of producing necrosis

and rupture, or may be very slow and persist almost unchanged for

years. The disease is uncommon among the native-born population of

the United States, and most of its examples are seen in emigrants.

It is exceedingly prevalent in Iceland and in New Zealand. It occurs

most often in the liver, but is frequently met with in these countries

in the lungs, the brain and spinal canal, and the bones, but may be

encountered in any part of the body. When located near the intestinal

tract or the air tract the cysts are more liable to penetration by

ordinary germs of sepsis, and then may suppurate. It is not infrequent

to have conversion of an hydatid cyst into an abscess. Before or after

such change it may undergo rupture, spontaneous or traumatic, and this,

according to the nature and amount of its contents, and the location of

the opening, will promptly produce more or less grave symptoms. While

spontaneous recovery has, in rare instances, followed rupture, it has

perhaps more often led to fatal result. At all events, it will produce

serious and perhaps distressing symptoms.

The only radical treatment for hydatid cysts is extirpation. When this

is not possible the cyst may be opened and the margins of the opening

attached to those of the skin wound. After being evacuated it should

be packed and drained, and then may be expected to slowly contract,

perhaps even to the point of obliteration. The contents of such a cyst

should not be allowed to escape into any of the body cavities, since

their sterility can not be always relied upon.

=Cystic Degeneration.=--_Hematocele_ is an expression meaning a tumor

composed originally of effused blood which has undergone chemical

and other changes, which consist of lamination and thickening of

its exterior portion and fluidification of the interior, until in

course of time such an internal blood clot may be converted into a

distinct and plainly walled cyst. This condition may be seen in two

locations--namely, in the _pelvis_ and _between the cranium and the

brain_, or in the brain. The hemoglobin gradually disappears, and the

contents of these cysts are translucent or even watery in appearance.

Hematoceles may form where there has been internal hemorrhage in

certain locations which has failed to absorb, and where no pyogenic

infection has occurred.

Pseudocystic changes occur in other tumors and in other parts of

the body as the result of _mucoid_ and _colloid liquefactions_.

In the midst even of apparently dense and entirely defined tumor

masses changes of this kind occur, and lead to formation of cavities

containing fluid of variable consistence, causing the tumor when

divided to present the appearance of the geodes or quartz rocks,

containing cavities lined with quartz crystals. The occurrence of such

cystic changes is indicated, in naming such a tumor, by prefixing the

term _cysto-_, as cystosarcoma, cystofibroma, etc.

2. =Dermoids.=

Dermoids are _cysts or tumors containing tissues and appendages which

are developed from the epiblast_, and which occur when skin and mucous

membrane are not normally found. The simplest form of dermoid is a cyst

whose interior is lined with modified skin, containing sebaceous glands

and hair follicles, from which often numerous long hairs are produced.

Even sweat glands may be present. Its cavity is occupied by mixed

material, pultaceous in character, made up of sebum, cholesterine,

and growing hairs which are often rolled into balls. The sebum is the

product of the glands contained in the cyst wall.

A complex form of so-called dermoid cyst is met with in which there are

unstriped muscle fiber, teeth, mammary glands, etc. These belong rather

to the class of teratomas, as they contain more or less tissue not of

epiblastic origin.

A _dermoid tumor_ is one lacking cystic characteristics, made up of

tissue largely developed from the epiblast, with more or less tissue of

mesoblastic origin. Such a tumor may contain much connective tissue,

fat, fetal hyaline cartilage, and nerve tissue, while from its exterior

long hair may grow, and teeth project from its surface or be embedded

within its substance. Such tumors are generally found in the pharynx

and about the rectum.

The explanation of dermoids and teratomas may be gleaned from

embryology, and rests upon the arrangement of the different

blastodermic layers of the developing ovum, and upon the facts already

alluded to in explaining Cohnheim’s hypothesis of the origin of tumors.

Strictly speaking, a _dermoid_ should contain only that which may be

developed from the _epiblastic_ layer. It is well known that teeth

and hair, as well as sebaceous material, are epiblastic products.

Consequently such material may be found within a dermoid and needs

no further explanation than an epiblastic inclusion, according to

Cohnheim’s views. But so soon as such a tumor contains bone, muscle,

etc. (_i. e._, tissues of mesoblastic origin), we should drop the term

_dermoid_ and consider it a _teratoma_. Such is the distinction between

these two terms. According to Wilm’s researches, any tumor of this sort

which contains epithelial products as teeth or hair is sure to contain

also mesoblastic elements, and thus to belong to the latter. The term

_epidermoids_ has been applied to the former.

The most prominent characteristics of dermoid cysts are: (1) _Skin_,

which may be thick or thin, lined with papillæ, containing more or less

pigment, its deeper layers possessing a quantity of fat. (2) _Hair_,

which next to skin is the most constant structure found in dermoids;

this may be present in trifling amount or in long coils or balls. It

is of interest that in dermoids found in animals covered with wool we

find the same character of hairy structure, while in birds dermoids

contain feathers rather than hairs. (3) _Sebaceous glands_ and their

peculiar secretion are invariably found. These may be of large size,

and sebaceous retention cysts may be seen in the walls of dermoids.

Sometimes _horny_ matter or tissue is found in these, indicating the

same relation between horn and sebaceous structures, as we see upon

the external skin in other instances. So, too, material resembling

the texture of finger-nails is occasionally found projecting into the

cavity.

The fluid or semifluid contents of these cysts consist usually of

sebaceous material, cholesterin, epithelial debris, etc. Sometimes it

is thick, sometimes thin--and occasionally consists almost entirely of

mucus.

It is not uncommon to find structures in _ovarian_ dermoids closely

analogous to, or actually resembling, _mammary glands_. These may be

mere nipple-like processes of skin, or completely developed _mammæ_,

well formed, but without ducts or gland tissue, may occupy such a

cyst. These really are _pseudomammæ_, because they have no ducts.

Nevertheless, glandular tissue is not always absent. This resemblance

proceeds even farther, in that in some of these ovarian mammæ changes

occur analogous to those which take place in normal breasts.

The epiblast seems to have the power of developing mammary glands or

supernumerary mammæ in many locations--in fact, upon any part of the

body surface. About the thorax they are common; upon the abdomen they

are rarely observed; and they have been found even upon the labia.

_Sweat glands_ are infrequent in dermoids. _Teeth_ are quite common.

These may vary in number from two or three up to several hundred--may

be embedded in definite sockets or simply sprout from the cyst wall.

Occasionally bone material, lodging such teeth and crudely resembling a

jaw, will be found.

Dermoids containing _mucous membrane_ are found, especially in

connection with the ovary and with the postanal gut (_i. e._, the

original communication between the spinal and alimentary canals).

It is curious that under these circumstances mucous membrane is

sometimes furnished with hair, as it normally is in the stomach

or other cavities of some of the lower animals. Mucous glands and

retention cysts of these glands are also found in ovarian dermoids.

This will be more readily understood if the mutability of skin and

mucous membrane be not forgotten. The transition from one to the other

is not difficult, and we find all intermediate stages between the two

extremes--if not in man, at least in animals. This will account for the

fact that skin-covered dermoid tumors are found in certain parts of the

alimentary canal, and particularly in the pharynx. These tumors grow

also from the mucous membrane of the bowel, of the rectum, or even of

the small intestine.

Sutton has made a division of dermoids into three classes:

1. _Sequestration_;

2. _Tubulodermoids_;

3. _Ovarian_.

1. =Sequestration Dermoids.=--Sequestration dermoids occur chiefly in

situations where during embryonic life coalescence takes place between

two surfaces possessing an epiblastic covering, although sometimes this

coalescence practically occurs late in life and by implantation.

Dermoids of the trunk occur particularly where opposite halves of the

body wall coalesce--that is, in the midline of the trunk and head.

Dermoid cysts are rarely found in connection with _spina bifida_, and

certain tumors spoken of as spina bifida undoubtedly are dermoids.

Anteriorly dermoids occur frequently in the scrotum, and occasionally

in the testicle. At the umbilicus they are rarely found--usually as

pedunculated tumors projecting externally. In the midline of the thorax

and neck they are most common opposite the manubrium, dropping down

behind it to invade the anterior mediastinum. Near the hyoid bone they

occur relatively frequently; about the head they are met with most

commonly at the angles of the orbits--more so at the outer than at the

inner angle. Dermoid cysts are known to oculists as growing upon the

iris or springing from the conjunctiva. About the ear they are not

infrequent; in the roof of the mouth, especially if this be incomplete,

we frequently find cysts of epiblastic origin.

Sequestration dermoid cysts are also undoubtedly found in connection

with the _dura mater_, in the scalp, most commonly at the anterior

fontanelle, at the root of the nose, and at the external occipital

protuberance, where they may be confounded with sebaceous cysts or with

meningoceles. In order that a dermoid of the dura may communicate with

the skin there must of course be osseous defect.

Sequestration dermoids upon the limbs have been mostly reported as

sebaceous cysts. They are rare, and usually associated with antecedent

injury, by which epiblastic structures are driven in and implanted

in such a way that as they develop they give rise to these peculiar

tumors. These are what Sutton calls _implantation dermoids_. They are

found upon the fingers and elsewhere.

2. =Tubulodermoids.=--These are largely connected with obsolete canals

and ducts. It is a great service which Sutton has rendered in proving,

apparently beyond the possibility of doubt, that the central canal of

the nervous system is really of intestinal origin, and may be regarded

as a disused segment of the primary alimentary canal. He has also shown

how it behaves occasionally as do other functionless ducts, and that

cysts and dermoids in connection with it are to be thus explained.

He and others have also shown the anterior as well as the posterior

communication of these canals, and the pituitary body are to be

regarded in this light as the same formation of lymphoid tissue around

an obsolete canal which we see in Luschka’s tonsil close by, and in

Luschka’s gland at the other extreme of the canal.

[Illustration: FIG. 72

Solid dermoid escaping from pelvis. (Original.)]

[Illustration: FIG. 73

Congenital dermoid cyst of pelvis. (Ahlfeld.)]

The primary alimentary canal was a continuous tube lined with a

continuous layer of columnar epithelium. That portion connected with

the yolk sac develops into the intestine, the balance into the central

nervous canal. Portions of this canal are in postnatal life absolutely

obsolete; others persist in a rudimentary condition. Dermoid cysts and

dermoid tumors develop in connection with each of these. In some there

is a large central cavity; others are almost absolutely solid. Thus

we find dermoids in the coccygeal region, which have been variously

regarded as sarcomas, adenomas, etc., which are really of origin as

stated above and should be considered simply as dermoid tumors. Most

of these project outwardly; some of them arise and develop within the

pelvis. Dermoid cysts and tumors are also met with in connection with

the rectum--sometimes between the rectum and the bladder, and between

the rectum and the spine. Dermoid tumors are also found in connection

with the pituitary body. These sometimes develop within the cranium,

or, again, protrude perhaps into the orbit, perhaps into the pharynx.

_Thyroid dermoids_ are tumors of great interest. They develop sometimes

about the craniopharyngeal canal, which may be detected as a small

canal in the macerated sphenoid bone of a fetus, and which before birth

is filled with fibrous tissue. It connects with a recess in the middle

line and at the base of the skull, presenting in the pharynx, which is

often referred to as the _bursa pharyngea_. It is around this recess

that the lymphoid tissue known as the “pharyngeal tonsil” develops.

It may be thus expected that the roof of the pharynx should be the

occasional site of dermoids. It is from the pharynx or the floor of

the mouth that in vertebrates the thyroid body arises. In higher forms

it becomes dissociated from the pharynx and shifts its position. The

thyroid body is developed around the thyroid duct, which first appears

as the thyrohyoid duct, which later becomes divided, that portion in

relation with the tongue becoming the thyrolingual duct, the remaining

portion persisting as the thyroid duct. These are present about once

in every ten subjects, according to Sutton, the canal when persistent

being lined with epithelium. When the extremities of these ducts

become occluded retention cysts may form. In the same way dermoids of

the tongue are formed, similar to those occurring on the scalp. These

are frequently mistaken for sebaceous cysts. They may be unilateral,

central, or even bilateral. The _lingual_ duct is also of interest,

because it would appear that certain cases of epithelioma of the tongue

arise along this duct, and perforating malignant ulcer of the tongue is

thus produced. Dermoid tumors of the lingual or thyroid ducts resemble

in structure the thyroid body. The thyroid duct may also be detected

in many adults running from the isthmus of the thyroid body to the

posterior aspect of the hyoid bone, and surrounded by muscle tissue.

Sometimes the space usually occupied by this duct is represented by

a series of detached bodies known as _accessory thyroids_. These are

not infrequently the seat of cysts, sometimes of considerable size.

(The accessory thyroids often enlarge when the main thyroid has been

extirpated for disease.) Thus cysts in close relation to the hyoid bone

are common. Some of them grow slowly, while others grow rapidly and

contain much fluid. Many of them are unilateral, and are often mistaken

for enlargements of one lobe of the thyroid. Cysts growing from

accessory thyroids are often filled with papillomatous masses, and are

occasionally the seat of malignant degeneration.

In the _omphalomesenteric_ duct or its remains, especially in relation

with the umbilicus, we often meet with small cysts or tumors in infants

and young children. When the duct is persistent it presents normal

intestinal structure, and, like the appendix, possesses much adenoid or

lymphoid tissue.

Another and very important form of _tubulodermoids_ develops in

connection with the _branchial clefts_ of the neck. Congenital fistulas

of the neck have been long known, but only comparatively recently

understood. Of the branchial clefts it is well known that the first

alone should persist, as the Eustachian tube. Occasionally, however,

they fail to become obliterated, and then we have congenital tumors

or cysts, which may, perhaps, not develop to appreciable size until

somewhat late in life; or there may be fistulous passages opening

either into the pharynx or externally, forming canals varying in

length from half an inch to two inches, secreting a little fluid

because lined with epithelium. When these become inflamed an abscess

results. When they open externally the opening is often marked by a

little tag of skin containing a fragment of yellow cartilage. These

are often referred to as _cervical auricles_. They open along the line

of the sternomastoid muscle. The internal openings of these fistulas

frequently form diverticula from the pharynx or esophagus. Thus it will

be seen that dermoid cysts about the neck are principally relics of

openings or ducts, which are normal in embryonic life, but which should

have been obliterated at or long before birth. Congenital fistulas,

however, may be met with in the middle line of the neck, which are not

to be confounded with branchial fistulas, but rather with the ducts

previously described.

3. =Ovarian Dermoids and Teratomas.=--These may be unilocular or

multilocular cysts, usually the latter. They are lined with epithelium,

and contain mostly mucoid fluid, the inner coat being practically

identical with mucous membrane. Occasionally, however, the skin is

furnished with hair, sebaceous glands, teeth, and even nipples. The

multilocular cysts are practically an aggregation of those just

described. They are surrounded by dense capsules, often attain great

dimensions, and are made up of primary cysts resembling large cavities

in a honeycomb-like mass, which itself is occupied by secondary

cysts, and belong rather to the class of mucous retention cysts,

these being occupied by still smaller ones, which are histologically

indistinguishable from distended ovarian follicles. In these large

tumors we find in some cases hair, in others teeth, and in others

sebaceous glands, etc., the dermoid constituents being scattered

throughout. As Wilms has shown, in almost every tumor of this character

a projection may be found whose summit is covered with epiblastic

elements, which when cut in serial transverse sections will show in

its deeper portion other epithelial collections representing a feeble

attempt to develop a nervous system, or lung tissue, while mesoblastic

elements, like connective tissue, cartilage, and bone, appear scattered

throughout, as though a very crude effort had been made to reproduce an

atypical embryo.

3. =Teratomas.=

So far the endeavor has been to limit the term _dermoid_ to tumors

which are essentially of _epiblastic_ formation, their location

being explained on the inclusion theory of Cohnheim. There is also

a still more complicated type of tumor, composed of tissues of both

_epiblastic and mesoblastic_ origin, perhaps even _hypoblastic_.

Their consideration belongs to that department of pathology known as

_teratology_, which is supposed to deal especially with monsters.

Strictly speaking a _teratoma_ refers to an irregular tumor or mass

containing tissues and fragments of viscera of a suppressed fetus which

is attached to an otherwise normal individual. Nevertheless the term is

often applied to growths which are the result of luxuriant mesoblastic

development in which neither form nor member of a suppressed fetus is

present.

The presence of supernumerary members is largely connected with what

is called _dichotomy_, alluding thereby to cleavage either at the

anterior or posterior end of the developing embryo. _When the whole

embryonic axis divides twins may be produced_, but should cleavage be

partial we may have a monster with two heads if it be anterior, or

one with three or more limbs if it be posterior. Children born with

these deformities are usually called _monsters_, and the study of such

cases belongs entirely to teratology. But in certain tumors small

portions of a suppressed fetus may develop, as, for instance, from the

posterior portion of the sacrum, or within the abdomen or thorax, or

upon the neck or face, which on dissection may contain a few vertebrae

or processes resembling fingers associated perhaps with a structure

resembling intestine or liver. This should be called a teratoma. Such

tumors possess for the pathologist the greatest value. In surgery,

however, they are rare, and there are scarcely two cases alike. The

question of operation will often arise, as it does with supernumerary

limbs, and each case should be studied upon its own merits. Sometimes

they are amenable to extirpation.

=Embryonal Adenosarcoma.=--Embryonal adenosarcoma is a term given to

certain teratomatous tumors peculiar to renal and adrenal structure,

which present peculiar characteristics in the mixture of elements which

enter into their composition. At various times these tumors have been

called adenoma, sarcoma, rhabdomyoma, congenital cystic kidney, etc.

They have been also likened to the thyroid. They comprise a group of

neoplasms, always congenital in origin, which usually appear early in

life, but occasionally occur in advanced adult life. One of the most

marked specimens of this kind the writer removed from a man over fifty

years of age. Most of the specimens, however, described in literature

pertain to the young. On minute examination they often present a

strange, mixed picture of voluntary muscle elements intermingled with

epithelium arranged to imitate acinous glands, with cystic dilatations

of the true kidney tissue. They often attain enormous size, and

undergo such proliferation of mesoblastic elements as to resemble

sarcoma. Their occurrence is to be explained only on the principles

of Cohnheim’s hypothesis. When the original Wolffian body is being

differentiated from the elements about it a confusion of the same

with the excretory tubular beginnings, which are to empty into the

Wolffian duct, occurs. Thus we have the commencement of a mixed mass

which presents itself as a more or less rapidly growing tumor, in

which even cartilage or other mesoblastic structures may be met with.

It is scarcely possible that any two specimens should yield exactly

the same microscopic picture, much depending on whether one element

or the other prevail. In a few of them there may occur also a mixture

of adrenal elements. Sometimes the renal structure itself is more or

less distinct, and rides, as it were, upon the surface of the tumor;

at other times it is entirely mixed up with it. While the condition

is usually limited to one side it may be a double affection, so that

the second kidney becomes useless and the patient succumbs. The only

treatment is extirpation.

Teratomatous tumors are sometimes found hanging in the pharynx,

attached by a small pedicle, where they may be confounded with dermoids

unless carefully examined after removal. Many instances of this type

of tumor are found in animals. Here no false sentiment will prevent

complete examination and preservation of the specimen. They are also

encountered in the sacral and coccygeal regions.

4. =Tumors of Connective-tissue Type.=

=Lipoma.=--Lipomas, or tumors composed of fat, are the most common of

the neoplasms. Their normal type is the _ordinary adipose tissue_ of

the body, and may be divided into the _encapsulated_ and the _diffuse_,

the former of which are surrounded by fibrous tissue. The diffuse

lipomas are those which have no capsule, and where the pathological

collection of fat merges into that normally present--in other words,

they are not circumscribed.

=Subcutaneous Lipomas.=--Subcutaneous lipomas are perhaps the most

common of all, and are usually irregularly lobulated and encapsulated,

adherent rather to the skin than to the deeper tissues. Usually but

one is found in an individual, though instances of multiple lipomas

are not rare. They develop sometimes to enormous size, cases being on

record where the tumor has even weighed one hundred pounds. They may

be met with at any point on the surface of the body. The lobules often

burrow between the muscles, and those found in the palm of the hand

penetrate even beneath the palmar fasciæ. They are sometimes markedly

pedunculated, and often hang by a small stem. The diffuse subcutaneous

lipoma is most common about the neck, in the groin, and in the axilla.

=Subserous Lipomas.=--Subserous lipomas are mostly retroperitoneal,

and large tumors of this character, mistaken for ovarian, have been

successfully removed by operation. They also occur in the hernial

canals and spaces. They develop beneath the peritoneum covering

the intestines, and in this location give rise occasionally to

_intussusception_. Here in their pathological development they have the

general form and significance of _appendices epiploicæ_.

=Subsynovial Lipomas.=--Subsynovial lipomas occur about various joints

and tendon sheaths; within the knee they assume a distinctive type

which has been called _lipoma arborescens_, where they take on a

dendritic appearance and arrangement. _Submucous_ lipomas are rare.

_Intermuscular_ fatty tumors are occasionally met with, an interesting

variety being that which develops between the masseter and buccinator

muscles. _Intramuscular_ forms rarely occur, as well as a variety known

as _parosteal_, which arises in connection with the periosteum. Fatty

tumors also occur within the spinal dura, as well as outside of it

within the spinal canal, and more or less lipomatous alterations are

common in connection with spina bifida.

Lipomas are ordinarily easy of recognition, save when deeply located.

The subcutaneous forms are intimately related with the overlying skin,

and have a dough-like consistence which is usually pathognomonic.

Tumors, suspected to be fatty, in the middle line of the back or

cranium are always to be viewed with suspicion, as they are often

connected with congenital meningeal protrusions.

An encapsulated lipoma when thoroughly removed will not return.

Mixed forms of fibrous and fatty neoplasm are occasionally seen, and

are referred to as _lipoma fibromatosum_ or _fibroma lipomatosum_,

according as one or the other tissue predominates. These growths are

innocent in their character, but call for thorough extirpation. They

frequently give rise to considerable discomfort or pain, and are called

_lipoma dolorosa_.

=Fibroma.=--Fibromas are tumors composed of fibrous tissue, which, when

of pure type, are found to be not so common as was formerly supposed,

the majority of tumors hitherto roughly grouped as fibromas containing

either muscle tissue or sarcomatous elements, which takes them out of

the category of pure fibroma. A typical fibroma is ordinarily dense,

and is composed of wavy bundles of fibrous tissue whose cells are long

and slender and closely packed together, the mass being permeated by

distinct bloodvessels.

Fibroma occurs most commonly in the _ovary_, the _uterus_, the

_intestine_, the _gum_ (epulis), in _nerve sheaths_, and in the

_skin_ in the form of so-called _painful subcutaneous tubercles_ and

_molluscum fibrosum_. There is also a fibrous tumor of the skin, known

as _keloid_, sustaining to fibroma the same relation that exists

between exostosis and osteoma.

_Painful subcutaneous tubercle_ is a sample of pure fibroma in the

shape of a small, flattened, pea-like tumor which never attains great

size. It is situated loosely in the subcutaneous structure and may form

a visible prominence. Insignificant as it would thus appear, it becomes

the seat of exasperating pain, particularly when touched or handled,

which may radiate to considerable distances. The etiology of these

growths is unknown.

In the ovary, the uterus, the intestine, and the larynx true fibrous

tumors are pathological curiosities rather than common lesions.

[Illustration: FIG. 74

Keloid of external ear: _a_, dense tissue of skin; _b_, fibrous

connective tissue; _c_, epidermis. (Klebs.)]

=Epulis.=--Epulis means any tumor growing upon the gum. The term was

formerly applied in an indistinct and too comprehensive way, although

it is still retained in literature. But pure fibromas do spring from

the fibroösseous structure of the gum and alveolar process. They are

covered with the gingival mucous membrane and seem to spring from the

periodontal membrane. They seldom attain large size, and then only by

neglect. By the pressure of such tumors teeth may be separated and

distortion of the mouth produced. They should be promptly extirpated.

=Keloid.=--Keloid is a fibrous neoplasm arising mainly in cicatricial

tissue, which is essentially fibroid in structure. It is a neoplasm

which often follows the general outline of the scar in which it

grows, consists in elevation of the surface, ordinarily quite smooth,

sometimes of a delicate pink from the dilated vessels which it

contains. Keloid is the _bête noir_ of surgeons, as it frequently

complicates and disfigures scars which have at first been satisfactory,

and since it indicates a condition which it is discouraging to deal

with, because when it is removed there is usually recurrence of growth

within a few months after cicatrization. It often occurs in stitch-hole

scars and upon the site of extensive burns, and may be observed after

puncture of the ears for ear-rings, and has also been observed in scars

left by smallpox, acne, etc. It is more prevalent in the colored race

than in the white. In negroes multiple keloid tumors are often seen,

occasionally in large numbers. Their explanation is unknown, and it

may be that some trifling injury has preceded each individual tumor

(Fig. 74).

The _treatment_ of _keloid_ will be considered in the chapter on the

Surgical Diseases of the Skin.

=Desmoids.=--This term has been applied to tumors of a certain clinical

type which arise from the fibrous structures, usually of the abdominal

wall, and produce neoplasms like the fibromas of other parts of the

body. The use of the term should be restricted to those tumors which

proceed primarily only from muscles, tendons, and aponeuroses, or

perhaps from ligamentous and periosteal tissues. These tumors are

usually single, attain sometimes considerable size, grow slowly, rarely

involve other structures, and not infrequently develop to such an

extent as to encroach upon either pelvis or the abdomen, or both. They

have been known to attain to the weight even of ten pounds or more.

They are usually more or less encapsulated, and are firm and dense

in structure. Under the microscope they have the general appearance

of cellular fibroma. Sarcomatous elements may be met, while they

occasionally undergo cystic degeneration. Their occurrence may be

explained, at least in some instances, on the embryological theory of

Cohnheim.

[Illustration: FIG. 75

Multiple enchondromas.]

The _treatment_ of desmoids consists in their complete extirpation.

They should not be allowed to attain large size because their removal

may entail a serious weakening of the abdominal wall. There should be

such plastic rearrangement of abdominal protecting membranes as to

reduce the resulting weakening to a minimum.

=Psammoma.=--Psammoma is a term applied to a form of hard fibroma met

with in the dura mater, in which there has occurred a petrefaction of

some of the cells--_i. e._, a deposition of calcareous salts, which

gives it a gritty or sandy appearance.

=Chondroma.=--The true chondroma is a tumor _composed of hyaline

cartilage_. It occurs in the long bones, usually in relation with

epiphyseal cartilages, and is often noted during the earlier years

of life. While it is usually a solitary tumor, multiple chondromas

are often seen, especially upon the hands. These tumors are often

encapsulated and form deep hollows, in which they rest. Unless

pressing upon nerve trunks they are painless and slow of growth. They

are exceedingly dense and hard, and ordinarily immovable. _Mucoid

softening_ (_i. e._, _cystic degeneration_) is common, and the

softened areas may give rise to fluctuation. There may be coincident

_calcification_ or _ossification_ in any of these growths. It is

noted as a curious circumstance by Sutton that their tissue resembles

histologically the bluish, translucent, epiphyseal cartilage seen in

progressive rickets.

To the small local hypertrophies of cartilage which are seen especially

about joints, about the laryngeal cartilages, and the triangular

cartilage of the nose, are given the term _ecchondroses_. They are

most common in the knee in connection with rheumatoid arthritis, and

occur as prominences along the margins of the joint cartilage. They

may project to such an extent as to be detached by accident, after

which they become movable and floating bodies in the joints. Many

of the floating cartilages or bodies found in joints are detached

ecchondroses, which may be smoothed off by attrition, and may be found

singly or multiple, even several hundred existing in one joint.

_Chondromatous changes_ as occurring in _sarcomatous tumors_ have been

alluded to. It seems to be easy for connective tissue to form hyaline

cartilage, and mixed tumors may thus be seen in connection either with

sarcoma, fibroma, or other forms.

=Treatment.=--The treatment of chondroma is solely operative. Unless

the integrity of a member or a limb be compromised, such a tumor can

usually be shelled out from its location, but requires that the matrix

be completely extirpated; all of which may call for the use of powerful

bone instruments. At other times _amputation_ is the only measure which

may relieve from deformity, pain, and disability. The _ecchondroses_

occurring within joints necessitate incision and evacuation, with

the most rigid aseptic precautions, with or without drainage. When

practised according to modern technique this is almost invariably

successful. In former times many lives were lost because of septic

infection.

=Osteoma.=--Under the head of nomenclature I have already endeavored to

distinguish as between _exostosis_, or irregular bone outgrowth, and

_osteoma_, as a distinct tumor which is composed of bone tissue, with

the subvariety _odontoma_, or tumors of dental origin and structure.

Osteoma is regarded by some as ossifying chondroma, for it is nearly

always found near epiphyseal lines, and is always covered by hyaline

cartilage when thus found. Nevertheless it is not invariably such.

We speak of _compact_ or _ivory_ osteoma and of a _cancellous_ form.

The former is identical with the compact tissue of the shafts of long

bones, and may occur anywhere, but is most common about the cranium,

at the frontal sinus, the external meatus, and the mastoid process.

Osteomas growing into the frontal sinus of oxen form large, lobulated,

bony masses, sometimes weighing several pounds, and as dense as ivory.

Some of these tumors growing into the cranial cavity have been regarded

as ossified brains. Osteomas in connection with the external auditory

meatus may partially obscure this channel and cause deafness. They

constitute _ivory-like growths_, which sometimes defy the finest steel

instruments with which the surgeon can supply himself.

[Illustration: FIG. 76

Double osteoma of the skull. (Musée Dupuytren.)]

Cancellous osteomas grow in the cranium as well as in the long bones,

and, like the compact forms, only occasion pain by pressure upon nerve

trunks.

=Exostoses.=--Exostoses are classed by Sutton as--

1. Those formed by _ossification of tendons_ and their attachments.

There should be excluded from this group such natural or evolutionary

processes as the supracondyloid process, the third trochanter of the

femur, etc. Over or around such exostoses bursæ will form to mitigate

as much as possible the effect of friction. Such an outgrowth is known

as an _exostosis bursa_; it is most frequently seen on the inside of

the femur immediately above the knee.

2. _Subungual exostoses_, occurring usually beneath the nail of the big

toe.

3. Exostoses due to _calcification of inflammatory exudations_,

including the rare condition known as _myositis ossificans_.

[Illustration: PLATE XVII

FIG. 1

Round-cell Sarcoma. (Low power.)

FIG. 2

Spindle-cell Sarcoma. (Low power.)]

When a true osteoma is once thoroughly removed there is no tendency to

recurrence. Thorough removal, however, calls sometimes for serious and

often mutilating operations, which may become dangerous when the growth

involves the curve of a rib or a large portion of the skull. At other

times amputation is rendered necessary. Special forms require special

treatment.

=Sarcoma.=--Formerly this name implied a fleshy tumor, and was made to

cover many different conditions. Now _sarcoma means a tumor composed

of immature mesoblastic or embryonic tissue in which cells predominate

over intercellular material_. Sarcomas are sometimes encapsulated;

they merge into and infiltrate the surrounding tissue and disseminate

widely, and have usually these propensities and characteristics to

such a degree as to constitute malignancy. For the laity sarcomas and

carcinomas are together included in the comprehensive term of _cancer_;

for the surgeon they constitute but one form of cancer. Sarcomas

are classified, according to the shape of their cells and their

disposition, into--

A. _Round-cell_;

B. _Spindle-cell_;

C. _Myeloid_.

To these are added other varieties mentioned below.

[Illustration: FIG. 77

Osteoma of frontal sinus. (Neisser.)]

[Illustration: FIG. 78

Recurring sarcoma of parotid. (Original.)]

A. =Round-cell Sarcoma.=--This is simple in construction, and consists

of round cells containing very little intercellular substance. The

nuclei of the tumor cells stain easily, the cells themselves varying in

size in different cases. Bloodvessels lead up to the tumor, but in the

interior appear rather as channels. These tumors have no lymphatics:

they grow rapidly, infiltrate easily, recur quickly, and give rise to

numerous metastatic or secondary deposits. They may affect any part of

the human body. The size of the cells is supposed to be in some measure

an index of their malignancy--the smaller the cell the more malignant

the tumor. They appear at all periods of life. They are perhaps the

most commonly seen of malignant tumors in animals. (See Plate XVII.)

=Lymphosarcoma.=--This tumor is composed of cells similar to the

previous form, but enclosed in a delicate meshwork resembling that of

lymph nodes, hence the term _lymphosarcoma_. Lymphosarcomas are not

to be confounded with enlargements nor with the specific granulomas

involving these lymphatic structures.

B. =Spindle-cell Sarcoma.=--In this form the cells have a spindle shape

and run in all directions, so that sections will show them in various

shapes and sizes. In some cases the cells are small and slender, in

others large. The size of the cell is a measure of the malignancy of

the tumor. (See Plate XVII.)

The largest of these spindle cells are frequently striated transversely

like voluntary muscle fiber, and tumors composed of this form have

been considered as tumors of striped muscle tissue, and are generally

called _rhabdomyoma_. There is no tumor of striped muscle fiber,

and the rhabdomyomas of writers generally should be considered as

spindle-cell sarcoma, or may be dignified by the name _myosarcoma_.

(See Rhabdomyoma, under Myoma.)

=Alveolar Sarcoma.=--This is a rare form, in which the cells, contrary

to the general rule of sarcomas, assume an alveolar arrangement

strongly imitating that of epithelial cells in carcinoma. Almost

invariably, however, on close examination it will be possible to

distinguish a delicate reticulum between individual cells, which is

never met with in cancer.

C. =Myeloid, or Giant-cell Sarcoma.=--In this form the tissue resembles

histologically the red marrow of young and growing bone, containing

large numbers of multinuclear cells embedded in a matrix of spindle or

round cells. These tumors usually occur in the long bones, and when

freshly cut look like a piece of liver. They constitute most of the

_epulides_ or cases of _epulis_--_i. e._, spongy tumors springing from

the gums. (See Plate XVIII., Fig. 2.)

[Illustration: FIG. 79

Sarcoma of femur following fracture--_i. e._, developing in callus.

(Original.)]

Giant or multinuclear cells should be present in considerable numbers

to entitle a tumor to classification in this group. When round cells,

spindle cells, or giant cells mingle in nearly equal proportion the

tumor should be called a _mixed-cell sarcoma_.

D. =Osteosarcoma.=--Osteosarcoma is something more than sarcoma of

bone, which latter may spring from the fibrous or medullary elements.

It is sarcoma of the specific bone-forming connective tissue, including

the osteoblasts and osteoclasts; in other words, of the stroma of the

bone. Under these circumstances real bone develops throughout the

tumor, and it is essentially a bony neoplasm. In like manner there may

be true _osteofibroma_. These tumors are to be distinguished, even

clinically, from the medullary sarcomas, which develop within the bone

and expand it, even to enormous proportions, the bony covering then

being a mere shell.

E. =Chondrosarcoma.=--Chondrosarcoma resembles osteosarcoma in that it

is sarcoma of the stroma of cartilage, or of the specific tissue which

produces cartilage. In it true cartilage (white fibrous) also is found

throughout the tumor. Chondrofibroma is also possible. (See Plate XIX.)

F. =Endothelioma.=--Endothelioma has been called various names, and

its true character has been only lately determined. It is composed

particularly of the endothelial cells which line the lymph spaces, and

which have no peculiar secretion. It is met with most often in the skin

(especially of the face), in the parotid region, in the genital glands,

the bones, the lymph nodes, and dura.

[Illustration: PLATE XVIII

FIG. 1

Angiosarcoma. (Low power.)

FIG. 2

Giant-cell Sarcoma. (High power.)]

[Illustration: PLATE XIX

FIG. 1

Chondrosarcoma. (Low power.)

FIG. 2

Osteosarcoma. (Low power.)]

[Illustration: PLATE XX

Melanosarcoma of Skin. (Dry high power.)]

The microscopic picture of these tumors varies greatly, the endothelial

cells often shaping and grouping themselves so as to imitate

epithelioma. In doubtful cases the primary location or origin of the

growth should be ascertained.

Endotheliomas are mainly of rapid growth, and often show a high degree

of malignancy. If thoroughly extirpated before metastasis has occurred,

prognosis is fair; but metastases happen early because of the direct

connection of the tumor with the lymph current.

[Illustration: FIG. 80

Endothelioma of the soft palate: _a_, dilated lymph space; _b_,

endothelial cells with beginning cystic formation; _c_, completely

formed cyst. (Volkmann.)]

G. =Angiosarcoma.=--Angiosarcoma is a sarcoma arising from the

adventitia of the bloodvessels. It is characterized by its

extraordinary vascularity, the ease with which hemorrhages into the

structure of the tumor take place, and the frequency of pigmentation.

_Peritheliomas_ constitute a subvariety, met with especially in the

kidneys, the bones, and the skin, and originate in the perithelial

cells between the capillaries and the perivascular lymph spaces. They

are more vascular than the angiosarcomas. The latter are common in the

liver. In many cases the cells of these tumors simulate the columnar

epithelium of adenocarcinoma. (See Plate XVIII, Fig. 1.)

H. =Cylindroma.=--This is a term applied to tumors of the

angiosarcomatous type in which hyaline changes have occurred, so that

along the vessels appear cylindrical masses of altered cells. Similar

appearances are noted in certain endotheliomas and are due to the same

hyaline degeneration.

I. =Melanosarcoma= (_better known as Melanoma_).--This refers to the

deposition of pigment, rather than to type or shape of cell, the

distinguishing feature of these growths being the presence both in the

cells and in the intercellular substance of a variable quantity of

blackish pigment. Of all the forms the melanotic growths are considered

the most malignant. They invariably recur after removal, lead to

secondary deposits at long distances, and present the most intractable

and incurable forms of cancer. Deposition of pigment in carcinomas is

most rare, if ever met with, and the growths of melanotic type should

be relegated entirely to the class under consideration. The tumors most

often develop from pigmented nevi of the skin, though primary melanoma

of the deeper parts of the body is known. These will be treated more

fully in the chapter on the Skin. (See Plate XX.)

This name has been variously applied by different writers to different

growths. In order to avoid confusion it would be well, in using it, to

be definite.

=General Characteristics of Sarcomas and Endotheliomas.=--The vascular

supply of sarcomas varies within wide limits. In nearly all instances

it is of capillary character, the blood circulating rather through

vessels without well-marked walls. While large vessels may be found

about and in the periphery of these tumors, distinct vascular structure

is usually absent from the more internal portions, which will explain

the frequency of hemorrhage, its persistency after operation, and the

ease with which large extravasations occur. True hematocele may thus

take place within sarcomatous tumors, with the usual later cystic

alterations, and thus in one way we have the condition known as

_cystosarcoma_.

In attacking these growths the vascular and bloody area may be met just

about their margins, the bloodvessels expanding as they arrive at the

tumor, and sometimes bleeding extensively. Under most circumstances,

however, this hemorrhage can be controlled by packing or by operating

at a greater distance from the circumference of the growth.

_Metastasis in sarcoma is common_, dissemination occurring mainly

along the veins, as these growths connect with the venous channels and

permit of easy detachment of fragments, which are then carried along as

emboli. These emboli pass naturally to the right side of the heart, and

thence to the lungs, where it is most common to find secondary growths,

except in areas emptying into the portal veins, in which case the liver

will be the most common site. Sarcomas are destitute of lymphatics, and

dissemination does not occur through these channels.

Infiltration is also a common phenomenon with these growths. This is

generally seen in muscular tissue, particularly with growths proceeding

from the periosteum and projecting into it.

Sarcomas, like other tumors, tend to grow along the lines of least

resistance. Hence processes of these tumors will insinuate themselves

into fissures and interspaces, and penetrate perhaps even into the

cavities, from which it is hazardous or impossible to remove them.

Thus, sarcomas springing from the head of a rib have been known

to extend through an intervertebral foramen and give rise to an

intraspinal tumor, causing fatal pressure.

_Secondary changes_ are usually seen in sarcomas, the most frequent

being hemorrhage. _Myxomatous degeneration_ is also frequent, and gives

rise to _cystic_ conditions. _Calcification_ is common, particularly

in the slowly growing tumors which arise from bone. Upon the other

hand, _necrosis_ (_i. e._, ulceration) is common in growths which

project upon the surface or into any of the open cavities of the body.

Ulceration here is growth at a rate faster than nutrition will justify,

and gangrene is to be regarded as a failure to supply sufficient blood.

It may also mean infection, of which it is a usual expression.

Tumors of this character, which luxuriate upon reaching the surface,

and bleed easily upon the slightest touch, were formerly known

as _fungus hematodes_. The name may be preserved for the sake of

convenience, but should be held to mean, in almost every instance, a

rapidly growing round-cell sarcoma.

Sarcoma is common in the lower animals, particularly so in horses--most

common in those of gray color. It is met with also in cows and various

other domestic and undomesticated animals.

=Myxoma.=--The myxomas are composed of _mucous tissue_, whose

best-known normal representative is the Whartonian jelly of the

umbilical cord. True myxoma should be distinguished from _myxomatous

degeneration_, which occurs frequently in cartilage, fibrous tissue,

and sarcoma, and which brings about a similar condition of affairs,

though of essentially different origin. Myxomas appear under the

following forms:

1. =Polypi.=--These include many of those which grow in the nose.

The pure form of nasal myoma proceeds from the mucous membrane of

the nasal passages or sometimes from the accessory sinuses. But most

of the so-called nasal polypi are due to edematous hypertrophies

of the submucosa. The polypi usually hang as gelatinous tumors of

grayish-yellow tint, being present sometimes singly, sometimes in

clusters or in large numbers. Their principal effect is to produce

nasal obstruction, with, perhaps, subsequent serious disorder, due

to decomposition or to extension into the pharynx or other cavities.

Similar growths also occur from the mucous membrane of the tympanum,

and constitute the common variety of aural polypi.

2. =Cutaneous Myxoma.=--Cutaneous myoma is not common. It presents

usually as a sessile tumor, although about the perineum and labia the

tumors may become pedunculated. It is often difficult to distinguish

between a myoma of the skin and a sarcoma of the same which has

undergone myxomatous degeneration, and which then should be called

sarcoma myxomatodes. The latter tend to recur after removal; hence the

importance of exact diagnosis.

3. =Neuromyxoma.= Neuromyxoma is a similar condition involving the

nerve trunks, and is dealt with under Neuroma.

Myxomas require complete removal, and, in the nose especially,

cauterization or destruction of the surface from which they spring.

When this is thoroughly done they do not recur; otherwise, they are

likely to require subsequent operation.

=Myoma.=--The true myoma is a tumor composed of _unstriped_ or

_involuntary_ muscle fiber. Until recently it has been customary to

divide the myomas into the _leiomyomas_ in contradistinction to the

_rhabdomyomas_, the latter being supposed to be tumors of voluntary

muscle fiber. _Myomas_ are met with only where _involuntary muscle

fiber_ is found--namely, in the uterus and adnexa, the vagina, the

esophagus, alimentary canal, the prostate, the bladder, and the skin.

They form _encapsulated_ tumors composed of fusiform muscle cells with

a rod-like nucleus, the size of the cells varying greatly in different

specimens. The bundles of muscle fibers are much contorted, and it is

often difficult in a single section to decide to just what class of

cells they belong.

These tumors are most common in and about the uterus, and are referred

to as _intramural_ when developing in the true uterine tissue, and

_submucous_ and _subserous_ when situated just beneath one or the other

of the adjoining membranes. They differ in their rate of growth, are

firm in composition, and are moderately vascular, sometimes containing

areas of softening and becoming even cystic. In rare instances they

become enormously vascular, and are then known as _cavernous myomas_.

Aside from mucoid or colloid changes they occasionally undergo fatty

metamorphosis or calcareous infiltration. The latter is possible to

such an extent as to lead to a condition of _uterine calculi_.

Uterine myoma is liable to septic infection, which frequently follows

exploration of the uterus or the changes incident to pregnancy

or parturition. It then becomes a case for immediate operation.

Uterine myomas do not occur before puberty, rarely before the age

of thirty-five, and are most common between the thirty-fifth and

forty-fifth years of life. They produce disaster not alone by their

size, but by hemorrhage, by pressure on adjoining viscera (rectum,

kidneys, etc.), and occasionally by torsion of a long pedicle.

Myomas are found in the _esophagus_, in the walls of the _stomach_,

where they are frequently confounded with malignant tumors, in the

_prostate_ and wall of the _bladder_, and in connection with the

_skin_. As soon as they give rise to inconvenience or to dangerous

symptoms they are to be dealt with surgically, as no other treatment

has proved of lasting benefit.

The _rhabdomyomas_ deserve but brief description. The striated muscle

fibers of which these tumors are composed have been often confused with

spindle-shaped sarcoma cells. They are met with almost exclusively in

the mixed tumors of the kidney under Teratomas.

Myoma or myofibroma is exceedingly likely to undergo sudden conversion

into a form of growth entitling it to be called _malignant myoma_.

=Angioma.=--Angiomas are tumors composed of bloodvessels, and group

themselves under three headings, in accordance with the structure of

the vascular system:

1. =Capillary Angioma, or Nevus.=--Capillary angioma, or nevus, is

the most common form of all, and is frequently seen in the skin and

subcutaneous tissue. When the condition is spread over a relatively

large area it gives rise to a discoloration known as _port-wine mark_,

and called _telangiectasis_ by the pathologists. The condition is often

congenital or begins soon after birth. The color of the affected area

determines whether the vessels belong to the venous or to the arterial

system. These tumors may be found in all parts of the body, on the

surface, on the submucous surfaces of the tongue, the inside of the

mouth, the conjunctiva, and the vulva. The tendency is toward gradual

increase in size; rarely, spontaneous contraction and obliteration

occur.

2. =Cavernous Tumors.=--These are similar in structure to the corpus

cavernosum, and are called _erectile tumors_. They are common in

connection with the skin, and are exaggerated forms of the variety

first described, the vessels becoming not merely dilated but cavernous

in arrangement. They occur occasionally in the tongue, in the voluntary

muscles, and in the liver, and are noted very rarely in the mammæ, in

the larynx, and subperitoneally.

A similar condition is met with in the so-called cavernous tumors

which involve various organs, especially the thyroid and the liver. In

these instances a part or the whole of the organ may be involved, and

presents great increase in size and evidences of vascularity.

In cavernous growths of the thyroid are vessels, veins especially, the

size of the thumb, while with the ear not touching the body of the

patient a distinct venous murmur may be heard.

3. =Arterial or Plexiform Angiomas.=--Arterial or plexiform angiomas,

when of any particular size, are called _cirsoid aneurysm_ or _aneurysm

by anastomosis_. This form consists of arteries abnormal both in

number, length, and diameter, tortuous in arrangement, occurring often

in the scalp, but rarely in the perineum or genitalia, and seldom in

other parts of the body. (See Aneurysm, Chapter XXIX.) These tumors are

liable to rupture from external injury, and necessitate ligation of the

main arterial trunks, with perhaps extirpation of the tumor mass.

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.

[Illustration: FIG. 81

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.

[Illustration: FIG. 82

Congenital lymphangioma. (Original.)]

[Illustration: FIG. 83

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.

[Illustration: FIG. 84

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

[Illustration: FIG. 85

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.

[Illustration: FIG. 86

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.

[Illustration: PLATE XXI

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).

[Illustration: 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.

[Illustration: PLATE XXII

FIG. 1

Fibromyoma of Uterus. (Low power.)

FIG. 2

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

[Illustration: PLATE XXIII

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.

[Illustration: FIG. 88

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.)

[Illustration: PLATE XXIV

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.)]

[Illustration: PLATE XXV

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.)]

[Illustration: PLATE XXVI

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.)

[Illustration: FIG. 89

Epithelioma of forehead and eyelid. (Neisser.)]

[Illustration: FIG. 90

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.

[Illustration: FIG. 91

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.)

[Illustration: FIG. 93

“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.

[Illustration: PLATE XXVII

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.)

[Illustration: FIG. 94

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.