Alexis Thomson and Alexander Miles - Manual of Surgery

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The _ivory_ or _compact osteoma_ is composed of dense bone, and usually
grows from the skull. It is generally sessile and solitary, and may grow
into the interior of the skull, into the frontal sinus, into the cavity
of the orbit or nose, or may fill up the external auditory meatus,
causing most unsightly deformity and interference with sight, breathing,
and hearing.

Bony formations occur in _muscles and tendons_, especially at their
points of attachment to the skeleton, and are known as false exostoses;
they are described with the diseases of muscles.

#Odontoma.#--An odontoma is composed of dental tissues in varying
proportions and different degrees of development, arising from
tooth-germs or from teeth still in process of growth (Bland Sutton).
Odontomas resemble teeth in so far that during their development they
remain hidden below the mucous membrane and give no evidence of their
existence. There then succeeds, usually between the twentieth and
twenty-fifth years, an eruptive stage, which is often attended with
suppuration, and this may be the means of drawing attention to the
tumour. Following Bland Sutton, several varieties of odontoma may be
distinguished according to the part of the tooth-germ concerned in their
formation.

The _epithelial odontoma_ is derived from persistent portions of the
epithelium of the enamel organ, and constitutes a multilocular cystic
tumour which is chiefly met with in the mandible. The cystic spaces of
the tumour contain a brownish glairy fluid. These tumours have been
described by Eve under the name of multilocular cystic epithelial
tumours of the jaw.

The _follicular odontoma_, also known as a _dentigerous cyst_, is
derived from the distension of a tooth follicle. It constitutes a cyst
containing a viscid fluid, and an imperfectly formed tooth is often
found embedded in its wall. The cyst usually forms in relation to one of
the permanent molars, and may attain considerable dimensions.

The _fibrous odontoma_ is the result of an overgrowth of fibrous tissue
surrounding the tooth sac, which encapsulates the tooth and prevents its
eruption. The thickened tooth sac is usually mistaken for a fibrous
tumour, until, after removal, the tooth is recognised in its interior.

_Composite Odontoma._--This is a convenient term to apply to certain
hard dental tumours which are met with in the jaws, and consist of
enamel, dentine, and cement. The tumour is to be regarded as being
derived from an abnormal growth of all the elements of a tooth germ, or
of two or more tooth germs, indiscriminately fused with one another. It
may appear in childhood, and form a smooth unyielding tumour, often of
considerable size, replacing the corresponding permanent tooth. It may
cause a purulent discharge, and in some cases it has been extruded after
sloughing of the overlying soft parts. Many examples of this variety of
odontoma, growing in the nasal cavity or in the maxillary sinus, have
been erroneously regarded as osteomas even after removal.

On section, the tumour is usually laminated, and is seen to consist
mainly of dentine with a partial covering of enamel and cement.

_Diagnosis._--Odontomas are often only diagnosed after removal. When
attended with suppuration, the condition has been mistaken for disease
of the jaw. Fibrous odontomas have been mistaken for sarcoma, and
portions of the maxilla removed unnecessarily. Any circumscribed tumour
of the jaw, particularly when met with in a young adult, should suggest
the possibility of an odontoma. Skiagrams often give useful information
both for diagnosis and for treatment.

_Treatment._--The solid varieties of odontoma can usually be shelled out
after dividing the overlying soft parts. In the follicular variety, it
is usually sufficient to excise a portion of the wall, scrape out the
interior, and remove any tooth that may be present. The cavity is then
packed and allowed to heal from the bottom.

#Fibroma.#--A fibroma is a tumour composed of fibrous connective tissue.
A distinction may be made between the _soft fibroma_, which is
comparatively rich in cells and blood vessels, and in which the fibres
are arranged loosely; and the _hard fibroma_, which is composed of
closely packed bundles of fibres often arranged in a concentric fashion
around the blood vessels. The cut surface of the soft fibroma presents a
pinkish-white, fleshy appearance, resembling the slowly growing forms of
sarcoma; that of a hard fibroma presents a dry, glistening appearance,
aptly compared to watered silk. The soft variety grows much more rapidly
than the hard. In certain fibromas--in those, for example, which grow
from the periosteum of the base of the skull and project into the
naso-pharynx--the blood vessels are dilated into sinuses and have no
proper sheaths; they therefore tend to remain open when divided, and to
bleed excessively. Transition forms between soft fibroma and sarcoma are
met with, so that in operating for their removal it is safer to take
away the capsule along with the tumour, and the patient should be kept
under observation in view of the risk of recurrence.

The skin--especially the skin of the buttock--is one of the favourite
seats of fibroma, and it may occur in a multiple form. It is met with
also in the subcutaneous and intermuscular cellular tissue, and in the
abdominal wall, where it sometimes attains considerable dimensions.
Various forms of fibroma are met with in the mamma and are described
with diseases of that organ. The fibrous overgrowths in the skin, known
as _keloid_ and _molluscum fibrosum_, and those met with in the _sheaths
of nerves_, are described elsewhere. Fibroid tumours of the uterus are
described with myoma.

_Diffuse fibroma_ or _Fibromatosis_, analogous to lipomatosis, is met
with in the connective tissue of the skin and sheaths of nerves, and
constitutes one form of neuro-fibromatosis; a similar change is also met
with in the stomach and colon.

#Myxoma.#--A myxoma is composed of tissue of a soft gelatinous,
semifluid consistence. The pure myxoma is extremely rare, and
clinically resembles the lipoma. Myxomatous tissue is, however,
frequently found in other connective-tissue tumours as a result of
degeneration, for example, in cartilaginous tumours and in sarcomas.
Myxomatous tissue is also a prominent constituent of the "innocent
parotid tumour." Mucous polypus of the nose, which is often described as
a myxoma, is merely a pendulous process of oedematous mucous membrane.

[Illustration: FIG. 53.--Myeloma of Shaft of Humerus, causing
pathological fracture. (Mr. J. W. Struthers' case.)

(The unusual site of the tumour is to be noted.)]

#Myeloma.#--A myeloma is composed of large multinuclear giant cells
surrounded by round and spindle cells. The cut surface of the tumour
presents a deep red or maroon colour. While occasionally met with in
tendon sheaths and bursae, and is then of an orange-yellow colour, the
myeloma occurs most frequently in the cancellous tissue at the ends of
the long bones, its favourite site being the upper end of the tibia.
Although formerly classified as a sarcoma, it is the exception for it to
present malignant features, and it can usually be extirpated by local
measures without fear of recurrence. The diagnosis, X-ray appearances,
and the method of removal are considered with the diseases of bone.
Sometimes the myeloma is met with in multiple form in the skeleton, in
association with an unusual form of protein in the urine (Bence Jones).

#Myoma.#--A myoma is composed of non-striped muscle fibres. A pure myoma
is very rare, and is met with in organs possessed of non-striped muscle,
such as the stomach, intestine, urinary bladder, and prostate. In the
uterus, which is the most common situation, these tumours contain a
considerable admixture of fibrous tissue, and are known as _fibroids_ or
_fibro-myomas_. They present on section a fasciculated appearance, which
may resemble that of a section of balls of cotton (Fig. 54). They are
encapsulated and vascular, frequently attain a large size, and may be
single or multiple. While they may occasion neither inconvenience nor
suffering, they frequently give rise to profuse haemorrhage from the
uterus, and may cause serious symptoms by pressing injuriously on the
ureters or the intestine, or by complicating pregnancy and parturition.

The #Rhabdomyoma# is an extremely rare form of tumour, met with in the
kidney, uterus, and testicle. It contains striped muscle fibres, and is
supposed to originate from a residue of muscular tissue which has become
sequestrated during development.

[Illustration: FIG. 54.--Fibro-myoma of Uterus.

(Anatomical Museum, University of Edinburgh.)]

#Glioma.#--A glioma is a tumour composed of neuroglia. It is met with
exclusively in the central nervous system, retina, and optic nerve. It
is a slowly growing, soft, ill-defined tumour, which displaces the
adjacent nerve centres and nerve tracts, and is liable to become the
seat of haemorrhage and thus to give rise to pressure symptoms resembling
apoplexy. The glioma of the retina tends to grow into the vitreous
humour and to perforate the globe. It is usually of the nature of a
glio-sarcoma and is highly malignant.

#Endotheliomas# take origin from the endothelium of lymph vessels and
blood vessels, and serous cavities. They show great variation in type,
partly because of the number of different kinds of endothelium from
which they are derived, and partly because the new connective tissue
which is formed is liable to undergo transformation into other tissues.
They may be soft or hard, solid or cystic, diffuse or circumscribed;
they grow very slowly, and are almost always innocent, although
recurrence has been occasionally observed. Cases of multiple
endotheliomata of the skin have recently been described by Wise.

_Angioma_, _lymphangioma_, and _neuroma_ are described with the disease
of the individual tissues.

MALIGNANT CONNECTIVE-TISSUE TUMOURS--SARCOMA

The term sarcoma is applied to any connective-tissue tumour which
exhibits malignant characters. The essential structural feature is the
predominance of the cellular elements over the intercellular substance
or stroma, in which respect a sarcoma resembles the connective tissue of
the embryo. The typical sarcoma consists chiefly of immature or
embryonic connective tissue. It most frequently originates from fascia,
intermuscular connective tissue, periosteum, bone-marrow, and skin, and
forms a rounded or nodulated tumour which appears to be encapsulated,
but the capsule merely consists of the condensed surrounding tissues,
and usually contains sarcomatous elements. The consistence of the tumour
depends on the nature and amount of the stroma, and on the presence of
degenerative changes. The softer medullary forms are composed almost
exclusively of cells; while the harder forms--such as the fibro-,
chondro-, and osteo-sarcoma--are provided with an abundant stroma and
are relatively poor in cells. Degenerative changes may produce areas of
softening or liquefaction which result in the formation of cystic
cavities in the interior of the tumour. The colour depends on the amount
of blood in the tumour, and on the presence of the products of
degeneration.

The blood vessels are usually represented by mere chinks or spaces
between the cells. This peculiarity accounts for the facility with which
haemorrhage takes place into the substance of the tumour, the persistence
of the bleeding when it is incised or ulcerates through the skin, and
the readiness with which the sarcomatous cells are carried off and
infect distant parts through the blood-stream. Sarcomas are devoid of
lymphatics, and unless originating in lymphatic structures--for example,
in the tonsil--they rarely infect the lymph glands. Minute portions of
the tumour grow into the small veins, and, becoming detached, are
transported by the blood-current to distant organs, where they are
arrested in the capillaries and give rise to secondary growths. These
are most frequently situated in the lungs, except when the primary
growth lies within the territory of the portal circulation, in which
case they occur in the liver. The secondary growths closely resemble the
parent tumour. Sarcoma may invade an adjacent vein on such a scale that
if the invading portion becomes detached it may constitute a dangerous
embolus. This may be observed in sarcoma of the kidney, the growth
taking place along the renal vein until it projects into the vena cava.

[Illustration: FIG. 55.--Recurrent Sarcoma of Sciatic Nerve in a woman
aet. 27. Recurrence twenty months after removal of primary growth.]

In its growth, a sarcoma compresses and destroys neighbouring parts,
surrounds vessels and nerves, and may lead to destruction of the skin,
either by invading it, or more commonly by causing sloughing from
pressure. Inflammatory and suppurative changes may take place as a
result of pyogenic infection following upon sloughing of the overlying
skin or upon an exploratory incision. Once the skin is broken the tumour
fungates through the opening. Sarcomas vary in malignancy, especially as
regards rapidity of growth and capacity for dissemination. Certain of
them, such as the so-called "recurrent fibroid of Paget," grow
comparatively slowly, and are only malignant in the sense that they tend
to recur locally after removal; others--especially the more cellular
ones--grow with extreme rapidity, and are early disseminated throughout
the body, resembling in these respects the most malignant forms of
cancer. They are usually solitary in the first instance, although
primary multiple growths are occasionally met with in the skin and in
the bones.

Many varieties of sarcoma are recognised, according to its structural
peculiarities. Thus, in virtue of the size and character of the cells,
we have the _small round-celled_ and the _large round-celled_ sarcoma,
the _small_ and the _large spindle-celled_, the _giant-celled_ and the
_mixed-celled_ sarcoma. The _lympho-sarcoma_ presents a structure
similar to that of lymph-follicular tissue, and the _alveolar sarcoma_
an arrangement of cells in alveoli resembling that seen in cancers. When
there is a considerable amount of intercellular fibrous tissue, the
tumour is called a _fibro-sarcoma_.

[Illustration: FIG. 56.--Fungating Sarcoma of Arm.

(Dr. J. M'Watt's case.)]

The term _lymphangio-sarcoma_ is applied when the cells of the tumour
are derived from the endothelium of lymph spaces and vessels. The
_angio-sarcomas_ are those in which blood vessels form a prominent
element in the structure of the tumour. They are sometimes derived from
innocent angiomas, and they may be so vascular as to pulsate and on
auscultation yield a blowing murmur like an aneurysm. The
_glio-sarcoma_, _myxo-sarcoma_, _chondro-sarcoma_, and _myo-sarcoma_ are
mixed forms which usually develop in pre-existing innocent tumours. The
_osteo-sarcoma_ is characterised by the formation in the tumour of bone,
the medullary spaces being occupied by sarcomatous cells in place of
marrow. The _osteoid sarcoma_ is characterised by the formation of a
tissue resembling bone but deficient in lime salts, and the _petrifying
sarcoma_ by the formation of calcified areas in the stroma. These
varieties, although met with chiefly in the bones, may occur in soft
tissues such as muscle, and in such organs as the mamma. The pigmented
varieties include the _chloroma_, which is of a light-green colour, and
the _melanotic sarcoma_, which is brown or black. The _psammoma_ is a
sarcoma containing a material resembling sand; it is chiefly met with in
the membranes of the brain. The _chordoma_ is a rare form of tumour
originating from the remains of the notochord in the region of the
spheno-occipital synchondrosis or in the sacro-coccygeal region.

_Diagnosis of Sarcoma._--A sarcoma is to be differentiated from an
inflammatory swelling such as results from tubercle, actinomycosis, or
syphilis, from an innocent tumour, and from a cancer. The points on
which the diagnosis is founded are discussed with the different tissues
and organs.

_Treatment._--The removal of the tumour by operation is the most
reliable method of treatment; in order to be successful it must be
undertaken before dissemination has taken place, and a considerable area
of healthy tissue beyond the apparent margin of the growth must be
removed, and in tumours near the surface of the body, the overlying skin
also.

In order to prevent recurrence, a tube of _radium_, to which a silk
thread is attached, is inserted into the space from which the tumour was
removed; the thread is brought out at the drain-opening, and at the end
of a week or ten days the tube of radium is removed by pulling on the
thread. Radium causes a reaction in the tissues attended with exudation
from the vessels, for the escape of which provision must be made. If
radium is not available, the affected area is repeatedly exposed to the
action of the _X-rays_ as soon as the wound has healed. The employment
of these measures has diminished to a remarkable degree the recurrence
of sarcoma after operation.

It will readily be understood that the less thoroughly or radically the
growth has been removed, the more do we depend upon radium or the X-rays
for bringing about a permanent cure, and that in advanced cases of
sarcoma and in cases in which, on account of their anatomical situation,
removal by operation is necessarily incomplete, the prospect of cure is
still more dependent on the use of radium or of the X-rays. Finally,
there are cases in which removal by operation is impossible, the
so-called _inoperable sarcoma_; a tube of radium, to which a silk thread
is attached, is inserted into the substance of the tumour, either
through an opening made by a large trocar, or, when necessary, by open
dissection. A second tube of radium is placed upon the skin over the
tumour and is secured there by a stitch or by a strip of plaster, thus
securing a cross-fire action of the radium rays, both from within and
without, as this is found to be much more efficacious in destroying or
inhibiting the cellular elements of the growth. The tubes of radium are
left _in situ_ for from eight to fourteen days, according to the power
of the radium employed, but are moved about every second day or so in
order that every part of the tumour may be efficiently radiated. If the
tumour shrinks in size after the use of radium and becomes operable, it
should be removed before time is given it to resume its growth. It will
depend upon the subsequent course of the disease, whether or not a
second, or it may be even a third, application of radium will be
required.

Where neither radium nor X-rays is available or applicable, recourse may
be had to the injection of Coley's fluid, a preparation containing the
mixed toxins of the streptococcus of erysipelas and the bacillus
prodigiosus; or of selenium.

EPITHELIAL TUMOURS

An excessive and erratic growth of epithelium is the essential and
distinguishing feature of these tumours. The innocent forms are the
papilloma and the adenoma; the malignant, the carcinoma or cancer.

#Papilloma.#--A papilloma is a tumour which projects from a cutaneous or
mucous surface, and consists of a central axis of vascular fibrous
tissue with a covering of epithelium resembling that of the surface from
which the tumour grows. In the papillomas of the skin--commonly known as
_warts_--the covering consists of epidermis; in those growing from
mucous surfaces it consists of the epithelium covering the mucous
membrane. When the surface epithelium projects as filiform processes,
the tumour is called a _villous papilloma_, the best-known example of
which is met with in the urinary bladder. Papillomatous growths are
also met with in the larynx, in the ducts of the breast, and in the
interior of certain cystic tumours of the breast and of the ovary.
Although papillomas are primarily innocent, they may become the
starting-point of cancer, especially in persons past middle life and if
the papilloma has been subjected to irritation and has ulcerated. The
clinical features and treatment of the various forms of papilloma are
considered with the individual tissues and organs.

#Adenoma.#--An adenoma is a tumour constructed on the type of, and
growing in connection with, a secreting gland. In the substance of such
glands as the mamma, parotid, thyreoid, and prostate, adenomas are met
with as encapsulated tumours. When they originate from the glands of the
skin or of a mucous membrane, they tend to project from the surface, and
form pedunculated tumours or polypi.

Adenomas may be single or multiple, and they vary greatly in size. The
tumour is seldom composed entirely of gland tissue; it usually contains
a considerable proportion of fibrous tissue, and is then called a
_fibro-adenoma_. When it contains myxomatous tissue it is called a
_myxo-adenoma_, and when the gland spaces of the tumour become distended
with accumulated secretion, a _cystic adenoma_, the best examples of
which are met with in the mamma and ovary. A characteristic feature of
the cystic variety is the tendency the tumour tissue exhibits to project
into the interior of the cysts, constituting what are known as
_intracystic growths_. They are essentially innocent, but intracystic
growths, especially in the mamma of women over fifty, should be regarded
with suspicion and therefore should be removed on radical lines.
Transition forms between adenoma and carcinoma are also met with in the
rectum and large intestine, and these should be treated on the same
lines as cancer.

CARCINOMA OR CANCER

A cancer is a malignant tumour which originates in epithelium. The
cancer cells are derived by proliferation from already existing
epithelium, and they invade the sub-epithelial connective tissue in the
form of simple or branching columns. These columns are enclosed in
spaces--termed alveoli--which are probably dilated lymph spaces, and
which communicate freely with the lymph vessels. The cells composing the
columns and filling the alveoli vary with the character of the
epithelium in which the cancer originates. The malignancy of cancer
depends on the tendency which the epithelium has of invading the tissues
in its neighbourhood, and on the capacity of the cells, when
transported elsewhere by the lymph or blood-stream, of giving rise to
secondary growths.

Cancer may arise on any surface covered by epithelium or in any of the
secreting glands of the body, but it is much more common in some
situations than in others. It is frequently met with, for example, in
the skin, in the stomach and large intestine, in the breast, the uterus,
and the external genitals; less frequently in the gall-bladder, larynx,
thyreoid, prostate, and urinary bladder.

Tissues appear to be most liable to cancer when, having attained
maturity, they enter upon the phase of decadence or involution, and this
phase is reached by different tissues at different periods. It is not so
much, therefore, the age of the person in whom it occurs, as the age of
the tissue in which it arises, that determines the maximum incidence of
cancer. Cancer of the stomach appears and attains a maximum frequency
earlier than cancer of the skin; cancer of the uterus and mamma is more
frequent towards the decline of reproductive activity than in the later
years of life; rectal cancer is not infrequently met with during the
second and third decades. There is evidence that the irritation caused
by alcohol and tobacco plays a part in the causation of cancer, in the
fact that a large proportion of those who become the subjects of cancer
of the mouth are excessive drinkers and smokers.

A cancer may appear as a papillary growth on a mucous or a skin surface,
as a nodule in the substance of an organ, or as a diffuse thickening of
a tubular organ such as the stomach or intestine. The absence of
definition in cancerous tumours explains the difficulty of completely
removing them by surgical measures, and has led to the practice of
complete extirpation of cancerous organs wherever this is possible. The
boundaries of the affected organ, moreover, are frequently transgressed
by the disease, and the epithelial infiltration implicates the
surrounding parts. In cancer of the breast, for example, the disease
often extends to the adjacent skin, fat, and muscle; in cancer of the
lip or tongue, to the mandible; in cancer of the uterus or intestine, to
the investing peritoneum.

In addition to its tendency to infiltrate adjacent tissues and organs,
cancer is also liable to give rise to _secondary growths_. These are
most often met with in the nearest lymph glands; those in the neck, for
example, becoming infected from cancer of the lip, tongue, or throat;
those in the axilla, from cancer of the breast; those along the
curvatures of the stomach, from cancer of the pylorus; and those in the
groin, from cancer of the external genitals. In lymph vessels the cancer
cells may merely accumulate so as to fill the lumen and form indurated
cords, or they may proliferate and give rise to secondary nodules along
the course of the vessels. When the lymphatic network in the skin is
diffusely infected, the appearance is either that of a multitude of
secondary nodules or of a diffuse thickening, so that the skin comes to
resemble coarse leather. On the wall of the chest this condition is
known as _cancer en cuirasse_. Although the cancer cells constantly
attack the walls of the adjacent veins and spread into their interior at
a comparatively early period, secondary growths due to dissemination by
the blood-stream rarely show themselves clinically until late in the
course of the disease. It is probable that many of the cancer cells
which are carried away in the blood or lymph stream undergo necrosis and
fail to give rise to secondary growths. Secondary growths present a
faithful reproduction of the structure of the primary tumour. Apart from
the lymph glands, the chief seats of secondary growths are the liver,
lungs, serous membranes, and bone marrow.