Alexis Thomson and Alexander Miles - Manual of Surgery

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It is generally believed that the secondary growths in cancer that
develop at a distance from the primary tumour, those, for example, in
the medullary canal of the femur or in the diploe of the skull occurring
in advanced cases of cancer of the breast, are the result of
dissemination of cancer cells by way of the blood-stream and are to be
regarded as emboli. Sampson Handley disagrees with this view; he
believes that the dissemination is accomplished in a more subtle way,
namely, by the actual growth of cancer cells along the finer vessels of
the lymph plexuses that ramify in the deep fascia, a method of spread
which he calls _permeation_. It is maintained also that permeation
occurs as readily against the lymph stream as with it. He compares the
spread of cancer to that of an invisible annular ringworm. The growing
edge extends in a wider and wider circle, within which a healing process
may occur, so that the area of permeation is a ring, rather than a disc.
Healing occurs by a process of "peri-lymphatic fibrosis," but as the
natural process of healing may fail at isolated points, nodules of
cancer appear, which, although apparently separate from the primary
growth, have developed in continuity with it, peri-lymphatic fibrosis
having destroyed the cancer chain connecting the nodule with the primary
growth. This centrifugal spread of cancer is clearly seen in the
distribution of the subcutaneous secondary nodules so frequently met
with in the late stages of mammary cancer. The area within which the
secondary nodules occur is a circle of continually increasing diameter
with the primary growth in the centre.

In the rare cases in which the skin of the greater part of the body is
affected, the nodules rarely appear below the level of the deltoid or
the middle third of the thigh, the patient dying before the spread can
reach the distal portions of the limbs.

Handley argues against the embolic origin of the metastases in the bones
because of the rarity of these in the bones of the distal parts of the
limbs, because of the fact that secondary cancer of the femur nearly
always commences in the upper third of the shaft, which harmonises with
the intimate connection of the deep fascia with the periosteum over the
great trochanter, thus favouring invasion of the bone marrow when
permeation has spread thus far. He claims support for the permeation
theory from the fact that the humerus is rarely involved below the
insertion of the deltoid, and that spontaneous fracture of the femur is
three times more common on the side on which the breast cancer is
situated.

The tumour tissue may undergo necrosis, and when the overlying skin or
mucous membrane gives way an ulcer is formed. The margins of a
_cancerous ulcer_ (Fig. 57) are made up of tumour tissue which has not
broken down. Usually they are irregular, nodularly thickened or
indurated; sometimes they are raised and crater-like. The floor of the
ulcer is smooth and glazed, or occupied by necrosed tissue, and the
discharge is watery and blood-stained, and as a result of putrefactive
changes may become offensive. Haemorrhage is rarely a prominent feature,
but discharge of blood may constitute a symptom of considerable
diagnostic importance in cancer of internal organs such as the rectum,
the bladder, or the uterus.

[Illustration: FIG. 57.--Carcinoma of Breast with Cancerous Ulcer.]

_The Contagiousness of Cancer._--A limited number of cases are on record
in which a cancer appears to have been transferred by contact, as from
the lower to the upper lip, from one labium majus to the other, from the
tongue to the cheek, and from one vocal cord to the other; these being
all examples of cancer involving surfaces which are constantly or
frequently in contact. The transference of cancer from one human being
to another, whether by accident, as in the case of a surgeon wounding
his finger while operating for cancer, or by the deliberate introduction
of a portion of cancerous tumour into the tissues, has never been known
to occur. It is by no means infrequent, however, that when recurrence
takes place after an operation for the removal of cancer, the recurrent
nodules make their appearance in the main scar or in the scars of
stitches in its neighbourhood. In the lower animals the grafting of
cancer only succeeds in animals of the same species; for example, a
cancer taken from a mouse will not grow in the tissues of a rat, but
only in a mouse of the same variety as that from which the graft was
taken.

While cancer cannot be regarded as either contagious or infectious, it
is important to bear in mind the possibility of infection of a wound
with cancer when operating for the disease. A cancer should not be cut
into unless this is essential for purposes of diagnosis, and the wound
made for exploration should be tightly closed by stitches before the
curative operation is proceeded with; the instruments used for the
exploration must not be used again until they have been boiled. The
greatest care should be taken that a cancer which has softened or broken
down is not opened into during the operation.

Investigations regarding the cause of cancer have been prosecuted with
great energy during recent years, but as yet without positive result. It
is recognised that there are a number of conditions which favour the
development of cancer, such as prolonged irritation, and a considerable
number of cases have been recorded in which cancer of the skin of the
hands has followed prolonged and repeated exposure to the Rontgen rays.

_The Alleged Increase of Cancer._--Regarding the alleged increase of
cancer, it may be pointed out that it is impossible to ascertain how
much of the apparent increase is due to more accurate diagnosis and
improved registration. It is probable also that some increase has taken
place in consequence of the increased average duration of life; a larger
proportion of persons now reach the age at which cancer is frequent.

_The prognosis_ largely depends on the variety of cancer and on its
situation. Certain varieties--such as the atrophic cancer of the breast
which occurs in old people, and some forms of cancer in the rectum--are
so indolent in their progress that they can scarcely be said to shorten
life; while others--such as the softer varieties of mammary cancer
occurring in young women--are among the most malignant of tumours. The
mode in which cancer causes death depends to a large extent upon its
situation. In the gullet, for example, it usually causes death by
starvation; in the larynx or thyreoid, by suffocation; in the intestine,
by obstruction of the bowels; in the uterus, prostate, and bladder, by
haemorrhage or by implication of the ureters and kidneys. Independently
of their situation, however, cancers frequently cause death by giving
rise to a progressive impairment of health known as the _cancerous
cachexia_, a condition which is due to the continued absorption of
poisonous products from the tumour. The patient loses appetite, becomes
emaciated, pale, and feverish, and gradually loses strength until he
dies. In many cases, especially those in which ulceration has occurred,
the addition of pyogenic infection may also be concerned in the failure
of health.

_Treatment._--Removal by surgical means affords the best prospect of
cure. If carcinomatous disease is to be rooted out, its mode of spread
by means of the lymph vessels must be borne in mind, and as this occurs
at an early stage, and is not evident on examination, a wide area must
be included in the operation. The organ from which the original growth
springs should, if practicable, be altogether removed, because its lymph
vessels generally communicate freely with each other, and secondary
deposits have probably already taken place in various parts of it. In
addition, the nearest chain of lymph glands must also be removed, even
though they may not be noticeably enlarged, and in some cases--in cancer
of the breast, for example--the intervening lymph vessels should be
removed at the same time.

The treatment of cancer by other than operative methods has received a
great deal of attention within recent years, and many agents have been
put to the test, _e.g._ colloidal suspensions of selenium, but without
any positive results. Most benefit has resulted from the use of radium
and of the X-rays, and one or other should be employed as a routine
measure after every operation for cancer.

It has been demonstrated that cancer cells are more sensitive to radium
and to the Rontgen rays than the normal cells of the body, and are more
easily killed. The effect varies a good deal with the nature and seat of
the tumour. In rodent cancers of the skin, for example, both radium and
X-ray treatment are very successful, and are to be preferred to
operation because they yield a better cosmetic result. While small
epitheliomas of the skin may be cured by means of the rays, they are not
so amenable as rodent cancers.

Cancers of mucous membranes are less amenable to ray treatment because
they are less circumscribed and are difficult of access. In cancers
under the skin, the Rontgen rays are less efficient; if radium is
employed, the tube containing it should be inserted into the substance
of the tumour after the method described in connection with sarcoma--and
another tube should be placed on the overlying skin.

In the employment of X-rays and of radium in the treatment of cancer,
experience is required, not only to obtain the maximum effect of the
rays, but to avoid damage to the adjacent and overlying tissues.

Ray treatment is not to be looked upon as a rival but as a powerful
supplement to the operative treatment of cancer.

VARIETIES OF CANCER

The varieties of cancer are distinguished according to the character and
arrangement of the epithelial cells.

The _squamous epithelial cancer_ or _epithelioma_ originates from a
surface covered by squamous epithelium, such as the skin, or the mucous
membrane of the mouth, gullet, or larynx. The cancer cells retain the
characters of squamous epithelium, and, being confined within the lymph
spaces of the sub-epithelial connective tissue, become compressed and
undergo a horny change. This results in the formation of concentrically
laminated masses known as cell nests.

The clinical features are those of a slowly growing indurated tumour,
which nearly always ulcerates; there is a characteristic induration of
the edges and floor of the ulcer, and its surface is often covered with
warty or cauliflower-like outgrowths (Fig. 58). The infection of the
lymph glands is early and constant, and constitutes the most dangerous
feature of the disease; the secondary growths in the glands exhibit the
characteristic induration, and may themselves break down and lead to the
formation of ulcers.

[Illustration: FIG. 58.--Epithelioma of Lip.]

Epithelioma frequently originates in long-standing ulcers or sinuses,
and in scars, and probably results from the displacement and
sequestration of epithelial cells during the process of cicatrisation.

The _columnar epithelial cancer_ or _columnar epithelioma_ originates in
mucous membranes covered with columnar epithelium, and is chiefly met
with in the stomach and intestine. As it resembles an adenoma in
structure it is sometimes described as a _malignant adenoma_. Its
malignancy is shown by the proliferating epithelium invading the other
coats of the stomach or intestine, and by the development of secondary
growths.

_Glandular carcinoma_ originates in organs such as the breast, and in
the glands of mucous membranes and skin. The epithelial cells are not
arranged on any definite plan, but are closely packed in irregularly
shaped alveoli. If the alveoli are large and the intervening stroma is
scanty and delicate, the tumour is soft and brain-like, and is described
as a _medullary_ or _encephaloid cancer_. If the alveoli are small and
the intervening stroma is abundant and composed of dense fibrous tissue,
the tumour is hard, and is known as a _scirrhous cancer_--a form which
is most frequently met with in the breast. If the cells undergo
degeneration and absorption and the stroma contracts, the tumour becomes
still harder, and tends to shrink and to draw in the surrounding parts,
leading, in the breast, to retraction of the nipple and overlying skin,
and in the stomach and colon to narrowing of the lumen. When the cells
of the tumour undergo colloid degeneration, a _colloid cancer_ results;
if the degeneration is complete, as may occur in the breast, the
malignancy is thereby greatly diminished; if only partial, as is more
common in rectal cancer, the malignancy is not appreciably affected.
Melanin pigment is formed in relation to the cells and stroma of certain
epithelial tumours, giving rise to _melanotic cancer_, one of the most
malignant of all new growths. Cyst-like spaces may form in the tumour by
the accumulation of the secretion of the epithelial cells, or as a
result of their degeneration--_cystic carcinoma_. This is met with
chiefly in the breast and ovary, and the tumour resembles the cystic
adenoma, but it tends to infect its surroundings and gives rise to
secondary growths.

_Rodent cancer_ originates in the glands of the skin, and presents a
special tendency to break down and ulcerate on the surface (Figs. 102
and 103). It almost never infects the lymph glands.

DERMOIDS

A dermoid is a tumour containing skin or mucous membrane, occurring in a
situation where these tissues are not met under normal conditions.

The _skin dermoid_, or _derma-cyst_ as it has been called by Askanazy,
arises from a portion of epiblast, which has become sequestrated during
the process of coalescence of two cutaneous surfaces in development.
This form is therefore most frequently met with on the face and neck in
the situations which correspond to the various clefts and fissures of
the embryo. It occurs also on the trunk in situations where the lateral
halves of the body coalesce during development. Such a dermoid usually
takes the form of a globular cyst, the wall of which consists of skin,
and the contents of turbid fluid containing desquamated epithelium, fat
droplets, cholestrol crystals, and detached hairs. Delicate hairs may
also be found projecting from the epithelial lining of the cyst.

Faulty coalescence of the cutaneous covering of the back occurs most
frequently over the lower sacral vertebrae, giving rise to small
congenital recesses, known as post-anal dimples and coccygeal sinuses.
These recesses are lined with skin, which is furnished with hairs,
sebaceous and sweat glands. If the external orifice becomes occluded,
there results a dermoid cyst.

_Tubulo-dermoids_ arise from embryonic ducts and passages that are
normally obliterated at birth, for example, _lingual dermoids_ develop
in relation to the thyreo-glossal duct; _rectal and post-rectal_
dermoids to the post-anal gut; and _branchial dermoids_ in relation to
the branchial clefts. Tubulo-dermoids present the same structure as skin
dermoids, save that mucous membrane takes the place of skin in the wall
of the cyst, and the contents consist of the pent-up secretion of mucous
glands.

_Clinical Features._--Although dermoids are of congenital origin, they
are rarely evident at birth, and may not give rise to visible tumours
until puberty, when the skin and its appendages become more active, or
not till adult life. Superficial dermoids, such as those met with at the
outer angle of the orbit, form rounded, definitely limited tumours over
which the skin is freely movable. They are usually adherent to the
deeper parts, and when situated over the skull may be lodged in a
depression or actual gap in the bone. Sometimes the cyst becomes
infected and suppurates, and finally ruptures on the surface. This may
lead to a natural cure, or a persistent sinus may form. Dermoids more
deeply placed, such as those within the thorax, or those situated
between the rectum and sacrum, give rise to difficulty in diagnosis,
even with the help of the X-rays, and their nature is seldom recognised
until the escape of the contents--particularly hairs--supplies the clue.
The literature of dermoid cysts is full of accounts of puzzling tumours
met with in all sorts of situations.

The treatment is to remove the cyst. When it is impossible to remove the
whole of the lining membrane by dissection, the portion that is left
should be destroyed with the cautery.

_Ovarian Dermoids._--Dermoids are not uncommon in the ovary (Fig. 59).
They usually take the form of unilocular or multilocular cysts, the
wall of which contains skin, mucous membrane, hair follicles, sebaceous,
sweat, and mucous glands, nails, teeth, nipples, and mammary glands. The
cavity of the cyst usually contains a pultaceous mixture of shed
epithelium, fluid fat, and hair. If the cyst ruptures, the epithelial
elements are diffused over the peritoneum, and may give rise to
secondary dermoids.

[Illustration: FIG. 59.--Dermoid Cyst of Ovary showing Teeth in its
interior.]

The ovarian dermoid appears clinically as an abdominal or pelvic tumour
provided with a pedicle; if the pedicle becomes twisted, the tumour
undergoes strangulation, an event which is attended with urgent
symptoms, not unlike those of strangulated hernia.

The treatment consists in removing the tumour by laparotomy.

#Teratoma.#--A teratoma is believed to result from partial dichotomy or
cleavage of the trunk axis of the embryo, and is found exclusively in
connection with the skull and vertebral column. It may take the form of
a monstrosity such as conjoined twins or a parasitic foetus, but more
commonly it is met with as an irregularly shaped tumour, usually growing
from the sacrum. On dissection, such a tumour is found to contain a
curious mixture of tissues--bones, skin, and portions of viscera, such
as the intestine or liver. The question of the removal of the tumour
requires to be considered in relation to the conditions present in each
individual case.

CYSTS[3]

[3] Cysts which form in relation to new-growths have been considered
with tumours.

Cysts are rounded sacs, the wall being composed of fibrous tissue lined
by epithelium or endothelium; the contents are fluid or semi-solid, and
vary in character according to the tissue in which the cyst has
originated.

_Retention and Exudation Cysts._--_Retention cysts_ develop when the
duct of a secreting gland is partly obstructed; the secretion
accumulates, and the gland and its duct become distended into a cyst.
They are met with in the mamma and in the salivary glands. Sebaceous
cysts or wens are described with diseases of the skin. _Exudation cysts_
arise from the distension of cavities which are not provided with
excretory ducts, such as those in the thyreoid.

_Implantation cysts_ are caused by the accidental transference of
portions of the epidermis into the underlying connective tissue, as may
occur in wounds by needles, awls, forks, or thorns. The implanted
epidermis proliferates and forms a small cyst. They are met with chiefly
on the palmar aspect of the fingers, and vary in size from a split pea
to a cherry. The treatment consists in removing them by dissection.

_Parasitic cysts_ are produced by the growth within the tissues of
cyst-forming parasites, the best known being the taenia echinococcus,
which gives rise to the _hydatid cyst_. The liver is by far the most
common site of hydatid cysts in the human subject.

With regard to the further life-history of hydatids, the living elements
of the cyst may die and degenerate, or the cyst may increase in size
until it ruptures. As a result of pyogenic infection the cyst may be
converted into an abscess.

The _clinical features_ of hydatids vary so much with their situation
and size, that they are best discussed with the individual organs. In
general it may be said that there is a slow formation of a globular,
elastic, fluctuating, painless swelling. Fluctuation is detected when
the cyst approaches the surface, and it is then also that percussion
may elicit the "hydatid thrill" or fremitus. This thrill is not often
obtainable, and in any case is not pathognomonic of hydatids, as it may
be elicited in ascites and in other abdominal cysts. Pressure of the
cyst upon adjacent structures, and the occurrence of suppuration, are
attended with characteristic clinical features.

The _diagnosis_ of hydatids will be considered with the individual
organs. The disease is more common in certain parts of Australia and in
Shetland and Iceland than in countries where the association of dogs in
the domestic life of the inhabitants is less intimate. Pfeiler, who has
worked at the _serum diagnosis of hydatid disease_, regards the
complement deviation method as the most reliable; he believes that a
positive reaction may almost be regarded as absolutely diagnostic of an
echinococcal lesion.

The _treatment_ is to excise the cyst completely, or to inject into it a
1 per cent. solution of formalin. In operating upon hydatids the utmost
care must be taken to avoid leakage of the contents of the cyst, as
these may readily disseminate the infection.

A _blood cyst_ or haematoma results from the encapsulation of
extravasated blood in the tissues, from haemorrhage taking place into a
preformed cyst, or from the saccular pouching of a varicose vein.

A _lymph cyst_ usually results from a contusion in which the skin is
forcibly displaced from the subjacent tissues, and lymph vessels are
thereby torn across. The cyst is usually situated between the skin and
fascia, and contains clear or blood-stained serum. At first it is lax
and fluctuates readily, later it becomes larger and more tense. The
treatment consists in drawing off the contents through a hollow needle
and applying firm pressure. Apart from injury, lymph cysts are met with
as the result of the distension of lymph spaces and vessels
(_lymphangiectasis_); and in lymphangiomas, of which the best-known
example is the cystic hygroma or hydrocele of the neck.

GANGLION

This term is applied to a cyst filled with a clear colourless jelly or
colloid material, met with in the vicinity of a joint or tendon sheath.

The commonest variety--the _carpal ganglion_--popularly known as a
sprained sinew--is met with as a smooth, rounded, or oval swelling on
the dorsal aspect of the carpus, usually towards its radial side (Fig. 60).
It is situated over one of the intercarpal or other joints in this
region, and may be connected with one or other of the extensor tendons.
The skin and fascia are movable over the cyst. The cyst varies in size
from a pea to a pigeon's egg, and usually attains its maximum size
within a few months and then remains stationary. It becomes tense and
prominent when the hand is flexed towards the palm. Its appearance is
usually ascribed to some strain of the wrist--for example, in girls
learning gymnastics. It may cause no symptoms or it may interfere with
the use of the hand, especially in grasping movements and when the hand
is dorsiflexed. In girls it may give rise to pain which shoots up the
arm. Ganglia are also met with on the dorsum of the metacarpus and on
the palmar aspect of the wrist.

[Illustration: FIG. 60.--Carpal Ganglion in a woman aet. 25.]

The _tarsal ganglion_ is situated on the dorsum of the foot over one or
other of the intertarsal joints. It is usually smaller, flatter, and
more tense than that met with over the wrist, so that it is sometimes
mistaken for a bony tumour. It rarely causes symptoms, unless so
situated as to be pressed upon by the boot.

_Ganglia in the region of the knee_ are usually situated over the
interval between the femur and tibia, most often on the lateral aspect
of the joint in front of the tendon of the biceps (Fig. 61). The
swelling, which may attain the size of half a walnut, is tense and hard
when the knee is extended, and becomes softer and more prominent when it
is flexed. They are met with in young adults who follow laborious
occupations or who indulge in athletics, and they cause stiffness,
discomfort, and impairment of the use of the limb. A ganglion is
sometimes met with on the median aspect of the head of the metatarsal
bone of the great toe and may be the cause of considerable suffering; it
is indistinguishable from the thickened and enlarged bursa so commonly
present in this situation in the condition known as bunion.

[Illustration: FIG. 61.--Ganglion on lateral aspect of Knee in a young
woman.]

Ganglionic cysts are met with in other situations than those mentioned,
but they are so rare as not to require separate description.

Ganglia are to be diagnosed by their situation and physical characters;
enlarged bursae, synovial cysts, and new-growths are the swellings most
likely to be mistaken for them. The diagnosis is sometimes only cleared
up by withdrawing the clear, jelly-like contents through a hollow
needle.

_Pathological Anatomy._--The wall of the cyst is composed of fibrous
tissue closely adherent to or fused with the surrounding tissues, so
that it cannot be shelled out. There is no endothelial lining, and the
fibrous tissue of the wall is in immediate contact with the colloid
material in the interior, which appears to be derived by a process of
degeneration from the surrounding connective tissue. In the region of
the knee the ganglion is usually multilocular, and consists of a
meshwork of fibrous tissue, the meshes of which are occupied by colloid
material.