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.

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

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

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

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

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

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

[Illustration: PLATE XXVIII

FIG. 1

Hypernephroma Renalis. (Medium magnification.)

FIG. 2

Chorion Epithelioma.]

GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.

The following tables are here inserted, trusting that they may aid the young practitioner in distinguishing in a general way between benign and malignant tumors, and even in making a diagnosis between sarcoma and carcinoma. I have also inserted a table differentiating the clinical appearances of epithelioma and of lupus. In these tables comprehensiveness has not been aimed at, rather simplicity, while it is not denied that cases are met with in which diagnosis may be exceedingly difficult, and in which the common signs herein mentioned may be found either absent or misleading:

TABLE I.--DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT GROWTHS.

_Benign Growths._ _Malignant Growths._

Common at all ages. Rare in early life. Usually slow in growth. Usually rapid in growth. No evidences of infiltration or Infiltration in all cases, dissemination. dissemination in many. Are often encapsulated, nearly Never encapsulated, seldom always circumscribed. circumscribed. Rarely adherent unless inflamed. Always adherent. Rarely ulcerate. Often ulcerate--nearly always when surface is involved. Overlying tissue not retracted. Overlying tissue nearly always retracted. No lymphatic involvement when not Lymphatic involvement an almost inflamed. constant feature. No leukocytosis. Leukocytosis often marked. Elimination of urea unaffected. Deficient elimination of urea (?).

TABLE II.--DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA.

_Sarcoma._ _Carcinoma._

Occurs at any age. Rare before thirtieth year of life. Disseminates by the bloodvessels Disseminations by the lymphatics. (veins). Arises from mesoblastic Arises from glandular (epithelial) structures. tissues. Distant metastases are more Less so. common. Contains blood channels rather Contains vessels of normal type. than complete bloodvessels. Less prone to ulceration. More so. Involvement of adjacent Almost invariably adjacent lymphatics not common. lymphatics are involved. Secondary changes and Degenerations not common; other degenerations are more common. secondary changes rare. (Sugar present in the blood?) (Peptone present in the blood?)

Differential diagnosis between epithelioma and ulcerating gumma will be found in