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For clinical purposes, tumours are arbitrarily divided into two classes—the innocent and the malignant. The outstanding difference between them is, that while the evil effects of innocent tumours are entirely local and depend for their severity on the environment of the growth, malignant tumours wherever situated, in addition to producing similar local effects, injure the general health and ultimately cause death.
Innocent, benign, or simple tumours present a close structural resemblance to the normal tissues of the body. They grow slowly, and are usually definitely circumscribed by a fibrous capsule, from which they are easily enucleated, and they do not tend to recur after removal. In their growth they merely push aside and compress adjacent parts, and they present no tendency to ulcerate and bleed unless the overlying skin or mucous membrane is injured. Although usually solitary, some are multiple from the outset—for example, fatty, fibrous, and bony tumours, warts, and fibroid tumours of the uterus. They produce no constitutional disturbance. They only threaten life when growing in the vicinity of vital organs, and then only in virtue of their situation—for example, death may result from an innocent tumour in the air-passage causing suffocation, in the intestine causing obstruction of the bowels, or in the vertebral canal causing pressure on the spinal medulla.
Malignant tumours usually show a marked departure from the structure and arrangement of the normal tissues of the body. Although the cells of which they are composed are derived from normal tissue cells, they tend to take on a lower, more vegetative form; they may be regarded as parasites living at the expense of the organism, multiplying indefinitely and destroying everything with which they come in contact.
Malignant tumours grow more rapidly than innocent tumours, and tend to infiltrate their surroundings by sending out prolongations or offshoots; they are therefore liable to recur after an operation which is restricted to the removal of the main tumour. They are not encapsulated, although they may appear to be circumscribed by condensation of the surrounding tissues; they are rarely multiple at the outset, but show a marked tendency to spread to other parts of the body. Fragments of the parent tumour may become separated and be carried off in the lymph or blood-stream and deposited in other parts of the body, where they give rise to secondary growths. Malignant tumours tend to invade and destroy the overlying skin or mucous membrane, and thus give rise to bleeding ulcers; if the tumour tissue protrudes through the gap in the skin, it is said to fungate. In course of time they give rise to a condition of ill-health or cachexia, the patient becoming pale, sallow, feverish, and emaciated, probably as a result of chronic poisoning from the absorption of toxic products from the tumour. They ultimately destroy life, it may be by their local effects, such as ulceration and hæmorrhage, by favouring the entrance of septic infection, by interfering with the function of organs which are essential to life, by cachexia, or by a combination of these effects.
The situation of a malignant tumour exercises considerable influence on the rapidity, as well as on the mode, in which it causes death. Some cancers, such as that known as “rodent,” show malignant features which are entirely local, while others, such as melanotic cancer, exhibit a malignancy characterised by rapid generalisation of growths throughout the body. Tumours that are structurally alike may show variations in malignancy, according to their situation and to the age of the patient, as well as to other factors which are as yet unknown.
In attempting to arrive at a conclusion as to the innocence or malignancy of any tumour, too much reliance must not be placed on its histological features; its situation, rate of growth, and other clinical features must also be taken into consideration. It cannot be too emphatically stated that there is no hard-and-fast line between innocent and malignant growths; there is an indefinite transition from one to the other. The possibility of the transformation of a benign into a malignant tumour must be admitted. Such a transformation implies a change in the structure of the growth, and has been observed especially in fibrous and cartilaginous tumours, in tumours of the thyreoid gland, and in uterine fibroids. The alteration in character may take place under the influence of injury, prolonged or repeated irritation, incomplete removal of the benign tumour by operation, or the altered physiological conditions of the tissues which attend upon advancing years.
After a tumour has been removed by operation it should as a routine measure be subjected to microscopical examination; the results are often instructive and sometimes other than what was expected.
Varieties of Tumours.—In the following description, tumours are classified on an anatomical basis, taking in order first the connective-tissue group and subsequently those that originate in epithelium.
Innocent Connective-tissue TumoursLipoma.—A lipoma is composed of fat resembling that normally present in the body. The commonest variety is the subcutaneous lipoma, which grows from the subcutaneous fat, and forms a soft, irregularly lobulated tumour (Fig. 45). The fat is arranged in lobules separated by connective-tissue septa, which are continuous with the capsule surrounding the tumour and with the overlying skin, which becomes dimpled or puckered when an attempt is made to pinch it up. As the fat is almost fluid at the body temperature, fluctuation can usually be detected. These tumours vary greatly in size, occur at all ages, grow slowly, and, while generally solitary, are sometimes multiple. They are most commonly met with on the shoulder, buttock, or back. In certain situations, such as the thigh and perineum, they tend to become pedunculated (Fig. 46).
A fatty tumour is to be diagnosed from a cold abscess and from a cyst. The distinguishing features of the lipoma are the tacking down and dimpling of the overlying skin, the lobulation of the tumour, which is recognised when it is pressed upon with the flat of the hand, and, more reliable than either of these, the mobility, the tumour slipping away when pressed upon at its margin.
Fig. 45.—Subcutaneous Lipoma showing lobulation.
The prognosis is more favourable than in any other tumour as it never changes its characters; the only reasons for its removal by operation are its unsightliness and its probable increase in size in the course of years. The operation consists in dividing the skin and capsule over the tumour and shelling it out. Care must be taken that none of the outlying lobules are left behind. If the overlying skin is damaged or closely adherent, it should be removed along with the tumour.
Fig. 46.—Pedunculated Lipoma of Buttock of forty years' duration in a woman æt. 68.
Multiple subcutaneous lipomas are frequently symmetrical, and in a certain group of cases, met with chiefly in women, pain is a prominent symptom, hence the term adiposis dolorosa (Dercum). These multiple tumours show little or no tendency to increase in size, and the pain which attends their development does not persist.
In the neck, axilla, and pubes a diffuse overgrowth of the subcutaneous fat is sometimes met with, forming symmetrical tumour-like masses, known as diffuse lipoma. As this is not, strictly speaking, a tumour, the term diffuse lipomatosis is to be preferred. A similar condition was described by Jonathan Hutchinson as being met with in the domestic animals. If causing disfigurement, the mass of fat may be removed by operation.
Fig. 47.—Diffuse Lipomatosis of Neck.
Lipoma in other Situations.—The periosteal lipoma is usually congenital, and is most often met with in the hand; it forms a projecting lobulated tumour, which, when situated in the palm, resembles an angioma or a lymphangioma. The subserous lipoma arises from the extra-peritoneal fat in the posterior abdominal wall, in which case it tends to grow forwards between the layers of the mesentery and to give rise to an abdominal tumour; or it may grow from the extra-peritoneal fat in the anterior abdominal wall and protrude from one of the hernial openings or through an abnormal opening in the parietes, constituting a fatty hernia. A subsynovial lipoma grows from the fat surrounding the synovial membrane of a joint, and projects into its interior, giving rise to the symptoms of loose body. Lipomas are also met with growing from the adipose connective tissue between or in the substance of muscles, and, when situated beneath the deep fascia, such as the fascia lata of the thigh, the characteristic signs are obscured and a differential diagnosis is difficult. It may be differentiated from a cold abscess by puncture with an exploring needle.
Fig. 48.—Zanthoma of Hands in a girl æt. 14, showing multiple subcutaneous tumours (cf. Fig. 49).
(Sir H. J. Stiles' case.)
Zanthoma is a rare but interesting form of tumour, composed of a fibrous and fatty tissue, containing a granular orange-yellow pigment, resembling that of the corpus luteum. It originates in the corium and presents two clinical varieties. In the first of these, it occurs in the form of raised yellow patches, usually in the skin of the eyelids of persons after middle life, and in many instances is associated with chronic jaundice; the patches are often symmetrical, and as they increase in size they tend to fuse with another.
The second form occurs in children and adolescents; it may affect several generations of the same family, and is often multiple, there being a combination of thickened yellow patches of skin and projecting tumours, some of which may attain a considerable size (Figs. 48 and 49). On section, the tumour tissue presents a brilliant orange or saffron colour.
There is no indication for removing the tumours unless for the deformity which they cause; exposure to the X-rays is to be preferred to operation.
Fig. 49.—Zanthoma showing Subcutaneous Tumours on Buttocks. From same patient as Fig. 48.
Chondroma.—A chondroma is mainly composed of cartilage. Processes of vascular connective tissue pass in between the nodules of cartilage composing the tumour from the fibrous capsule which surrounds it. On section it is of a greyish-blue colour and semi-translucent. The tumour is firm and elastic in consistence, but certain portions may be densely hard from calcification or ossification, while other portions may be soft and fluctuating as a result of myxomatous degeneration and liquefaction. These tumours grow slowly and painlessly, and may surround nerves and arteries without injuring them. They may cause a deep hollow in the bone from which they originate. All intermediate forms between the innocent chondroma and the malignant chondro-sarcoma are met with. Chondroma may occur in a multiple form, especially in relation to the phalanges and metacarpal bones. When growing in the interior of a bone it causes a spindle-shaped enlargement of the shaft, which in the case of a phalanx or metacarpal bone may resemble the dactylitis resulting from tubercle or syphilis. A chondroma appears as a clear area in a skiagram.
Fig. 50.—Chondroma growing from infraspinous fossa of Scapula.
A skiagram of a bone in which there is a chondroma shows a clear rounded area in the position of the tumour, which must be differentiated from similar clear areas due to other kinds of tumour, especially the myeloma;
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