Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕
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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 Röntgen 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 Röntgen 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 CancerThe 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.
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.
DermoidsA 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 vertebræ, 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.
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 fœtus, 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
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