Manual of Surgery Volume I Part 19

Occasionally a syphilitic child suffers from a succession of these gummatous lesions with resulting ill-health, and, it may be, waxy disease of the internal organs; on the other hand, it may recover and present no further manifestations of the inherited taint.

_Affections of the Eyes._--At or near p.u.b.erty there is frequently observed an affection of the eyes, known as _chronic interst.i.tial kerat.i.tis_, the relationship of which to inherited syphilis was first established by Hutchinson. It occurs between the ages of six and sixteen years, and usually affects one eye before the other. It commences as a diffuse haziness or steaminess near the centre of the cornea, and as it spreads the entire cornea a.s.sumes the appearance of ground gla.s.s. The chief complaint is of dimness of sight, which may almost amount to blindness, but there is little pain or photophobia; a certain amount of conjunctival and ciliary congestion is usually present, and there may be _iritis_ in addition. The cornea, or parts of it, may become of a deep pink or salmon colour from the formation in it of new blood vessels. The affection may last for from eighteen months to two years. Complete recovery usually takes place, but slight opacities, especially in the site of former salmon patches, may persist, and the disease occasionally relapses. _Choroiditis_ and _retinitis_ may also occur, and leave permanent changes easily recognised on examination with the ophthalmoscope.

Among the rarer and more serious lesions of the inherited disease may be mentioned gummatous disease in the _larynx and trachea_, attended with ulceration and resulting in stenosis; and lesions of the _nervous system_ which may result in convulsions, paralysis, or dementia.

In a limited number of cases, about the period of p.u.b.erty there may develop _deafness_, which is usually bilateral and may become absolute.

_Changes in the Permanent Teeth._--These affect specially the upper central incisors, which are dwarfed and stand somewhat apart in the gum, with their free edges converging towards one another. They are tapering or peg-shaped, and present at their cutting margin a deep semilunar notch. These appearances are commonly a.s.sociated with the name of Hutchinson, who first described them. Affecting as they do the permanent teeth, they are not available for diagnosis until the child is over eight years of age. Henry Moon drew attention to a change in the first molars; these are reduced in size and dome-shaped through dwarfing of the central tubercle of each cusp.

#Diagnosis of Inherited Syphilis.#--When there is a typical eruption on the b.u.t.tocks and snuffles there is no difficulty in recognising the disease. When, however, the rash is scanty or is obscured by co-existing eczema, most reliance should be placed on the distribution of the eruption, on the brown stains which are left after it has pa.s.sed off, on the presence of condylomata, and of fissuring and scarring at the angles of the mouth. The history of the mother relative to repeated miscarriages and still-born children may afford confirmatory evidence.

In doubtful cases, the diagnosis may be aided by the Wa.s.sermann test and by noting the therapeutic effects of grey powder, which, in syphilitic infants, usually effects a marked and rapid improvement both in the symptoms and in the general health.

While a considerable number of syphilitic children grow up without showing any trace of their syphilitic inheritance, the majority retain throughout life one or more of the following characteristics, which may therefore be described as _permanent signs of the inherited disease_: Dwarfing of stature from interference with growth at the epiphysial junctions; the forehead low and vertical, and the parietal and frontal eminences unduly prominent; the bridge of the nose sunken and rounded; radiating scars at the angles of the mouth; perforation or destruction of the hard palate; Hutchinson's teeth; opacities of the cornea from antecedent kerat.i.tis; alterations in the fundus oculi from choroiditis; deafness; depressed scars or nodes on the bones from previous gummata; "sabre-blade" or other deformity of the tibiae.

#The Contagiousness of Inherited Syphilis.#--In 1837, Colles of Dublin stated his belief that, while a syphilitic infant may convey the disease to a healthy wet nurse, it is incapable of infecting its own mother if nursed by her, even although she may never have shown symptoms of the disease. This doctrine, which is known as _Colles' law_, is generally accepted in spite of the alleged occurrence of occasional exceptions.

The older the child, the less risk there is of its communicating the disease to others, until eventually the tendency dies out altogether, as it does in the tertiary period of acquired syphilis. It should be added, however, that the contagiousness of inherited syphilis is denied by some observers, who affirm that, when syphilitic infants prove infective, the disease has been really acquired at or soon after birth.

There is general agreement that the subjects of inherited syphilis cannot transmit the disease by inheritance to their offspring, and that, although they very rarely acquire the disease _de novo_, it is possible for them to do so.

#Prognosis of Inherited Syphilis.#--Although inherited syphilis is responsible for a large but apparently diminishing mortality in infancy, the subjects of this disease may grow up to be as strong and healthy as their neighbours. Hutchinson insisted on the fact that there is little bad health in the general community that can be attributed to inherited syphilis.

#Treatment.#--a.r.s.enical injections are as beneficial in the inherited as in the acquired disease. An infant the subject of inherited syphilis should, if possible, be nursed by its mother, and failing this it should be fed by hand. In infants at the breast, the drug may be given to the mother; in others, it is administered in the same manner as already described--only in smaller doses. On the first appearance of syphilitic manifestations it should be given 0.05 grm, nova.r.s.enbillon, injected into the deep subcutaneous tissues every week for six weeks, followed by one year's mercurial inunction--a piece of mercurial ointment the size of a pea being inserted under the infant's binder. In older children the dose is proportionately increased. The general health should be improved in every possible direction; considerable benefit may be derived from the use of cod-liver oil, and from preparations containing iron and calcium. Surgical interference may be required in the destructive gummatous lesions of the nose, throat, larynx, and bones, either with the object of arresting the spread of the disease, or of removing or alleviating the resulting deformities. In children suffering from kerat.i.tis, the eyes should be protected from the light by smoked or coloured gla.s.ses, and the pupils should be dilated with atropin from time to time, especially in cases complicated with iritis.

#Acquired Syphilis in Infants and Young Children.#--When syphilis is met with in infants and young children, it is apt to be taken for granted that the disease has been inherited. It is possible, however, for them to acquire the disease--as, for example, while pa.s.sing through the maternal pa.s.sages during birth, through being nursed or kissed by infected women, or through the rite of circ.u.mcision. The risk of infection which formerly existed by the arm-to-arm method of vaccination has been abolished by the use of calf lymph.

The clinical features of the acquired disease in infants and young children are similar to those observed in the adult, with a tendency, however, to be more severe, probably because the disease is often late in being recognised and treated.

CHAPTER X

TUMOURS[2]

Definition--Etiology--General characters of innocent and malignant tumours. CLa.s.sIFICATION OF TUMOURS: I. Connective-tissue tumours: (1) _Innocent_: _Lipoma_, _Xanthoma_, _Chondroma_, _Osteoma_, _Odontoma_, _Fibroma_, _Myxoma_, _Endothelioma_, etc.; (2) _Malignant_: _Sarcoma_--II. Epithelial tumours: (1) _Innocent_: _Papilloma_, _Adenoma_, _Cystic Adenoma_; (2) _Malignant_: _Epithelioma_, _Glandular Cancer_, _Rodent Cancer_, _Melanotic Cancer_--III. Dermoids--IV. Teratoma. Cysts: _Retention_, _Exudation_, _Implantation_, _Parasitic_, _Lymphatic or Serous_.

Ganglion.

[2] For the histology of tumours the reader is referred to a text-book of pathology.

A tumour or neoplasm is a localised swelling composed of newly formed tissue which fulfils no physiological function. Tumours increase in size quite independently of the growth of the body, and there is no natural termination to their growth. They are to be distinguished from such over-growths as are of the nature of simple hypertrophy or local giantism, and also from inflammatory swellings, which usually develop under the influence of a definite cause, have a natural termination, and tend to disappear when the cause ceases to act.

The _etiology of tumours_ is imperfectly understood. Various factors, acting either singly or in combination, may be concerned in their development. Certain tumours, for example, are the result of some congenital malformation of the particular tissue from which they take origin. This would appear to be the case in many tumours of blood vessels (angioma), of cartilage (chondroma), of bone (osteoma), and of secreting gland tissue (adenoma). The theory that tumours originate from ftal residues or "rests," is a.s.sociated with the name of Cohnheim.

These rests are supposed to be undifferentiated embryonic cells which remain embedded amongst fully formed tissue elements, and lie dormant until they are excited into active growth and give rise to a tumour.

This mode of origin is ill.u.s.trated by the development of dermoids from sequestrated portions of epidermis.

Among the local factors concerned in the development of tumours, reference must be made to the influence of irritation. This is probably an important agent in the causation of many of the tumours met with in the skin and in mucous membranes--for example, cancer of the skin, of the lip, and of the tongue. The part played by injury is doubtful. It not infrequently happens that the development of a tumour is preceded by an injury of the part in which it grows, but it does not necessarily follow that the injury and the tumour are related as cause and effect.

It is possible that an injury may stimulate into active growth undifferentiated tissue elements or "rests," and so determine the growth of a tumour, or that it may alter the characters of a tumour which already exists, causing it to grow more rapidly.

The popular belief that there is some const.i.tutional peculiarity concerned in the causation of tumours is largely based on the fact that certain forms of new growth--for example, cancer--are known to occur with undue frequency in certain families. The same influence is more striking in the case of certain innocent tumours--particularly multiple osteomas and lipomas--which are hereditary in the same sense as supernumerary or webbed fingers, and appear in members of the same family through several generations.

INNOCENT AND MALIGNANT TUMOURS

For clinical purposes, tumours are arbitrarily divided into two cla.s.ses--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 circ.u.mscribed 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 const.i.tutional 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-pa.s.sage causing suffocation, in the intestine causing obstruction of the bowels, or in the vertebral ca.n.a.l 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 circ.u.mscribed 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 haemorrhage, 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 cla.s.sified on an anatomical basis, taking in order first the connective-tissue group and subsequently those that originate in epithelium.

INNOCENT CONNECTIVE-TISSUE TUMOURS

#Lipoma.#--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, b.u.t.tock, 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.

[Ill.u.s.tration: 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 sh.e.l.ling 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.

[Ill.u.s.tration: FIG. 46.--Pedunculated Lipoma of b.u.t.tock of forty years'

duration in a woman aet. 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_ (Derc.u.m). 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 p.u.b.es a diffuse overgrowth of the subcutaneous fat is sometimes met with, forming symmetrical tumour-like ma.s.ses, 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 ma.s.s of fat may be removed by operation.

[Ill.u.s.tration: 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, const.i.tuting 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.

[Ill.u.s.tration: FIG. 48.--Zanthoma of Hands in a girl aet. 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 a.s.sociated with chronic jaundice; the patches are often symmetrical, and as they increase in size they tend to fuse with another.