Metastoma

“ All know that while primary carcinoma of the liver is very rare, its secondary or metastatic involvement is very common. The bones, lungs, spleen, kidney, and viscera generally are 130all often found to be the seat of metastases, and in general carcinosis, which has lasted some time, metastases will be found abundantly both in the lymphatics of many parts of the body and in many organs and tissues. Metastases in the lungs are not uncommon in breast cancer, as also metastasis in the bones of the thorax. ”

“ I explained at the time that any attempt to excise portions of tissue for such study would at once endanger the patient and imperil the success of treatment, by giving occasion to metastases, from the opening of blood vessels and lymphatics. This matter is treated of more fully in the present lectures. It is to be remembered that the vast majority of operations for cancer are undertaken upon a purely clinical diagnosis, and it may be undeniably stated that not one half of them are confirmed subsequently by competent microscopic evidence, except, of course, in properly equipped hospitals. ”

“ H. stated that four years after operation 43 per cent remained free of the disease, eight years after only 16 per cent, and 20 years after only 2.5 remained free from the disease. There were a great many cases of carcinoma of the breast reported in which the patient died from metastasis in different organs without local recurrence 10, 15, and 20 years after the operation. The late metastases most frequently took place in the skeleton, which was due to the fact that skeletal lesions might continue a long time without causing clinical symptoms. ”

“ 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. ”

“ In the vertebræ, it is attended with a painful form of paraplegia, which may involve the lower or all four extremities. On the other hand, the disease may show itself clinically as a tumour of bone, which may attain a considerable size, and may be mistaken for a sarcoma, unless the existence of the primary cancer is discovered.
The cancers most liable to give rise to metastasis in bone are those of the breast, liver, uterus, prostate, colon, and rectum; hyper-nephroma of the kidney may also give rise to metastases in bone. ”

“ Too often when a cancer is suspected or discovered it is taken as a foregone conclusion that the malady is hopeless, except as the results of the disease, that is the new growth, may be removed by the knife, X-ray, radium, caustics, etc. And after a surgical operation, as far as my observation goes, the patients are invariably left entirely to their own resources, with the hope, alas, too often futile, that the tumor will not regrow, but with no attempt to so guide the life that there shall not be the same tendency to a recurrent malignant new-formation. ”

“ 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. ”

“ There could hardly be devised a more effective plan to increase the mortality from cancer and to render many more cases really inoperable than this one would surely be; for by thus cutting into cancerous tissue and opening lymphatic channels and blood vessels, with the opportunity for absorption of cancerous elements during the necessary delay, metastases would certainly be induced which would render a surgical removal or a dietary and medicinal treatment immeasurably less effective. ”

“ 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. ”

“ Tumors originate from many causes. Some are congenital and others grow in later life from an inherited tendency.
Any continued irritation which acts mechanically or chemically so as to maintain a constant, though slight, degree of undue vascularity of a part, such as the hot, rough stem of a clay pipe or a jagged tooth, favors the development of a malignant growth. Certain benign growths, such as warts or moles, are especially prone to malignant change. Age and sex also predispose to tumor formation.
Thus carcinoma is a rarity under thirty years of age ”

“ Besides the sarcomata we find in young children frequently so-called mixed tumors, consisting of several kinds of tissue; in the kidney tumors for instance we may find side by side proliferating epithelial gland tissue, round cells resembling sarcoma, muscle and even bonelike tissue. In other organs also we find not rarely such mixed tumors to prevail among the cancers in children. Cancer of the female generative organs occurs in children not mainly in the uterus, as is the case in adults, but in the ovaries and in the vagina. ”

“ The sarcoma ta and carcinoma ta differ somewhat as regards the path of dissemination. The former are vascular tumours, well supplied with blood-vessels; consequently dissemination usually occurs by way of the blood-stream rather than by the lymphatic circulation, and the commonest site for the secondary deposits of sarcoma is the lung. The carcinoma ta are less vascular, and the tendency of the growth is to invade the small lymph channels, so that the first signs of metastases are to be looked for in the lymphatic glands ”

“ We little realize the fiendish resourcefulness of the cancer-cell. One such adrift in the body is like a ferret in a rabbit warren; no other cell can face it for an instant. It simply floats unmolested along the lymph-channels until its progress is arrested in some way, when it promptly settles down wherever it may happen to have landed, begins to multiply and push out columns in every direction, into and at the expense of the surrounding tissues, and behold, a new cancer, or "secondary nodule," is born (metastasis) . ”

“ An atypical tumor is one of epithelial or connective tissue origin in which, though the cells are the same as those in the tissue from which it grows, their arrangement is quite different. They are malignant.
The most important classification of tumors is that into benign and malignant.
A benign tumor is one in which there is no tendency to rapid growth; the symptoms are purely local, and the general health is not affected, except indirectly.
On the other hand a malignant tumor is one which takes on a rapid growth with a tendency to infiltrate or [Pg 153] adhere to surrounding tissues ”

“ TUMOR, in surgery, any morbid parasitic growth, generally, though not always, attended by swelling. Tumors are primarily divided into two classes, the first innocent, including non-malignant, solid, benign, or sarcomatous, and the second malignant growths. Tumors of the first type occur in comparatively few tissues, and do not alter the adjacent parts unless the tumor produces pressure and partial inflammation; they have no tendency to ulcerate or slough, and, if extirpated by a surgical operation, they do not grow again. ”

“ It is true that the simple tumours often remain stationary after attaining a certain size, but the general tendency of ali tumours is towards persistent and unlimited growth, and the cancer cell continues its career unchecked by everything save death.
The spontaneous tumours are seen in every tissue and organ of the body, though in some they are relatively infrequent. Nor are they confined to man, for they have been found throughout the vertebrate kingdom. It is often stated that a higher state of civilization has inflicted on European races a greater susceptibility to tumour formation. ”

“ The surgeon, after consultation, does not know whether the growth in a woman's pelvis is a malignant tumour or a sac containing an extrauterine foetus. If the growth is a malignant tumour, the woman is in actual and certain danger of life, her death is a mere matter of time if a malignant tumour is not removed, and the sooner the tumour is removed the better. If operation is deferred, metastases of the tumour will have occurred, and operation will be too late. The indication when we find a malignant tumour is, if it is not already too late to operate, to take it out at once. ”

“ These tumors are much more benign than the typical carcinomata—they grow very slowly and make ordinarily no metastases. But certain tumors are quite typical for young children. While in adults carcinomata are considerably more frequent than sarcomata, in children sarcomata are much more numerous than carcinomata. The most frequent seats of cancer in children are neither the gastro-intestinal tract nor the female generative organs, but kidney and adrenal, next the eye, brain, skin, cranium and liver. ”

“ If a far advanced primary growth of cancer could be stained in its entirety with a black dye, and if the patient were transparent, we should probably see that the tissues round about the growth were dusky, and that a thin, smoky coloring extended through the lymphatic vessels to the veins into which they empty. As a malignant tumor increases in size at its original situation the nerve filaments are pinched, and pain is caused as a rule; but sometimes the growth will progress with little or no accompanying pain. ”

“ The diagnosis is always difficult, and is seldom made until a portion of the growth has been removed and examined microscopically. The more slowly growing forms, if removed before ulceration has taken place, show little tendency to recur, but those which grow rapidly and break down, not only recur locally, but are liable to give rise to metastases. The treatment is the same as for cancer; the use of radium is more likely to be beneficial than in epithelioma.
Innocent Tumour and Cysts.—Lipoma, fibroma, and various forms of angioma (Fig. 258) are occasionally met with. ”

“ The tumour consists of a dense framework of fibrous tissue, with groups of cancer-cells in the spaces. The malignancy of the disease depends upon the cells, not upon the fibrous tissue. In young subjects the cells predominate, but in old ones the contraction of the fibrous tissue throughout the breast compresses and destroys the cells, and this sometimes to such an extent that there is at last nothing left at the site but contracted fibrous tissue, all trace of malignancy having disappeared. This variety of the disease is found in old people, and is called atrophic cancer. ”

“ Tumors are usually divided into benign and malignant growths. In a general way the malignant tumors are painful; they do not move about freely but become fixed to the adjacent parts; their growth is more rapid; they often have no well-defined borders; frequently they return after removal; the skin covering them is often attached and cannot be moved readily without also moving the tumor. Malignant tumors are divided into cancers (carcinomata) and sarcomas (sarcomata) . Cancer is much more frequent than sarcoma. Cancer occurs more often in persons over thirty ”

“ It is undoubtedly true that any incomplete cutting operation upon a malignant tumor, or its partial cauterization with silver nitrate or arsenic, only serves to stimulate its extension; but complete extirpation with the knife, including the adjacent connective tissue and lymphatics, leaves behind no disease to be extended. Recurrence of the disease in this case would take place after cicatrization of the wound, and would be by new cell proliferation and not by extension. External cancerous tumors have been excised, and in the course of a few weeks the patients have died of internal cancer ”

“ A third type of tumor, the semi-malignant, is intermediate between the first two, and includes some forms of sarcomic and of melanotic tumor, the painful subcutaneous tumor or tubercle, nævi, polypi, etc. Melanosis is commoner in horses than in the human subject, and chiefly in white or gray horses. Various tumors are inter-thoracic, affecting the heart, the lungs, etc. There are also tumors of the brain, of the liver, the rectum, etc.; and in women the uterus and the vagina are specially liable to be affected with tumor. ”

“ While the patient is still under the anaesthetic, a microscopical examination of the tissue, which can be made in a few minutes in a well-equipped hospital, will determine whether the growth is malignant. If so, the whole breast is taken off, and the patient, in all probability, saved. If not, sew up the wound, and the subject is none the worse. Much the better, in fact, for the most innocent growth may develop cancer by irritation. Thirty per cent, or more, of breast cancers develop in this way. ”