Fig. 40.—Ulcerating Gumma of Lips. (From a photograph lent by Dr. Stopford Taylor and Dr. R.W. Mackenna.)Fig. 40.—Ulcerating Gumma of Lips.(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)
Fig. 40.—Ulcerating Gumma of Lips.
(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)
The tertiary ulcermay be situated anywhere, but is most frequently met with on the leg, especially in the region of the knee (Fig. 42) and over the calf. There may be one or more ulcers, and also scars of antecedent ulcers. The edges are sharply cut, as if punched out; the margins are rounded in outline, firm, and congested; the base is occupied by gummatous tissue, or, if this has already separated and sloughed out, by unhealthy granulations and a thick purulent discharge. When the ulcer has healed it leaves a scar which is depressed, and if over a bone, is adherent to it. The features of the tertiary ulcer, however, are not always so characteristic as the above description would imply. It is to be diagnosed from the “leg ulcer,” which occurs almost exclusively on the lower third of the leg; from Bazin's disease (p. 74); from the ulcers that result from certain forms of malignant disease, such as rodent cancer, and from those met with in chronic glanders.
Gummatous Infiltration of the Skin(“Syphilitic Lupus”).—This is a lesion, met with chiefly on the face and in the region of the external genitals, in which the skin becomes infiltratedwith granulation tissue so that it is thickened, raised above the surface, and of a brownish-red colour. It appears as isolated nodules, which may fuse together; the epidermis becomes scaly and is shed, giving rise to superficial ulcers which are usually covered by crusted discharge. The disease tends to spread, creeping over the skin with a serpiginous, crescentic, or horse-shoe margin, while the central portion may heal and leave a scar. From the fact of its healing in the centre while it spreads at the margin, it may resemble tuberculous disease of the skin. It can usually be differentiated by observing that the infiltration is on a larger scale; the progress is much more rapid, involving in the course of months an area which in the case of tuberculosis would require as many years; the scars are sounder and are less liable to break down again; and the disease rapidly yields to anti-syphilitic treatment.
Fig. 41.—Ulceration of nineteen year's duration in a woman æt. 24, the subject of inherited syphilis, showing active ulceration, cicatricial contraction, and sabre-blade deformity of tibiæ.Fig. 41.—Ulceration of nineteen year's duration in a woman æt. 24, the subject of inherited syphilis, showing active ulceration, cicatricial contraction, and sabre-blade deformity of tibiæ.
Fig. 41.—Ulceration of nineteen year's duration in a woman æt. 24, the subject of inherited syphilis, showing active ulceration, cicatricial contraction, and sabre-blade deformity of tibiæ.
Tertiary lesions of mucous membrane and of the submucous cellular tissueare met with chiefly in the tongue, nose, throat, larynx, and rectum. They originate as gummata or as gummatous infiltrations, which are liable to break down and lead to the formation of ulcers which may prove locally destructive, and, in such situations as the larynx, even dangerous to life. In the tongue the tertiary ulcer may prove the starting-point of cancer; and in the larynx or rectum the healing of the ulcer may lead to cicatricial stenosis.
Tertiary lesions of thebones and joints, of themuscles, and of theinternal organs, will be described under these heads. The part played by syphilis in the production of disease of arteries and of aneurysm will be referred to along with diseases of blood vessels.
Fig. 42.—Tertiary Syphilitic Ulceration in region of Knee and on both Thumbs of woman æt. 37.Fig. 42.—Tertiary Syphilitic Ulceration in region of Knee and on both Thumbs of woman æt. 37.
Fig. 42.—Tertiary Syphilitic Ulceration in region of Knee and on both Thumbs of woman æt. 37.
Treatment.—The most valuable drugs for the treatment of the manifestations of the tertiary period are the arsenical preparations and the iodides of sodium and potassium. On account of their depressing effects, the latter are frequently prescribed along with carbonate of ammonium. The dose is usually a matter of experiment in each individual case; 5 grains three times a day may suffice, or it may be necessary to increase each dose to 20 or 25 grains. The symptoms of iodism which may follow from the smaller doses usually disappear on giving a larger amount of the drug. It should be taken after meals, with abundant water or other fluid, especially if given in tablet form. It is advisable to continue the iodides for from one to three months after the lesions for which they are given have cleared up. If the potassium salt is not tolerated, it may be replaced by the ammonium or sodium iodide.
Local Treatment.—The absorption of a subcutaneous gumma is often hastened by the application of a fly-blister. When a gumma has broken on the surface and caused an ulcer, this is treated on general principles, with a preference, however, for applications containing mercury or iodine, or both. If a wet dressing is required to cleanse the ulcer, black wash may be used; if a powder to promote dryness, one containing iodoform; if an ointment is indicated, the choice lies between the red oxide of mercury or the dilute nitrate of mercury ointment, and one consisting of equal parts of lanolin and vaselin with 2 per cent. of iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and other parts may be treated by excision or scraping with the sharp spoon.
Second Attacks of Syphilis.—Instances of re-infection of syphilis have been recorded with greater frequency since the more general introduction of arsenical treatment. A remarkable feature in such cases is the shortness of the interval between the original infection and the alleged re-infection; in a recent series of twenty-eight cases, this interval was less than a year. Another feature of interest is that when patients in the tertiary stage of syphilis are inoculated with the virus from lesions from these in the primary and secondary stage lesions of the tertiary type are produced.
Reference may be made to therelapsing false indurated chancre, described by Hutchinson and by Fournier, as it may be the source of difficulty in diagnosis. A patient who has had an infecting chancre one or more years before, may present a slightly raised induration on the penis at or close to the site of his original sore. This relapsed induration is often so like that of a primary chancre that it is impossible to distinguish between them, except by the history. If there has been a recent exposure to venereal infection, it is liable to be regarded as the primary lesion of a second attack of syphilis, but the further progress shows that neither bullet-buboes nor secondary manifestations develop. These facts, together with the disappearance of the induration under treatment, make it very likely that the lesion is really gummatous in character.
One of the most striking features of syphilis is that it may be transmitted from infected parents to their offspring, the children exhibiting the manifestations that characterise the acquired form of the disease.
The more recent the syphilis in the parent, the greater is the risk of the disease being communicated to the offspring; so that if either parent suffers from secondary syphilis the infection is almost inevitably transmitted.
While it is certain that either parent may be responsible for transmitting the disease to the next generation, the method of transmission is not known. In the case of a syphilitic mother it is most probable that the infection is conveyed to the fœtus by the placental circulation. In the case of a syphilitic father, it is commonly believed that the infection is conveyed to the ovum through the seminal fluid at the moment of conception. If a series of children, one after the other, suffer from inherited syphilis, it is almost invariably the case that the mother has been infected.
In contrast to the acquired form, inherited syphilis is remarkable for the absence of any primary stage, the infection being a general one from the outset. The spirochæte is demonstrated in incredible numbers in the liver, spleen, lung, and other organs, and in the nasal secretion, and, from any of these, successful inoculations in monkeys can readily be made. The manifestations differ in degree rather than in kind from those of the acquired disease; the difference is partly due to the fact that the virus is attacking developing instead of fully formed tissues.
The virus exercises an injurious influence on the fœtus, which in many cases dies during the early months of intra-uterine life, so that miscarriage results, and this may take place in repeated pregnancies, the date at which the miscarriage occurs becoming later as the virus in the mother becomes attenuated. Eventually a child is carried to full term, and it may be still-born, or, if born alive, may suffer from syphilitic manifestations. It is difficult to explain such vagaries of syphilitic inheritance as the infection of one twin and the escape of the other.
Clinical Features.—We are not here concerned with the severe forms of the disease which prove fatal, but with the milder forms in which the infant is apparently healthy when born, but after from two to six weeks begins to show evidence of the syphilitic taint.
The usual phenomena are that the child ceases to thrive, becomes thin and sallow, and suffers from eruptions on the skin and mucous membranes. There is frequently a condition known assnuffles, in which the nasal passages are obstructed by an accumulation of thin muco-purulent discharge which causes the breathing to be noisy. It usually begins within a monthafter birth and before the eruptions on the skin appear. When long continued it is liable to interfere with the development of the nasal bones, so that when the child grows up there results a condition known as the “saddle-nose” deformity (Figs. 43and44).
Fig. 43.—Facies of Inherited Syphilis. (From Dr. Byrom Bramwell's Atlas of Clinical Medicine.)Fig. 43.—Facies of Inherited Syphilis.(From Dr. Byrom Bramwell's Atlas of Clinical Medicine.)
Fig. 43.—Facies of Inherited Syphilis.
(From Dr. Byrom Bramwell's Atlas of Clinical Medicine.)
Affections of the Skin.—Although all types of skin affection are met with in the inherited disease, the most important is apapulareruption, the papules being of large size, with a smooth shining top and of a reddish-brown colour. It affects chiefly the buttocks and thighs, the genitals, and other parts which are constantly moist. It is necessary to distinguish this specific eruption from a form of eczema which occurs in these situations in non-syphilitic children, the points that characterise the syphilitic condition being the infiltration of the skin and the coppery colour of the eruption. At the anus the papules acquire the characters ofcondylomata, also at the angles of the mouth, where they often ulcerate and leave radiating scars.
Affections of the Mucous Membranes.—The inflammation of the nasal mucous membrane that causes snuffles has already been referred to. There may be mucous patches in the mouth, or a stomatitis which is of importance, because it results in interference with the development of the permanent teeth. The mucous membrane of the larynx may be the seat of mucous patches or of catarrh, and as a result the child's cry is hoarse.
Affections of the Bones.—Swellings at the ends of the long bones, due to inflammation at the epiphysial junctions, are most often observed at the upper end of the humerus and in the bones in the region of the elbow. Partial displacement and mobility at the ossifying junction may be observed. The infant cries when the part is touched; and as it does not move the limb voluntarily, the condition is spoken of asthe pseudo-paralysis of syphilis. Recovery takes place under anti-syphilitic treatment and immobilisation of the limb.
Diffuse thickening of the shafts of the long bones, due toa deposit of new bone by the periosteum, is sometimes met with.
Fig. 44.—Facies of Inherited Syphilis.Fig. 44.—Facies of Inherited Syphilis.
Fig. 44.—Facies of Inherited Syphilis.
The conditions of the skull known as Parrot's nodes or bosses, and craniotabes, were formerly believed to be characteristic of inherited syphilis, but they are now known to occur, particularly in rickety children, from other causes. Thebossesresult from the heaping up of new spongy bone beneath thepericranium, and they may be grouped symmetrically around the anterior fontanelle, or may extend along either side of the sagittal suture, which appears as a deep groove—the “natiform skull.” The bosses disappear in time, but the skull may remain permanently altered in shape, the frontal and parietal eminences appearing unduly prominent. The termcraniotabesis applied when the bone becomes thin and soft, reverting to its original membranous condition, so that the affected areas dimple under the finger like parchment or thin cardboard; its localisation in the posterior parts of the skull suggests that the disappearance of the osseous tissue is influenced by the pressure of the head on the pillow. Craniotabes is recovered from as the child improves in health.
Between the ages of three and six months, certain other phenomena may be met with, such aseffusion into the joints, especially the knees;iritis, in one or in both eyes, and enlargement of the spleen and liver.
In the majority of cases the child recovers from these early manifestations, especially when efficiently treated, and may enjoy an indefinite period of good health. On the other hand, when it attains the age of from two to four years, it may begin to manifest lesions which correspond to those of the tertiary period of acquired syphilis.
Later Lesions.—In the skin and subcutaneous tissue, the later manifestations may take the form of localised gummata, which tend to break down and form ulcers, on the leg for example, or of aspreadinggummatous infiltration which is also liable to ulcerate, leaving disfiguring scars, especially on the face. The palate and fauces may be destroyed by ulceration. In the nose, especially when the ulcerative process is associated with a putrid discharge—ozæna—the destruction of tissue may be considerable and result in unsightly deformity. The entire palatal portions of the upper jaws, the vomer, turbinate, and other bones bounding the nasal and oral cavities, may disappear, so that on looking into the mouth the base of the skull is readily seen. Gummatous disease is frequently observed also in the flat bones of the skull, in the bones of the hand, as syphilitic dactylitis, and in the bones of the forearm and leg. When the tibia is affected the disease is frequently bilateral, and may assume the form of gummatous ulcers and sinuses. In later years the tibia may present alterations in shape resulting from antecedent gummatous disease—for example, nodular thickenings of the shaft, flattening of the crest, or a more uniform increase in thickness and length of the shaft of the bone, which,when it is curved in addition, is described as the “sabre-blade” deformity. Among lesions of the viscera, mention should be made of gumma of the testis, which causes the organ to become enlarged, uneven, and indurated. This has even been observed in infants a few months old.
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 puberty there is frequently observed an affection of the eyes, known aschronic interstitial keratitis, 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 assumes the appearance of ground glass. 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 beiritisin 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.Choroiditisandretinitismay 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 thelarynx and trachea, attended with ulceration and resulting in stenosis; and lesions of thenervous systemwhich may result in convulsions, paralysis, or dementia.
In a limited number of cases, about the period of puberty there may developdeafness, 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 associated with the name of Hutchinson, who firstdescribed 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 buttocks 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 passed 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 Wassermann 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 aspermanent 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 keratitis; 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 tibiæ.
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 asColles' 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 shouldbe 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 diseasede 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.—Arsenical 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, novarsenbillon, 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 keratitis, the eyes should be protected from the light by smoked or coloured glasses, 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 passing through the maternal passages during birth, through being nursed or kissed by infected women, or through the rite of circumcision. The risk of infection which formerly existedby 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.
[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.
Theetiology of tumoursis 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 fœtal residues or “rests,” is associated 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 illustrated 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 constitutional 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.
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 lifewhen 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 tumoursusually 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 oroffshoots; 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 tofungate. In course of time they give rise to a condition of ill-health orcachexia, 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 innocenceor 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.
Lipoma.—A lipoma is composed of fat resembling that normally present in the body. The commonest variety is thesubcutaneous 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 withthe 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.Fig. 45.—Subcutaneous Lipoma showing lobulation.
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 consistsin 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.Fig. 46.—Pedunculated Lipoma of Buttock of forty years' duration in a woman æt. 68.
Fig. 46.—Pedunculated Lipoma of Buttock of forty years' duration in a woman æt. 68.
Multiple subcutaneous lipomasare frequently symmetrical, and in a certain group of cases, met with chiefly in women, pain is a prominent symptom, hence the termadiposis 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 asdiffuse lipoma. As this is not, strictly speaking, a tumour, the termdiffuse lipomatosisis 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.Fig. 47.—Diffuse Lipomatosis of Neck.
Fig. 47.—Diffuse Lipomatosis of Neck.
Lipoma in other Situations.—Theperiosteal lipomais 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. Thesubserous lipomaarises 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 afatty hernia. Asubsynovial lipomagrows 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 tissuebetween 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.)Fig. 48.—Zanthoma of Hands in a girl æt. 14, showing multiple subcutaneous tumours (cf.Fig. 49).(Sir H. J. Stiles' case.)
Fig. 48.—Zanthoma of Hands in a girl æt. 14, showing multiple subcutaneous tumours (cf.Fig. 49).
(Sir H. J. Stiles' case.)
Zanthomais 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. 48and49). 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.Fig. 49.—Zanthoma showing Subcutaneous Tumours on Buttocks. From same patient asFig. 48.
Fig. 49.—Zanthoma showing Subcutaneous Tumours on Buttocks. From same patient asFig. 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.Fig. 50.—Chondroma growing from infraspinous fossa of Scapula.
Fig. 50.—Chondroma growing from infraspinous fossa of Scapula.
Askiagramof a bone in which there is a chondroma shows aclear 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; when it has undergone calcification or ossification, it gives a shadow as dark as bone.
Treatment.—In view of the unstable quality of the chondroma, especially of its liability to become malignant, it should be removed as soon as it is recognised. In those projecting from the surface of a bone, both the tumour and its capsule should be removed. If in the interior, a sufficient amount of the cortex should be removed to allow of the tumour being scraped out, and care must be taken that no nodules of cartilage are left behind. In multiple chondromas of the hand, when the fingers are crippled and useless, exposure to the X-rays should be given atrial, and in extreme cases the question of amputation may have to be considered. When a cartilaginous tumour takes on active growth, it must be treated as malignant.