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 3. Adenocarcinoma.—Sutton has also described an adenocarcinoma
of the peculiar sebaceous glands named after Tyson. These are
found particularly at the base of the prepuce, this form of tumor
being rare. Adenomas arising from the mucous glands, which are
usually transformed into cysts, are also known, as well as other
gland tumors springing from the glands of Bartholin, Cowper, etc.
(See Plate XXIII, Fig. 2, and Plate XXIV.)
Pituitary adenomas are either analogous to struma or belong to
the mixed tumors of dermoid or teratomatous type.
Prostatic adenoma is in large degree fibromyoma of that body,
with more or less hypertrophy of its glandular structures. Minute
cystic alterations may occur also, as well as growth resembling
intracanalicular fibro-adenoma.
Adenoma is occasionally observed in the salivary glands, where it
is usually encapsulated, and may undergo cystic changes. It has
been observed in the liver and pancreas. In the former its pseudo-
ducts often contain inspissated material of bile-green tint.
The lesions of the kidney referred to as cystadenoma are now
grouped among the teratomas, and are described under that
heading. They present interesting examples of mixed tumors.
In the testis, as in the ovary, epithelial tumors frequently present
themselves, but they partake less often of the type of pure adenoma,
and incline rather to that already described under Ovarian Cystoma.
Even in the paradidymis tumors of this same character are found,
with cystic or even papillary alterations.
In the mucous membrane of the stomach and bowels adenoma
usually presents as an ovoid tumor, attaining such size as to give
rise to mechanical obstruction either by pressure or by traction.
Adenoma of the pyloric region is a repetition in structure of the
pyloric glands. In the rectum it presents usually as a polypoid
outgrowth, often seen in young children. Such tumors are generally
small, and when solitary they often hang by a distinct stalk.
Similar polypoid tumors present in the cervical canal of the uterus,
where are also found sessile and racemose tumors, all of which are
structural repetitions of the glands met with in the cervix uteri.
Adenoma of the uterine cavity is seldom seen; it is also rare in the
Fallopian tube, but occasionally presents as a dendritic outgrowth
from the mucous membrane distending the tube.
Epithelioma.—Epithelioma is common, especially where there is
transition from one kind of epithelium to another, and,
of all other localities, particularly where skin and mucous membrane
meet—e. g., the lips, the vulva, and the anus. Epithelioma differs
from papilloma in that the former is no longer limited by basement
membrane, but passes beyond it into the underlying connective
tissue and presents down—rather than up—growth. Characteristic of
epithelioma are the so-called cell nests or pearly bodies, where there
seems to be a tendency to globular arrangement of cells with such
condensation or alteration that they lose their ability to take stains,
and appear as a more or less lustrous mass, showing off by contrast
among the standard surrounding tissue. On this account they are
often called pearly bodies. Recognition of these is tantamount to
diagnosis of epithelium. (See Plate XXIII.)
This form of neoplasm is essentially the same, no matter what its
clinical varieties. These comprise a wart-like growth or nodule, which
quickly becomes an ulcer with elevated edges, ulceration being due
to necrosis of cells farthest from the periphery; or, again, the disease
may start as an ulcerated fissure, ulceration and infiltration keeping
pace, in which case there is a sharply defined ulcer with undermined
edges. A third variety, often seen upon the lips, comprises a
projecting mass, with more or less horny surface. In nearly all of
these, however, the characteristic cell nests with their onion-like
arrangements of cells will be found.
Epithelioma, especially when exposed to the air or to surface
irritation, quickly ulcerates and tends to involve all the surrounding
tissues, while occasionally the distinctive cells proliferate so rapidly
as to give the ulcer more or less of a bursal or a cauliflower-like
arrangement. From such a surface there is a constant discharge of
foul-smelling detritus or of sloughs. Even bone cannot resist its
progressive invasion and slowly disintegrates before the advancing
mass. Cartilage is resistant, and usually preserves its integrity. In
other words, the tendency of epithelioma is toward constant
encroachment and infiltration, and toward a fatal termination from
hemorrhage by ulceration, from septic infection, exhaustion, or other
accidents. The wart-like forms run the slowest course of all, but even
here the malignant tendency is most evident.
Lymph-node Infection.—A striking characteristic of epitheliomas is
the invasion of the adjoining lymph nodes, which attain a size
disproportionate and bearing no necessary relation to that of the
primary growth. This constitutes one of the most serious
complications of the condition. This lymphatic invasion partakes of
the malignant character of the disease, and from every focus of this
character infiltration and destruction proceed. Infected nodes also
show an early tendency to central degeneration and to spurious cyst
formation. When the overlying skin becomes involved we have
extensive sloughing and the conversion into large malignant ulcers.
Dissemination to a distance (i. e., metastasis) is rare in epithelioma
—much more so than in carcinoma. (See Plate XXV, Fig. 2.)
About the mouth epithelioma is not common before the thirty-fifth
year, though I have seen it on the lip of a twenty-year-old woman. It
is vastly more common in men than in women, and more frequent on
the lower than the upper lip. In the tongue it seldom occurs before
the fortieth year. It seems to be more common both on the lip and
tongue in men with bad teeth and in confirmed smokers, thus giving
rise to the view often held that it is purely a matter of irritation. It may,
however, be due to contact infection should it be regarded as of
parasitic origin. In one-fifth of the cases of epithelioma of the tongue
there are preceding lesions, usually described as leukoplakia or
ichthyosis of the tongue—conditions characterized by epithelial
reduplication and the formation of dense plaques or scales. These
lesions are usually regarded as precancerous conditions. (See Plate
XXVI.)
 PLATE XXIV
FIG. 1

Primary Papillary Adenocarcinoma of the Kidney.

(One-half original size.) (Gaylord.)
FIG. 2
Section of the Primary Growth. (Gaylord.)
 PLATE XXV
FIG. 1

Carcinoma developing in a Thrombus in the Portal

Vein. (Middle power.) (Gaylord.)
FIG. 2
Metastasis of Squamous Epithelioma in a Lymph
Node. Pearl Formation. (Middle Power.)
 PLATE XXVI
FIG. 1

Epithelioma of Tongue. Enlarged three diameters.

FIG. 2
 Paget’s Disease of the Nipple. Enlarged two
diameters.
Photographs from hardened unstained specimens.

The disease often starts near the stump of a carious tooth, in

which case infiltration and erosion begin promptly and progress
rapidly. Epithelioma of the tongue has been known to follow along
the obliterated track of the thyrolingual duct, and in this way to bring
about a perforating ulcer.
Epithelioma of the esophagus is a common cause of stricture of
this passage-way. It leads to ulceration, and usually to perforation
into the trachea or some other cavity or passage (i. e., a
bloodvessel). In the larynx the disease is well known, and gives rise
to intense and finally fatal symptoms, but has been dealt with
successfully by radical operations for extirpation of the entire organ.
(See Chapter XLI.)

Fig. 89 Fig. 90

Epithelioma of forehead and eyelid. Epithelioma of lip. (Neisser.)

(Neisser.)

Occurring upon the scrotum, epithelioma has been called

chimney-sweeper’s cancer, or soot-warts, and has been ascribed to
the irritation of foreign material. Ulceration and infection of the
inguinal nodes usually proceed rapidly and disastrously. It is believed
also that tar and paraffin may produce similar irritation, and paraffin
cancer has been described by various writers. It usually occurs upon
the scrotum.
The skin lesions which precede the formation of paraffin cancer
resemble those seen in chimney-sweeper’s cancer. The skin
becomes dry, thickened, parchment-like, while the openings of the
sebaceous glands become obstructed by the tar or other material,
producing acne-like lesions. Warty outgrowths then occur, and these
become the seat of malignant ulceration. In chimney-sweeper’s
cancer the scrotum is usually first affected in a chronic dermatitis, to
which warty outgrowths succeed, these enlarging and growing
downward as ulceration takes place.
About the external genitalia epithelioma is not uncommon,
particularly in and about the prepuce. Such a degree of phimosis as
leads to retention of smegma is certainly a predisposing cause, not
only in man but in the lower animals. Epithelioma of the vulva has
been described under the name esthiomène, and requires to be
recognized and dealt with promptly if the surgeon should attempt a
radical cure. In the vagina and about the cervix uteri it is common, a
large proportion of cases of cancer of the uterus being essentially
epitheliomas of the cervix.
In and about scars and upon granulating ulcers epithelioma is
quite common. One danger to which a chronic ulcer is always
exposed is that of epitheliomatous transformation. These growths
also attack lupus scars, or even any tissues actively involved in the
lupoid process. This is particularly true between the fortieth and
sixtieth years of life.
Among the viscera the gall-bladder is probably more often
involved in distinct epitheliomatous changes than any other. It
presents as a uniform thickening, and causes augmentation in size,
so that a distinct tumor projects from beneath the liver. In this
location dessemination is rare.
Epithelioma is to be regarded as having an essential malignant
tendency. Its treatment demands early removal of diseased parts
and complete extirpation of involved lymph nodes. It is only the small
and incipient growths which should be attacked by such destructive
agencies as cancer pastes or the electrolytic current.
Rodent Ulcers.
—Under the name of rodent ulcers, lupus exedens, noli-me-tangere,
etc., writers, mostly English, have described a variety of epithelioma,
met especially upon the face, to which a separate classification has
usually been assigned. Until recently it has been generally regarded
as a local ulceration, distinct from cancer. In some text-books it is
described as lupus exedens. It is preceded usually by a nodular
condition of the skin, vascular, breaking down into a regular
ulceration, but little elevated, the base of the ulcer deeply excavated,
with a striking disproportion between ulceration and new-growth. In
this particular variety infiltration seems to be continuously in advance
of the rodent process, the former being excessive, the latter but
slight. This variety of epithelioma rarely produces lymphatic
involvement; the discharge is slight, the pain complained of
inconsiderable. Occasionally it entirely alters its aspect, and may
present features of the conventional epitheliomatous type.

Fig. 91 Fig. 92

Rodent ulcer. (Original.)

 The development of cancer in lupus areas is now of sufficiently
frequent occurrence to demand attention. Whether the epithelium
which gives rise to it is to be accounted for by Cohnheim’s
hypothesis, as having been cut off in the course of healing and
become a cell rest to subsequently undergo malignant degeneration,
is not yet settled. It has been suggested that curettage might cause
fragments of epidermis to be loosened and then entangled in the
cicatrix, and thus be responsible for subsequent malignant changes.
When lupus thus degenerates it assumes usually the papillomatous
form, which rarely involves lymph nodes, while the change which
follows x-ray treatment often succeeds a hyperkeratosis and rapidly
involves gland structure.
Rodent ulcer allies itself with the type of tubular epithelioma
springing from the outer sheath of the hair follicle, sending out
cylindrical processes which freely blend with one another. It is to be
regarded as an equally malignant type of ulceration with other
cancerous ulcers, and demands the same thorough and radical
measures for its relief as do other forms of epithelioma. It is perhaps
the most favorable one with which to deal, because of the usual
freedom from involvement of deep lymphatics. No distinctive
measures are necessary for its relief—only those which are
thorough.
Carcinoma.—Carcinoma is a tumor springing from preëxisting
gland tissue, which it more or less closely resembles
in type, save that the structural similarity is incomplete, the epithelial
cells now collecting in irregular clusters, or filling the acini and
obstructing the ducts, or bursting beyond the basement membrane
and invading the surrounding tissues. They frequently so fill the
ducts as to appear in columnar arrangement when seen under the
microscope, and this has given rise to the use of a term so vague as
to have no place in pathology—i. e., cylindroma. Carcinomas may
arise from any of the secreting glands, but more commonly from
some than from others. They have no capsules. They infiltrate the
surrounding tissues, usually involve the lymphatics early, are liable
to spread to the superficial tissues and to ulcerate, and to undergo
various degenerative changes. Nearly all cancerous tumors abound
in lymphatics, which will explain the rapidity with which the lymph
nodes become infected, as well as the tendency to dissemination,
which is characteristic of these growths. Dissemination leads to so-
called secondary or metastatic growths, which may make their
appearance in any organ or tissue, even in the bones, where they
give rise to changes of texture that make spontaneous fracture easy.
It is characteristic of carcinoma that the metastatic tumors which it
may produce will reproduce almost perfectly the type of the primary
tumor whence the embolic fragments which have produced them
spring. The amount of dissemination varies exceedingly: it may even
become so marked and widespread as to produce a condition
analogous to that met with in miliary tuberculosis—miliary carcinosis.
A similar condition, much more rare, is seen in dissemination of
sarcoma, and is known as miliary sarcomatosis. A constantly
spreading cancerous infiltration of the superficial tissues, which is
noted most often after mammary cancer, is described under the form
of cancer en cuirasse, or jacket or corset cancer. Instances will be
seen in which this infiltration of the surrounding structures has
extended nearly or even completely around the thorax. It gives rise
to a brawny induration which is unyielding, and is studded here and
there by nodules that tend to ulcerate, to fungate, and to bleed
easily. It is perhaps the most hopeless form of cancerous disease.
The older writers have constituted two or three clinically distinct
forms of carcinoma, based mainly upon the relative hardness or
softness of the tumor and the invaded tissues. The term scirrhus is
thus applied to a tumor in which connective tissue preponderates
and epithelial cells are relatively deficient. On the other hand, the
term encephaloid has been applied to a tumor in which the
connective tissue seems barely sufficient to hold the mass together,
while the epithelial cells are in vast preponderance. These are all
tumors of the round epithelial-cell type, and these distinctions are of
clinical interest, yet have no great pathological import, save that in a
general way the greater the proportion of epithelial elements the
sooner will life be terminated by destructive processes. In other
words, the more the tumor may partake of the encephaloid type the
worse the prognosis or the shorter the probable duration of life.
Again, these tumors pursue a varying clinical course. In those
tumors, particularly of the scirrhus type, where the connective tissue
largely preponderates, there is often an eventual reduction in the
size of the part involved, and such reduction of vascularity and of
nutritive activity that the rate of growth is thereby perceptibly
checked. The so-called atrophying cancers of the breast are the best
examples of this type of cancerous disease. Here the volume of the
gland is diminished rather than augmented, and the disease may last
for a number of years. It is questionable whether it is well to operate.
The so-called colloid forms of cancer are simply the expression of
pathological changes occurring in growths of more distinct type.
Thus colloid softening may occur in any tumor in which cancer cells
predominate, and the so-called colloid cancers of the peritoneum,
the ovary, etc., are either examples of such alterations or are
possibly endotheliomas arising in these locations. The term villous
cancer, with other terms like it, should be expunged from all scientific
literature, unless these terms are used in purely adjective and clinical
sense, for they imply nothing accurate as to histological structure,
and are often misleading and inaccurate.
Carcinoma is most common in the following regions:
In the breast it appears particularly in two forms:
1. Acinous Cancer; and
2. Duct Cancer.
1. Acinous Carcinoma.—Acinous carcinoma is usually of the scirrhus
type. It may arise at any portion of the breast, and if anywhere near
the nipple it will cause retraction of that prominence, which is always
pathognomonic; elsewhere it leads to puckering and adhesion of the
overlying skin. These tumors infiltrate widely, especially along the
connective-tissue stroma and the fibrous tissue which intersperses
the fat of the breast. They are usually firm and sometimes
exceedingly dense. A form of scirrhus known as atrophying scirrhus
consists largely of strands of fibrous tissue, injected here and there
with epithelial cells. It is the slowest in growing of all the forms of
cancer, and by its contraction tends to reduce rather than augment
the size of the mamma.
Acinous cancer is rare before the age of thirty, most common
between forty and fifty. It occurs in women in all conditions of life,
married and single, but is rarely noted in the male breast. The most
dangerous form is that which appears during lactation. Ordinarily its
progress is slow. As it augments in volume it infiltrates the
surrounding tissues, becomes adherent to the pectoral fascia,
infiltrates the muscle fibers, and finally attaches itself to the
periosteum of the ribs. The infiltrated tissues tend to shrink rather
than to increase in volume. Lymphatic injection occurs early in this
form, and is a pathognomonic sign. It occurs mostly in the axillary
lymphatic nodes, but may often be detected in the neck above the
clavicle. When the skin is involved there is a tendency toward
ulceration and fungoid condition. This is preceded by the purplish
appearance of the tense skin. (See Plate XXVII.)
 Fig. 93

“Pig-skin” appearance of cancerous breast.

Pain is an uncertain and variable feature. It is important to

emphasize this fact, as many of these conditions have been lightly
regarded because of freedom from pain. Pain is not a constant
phenomenon in cancer. On the other hand, it is sometimes intense,
either localized or radiating and referred to distant points. Pain is
particularly noticed in cases which assume the form of cancer en
cuirasse. Secondary deposits in viscera frequently occur, particularly
in the abdominal organs and the lungs; but any organ may be the
seat of secondary infection, and this is found occasionally in the
bone-marrow, not alone of the sternum or ribs, but of distant bones,
and is called marrow injection. As the result of cancerous affection of
serous membranes effusions of fluid frequently take place, as in the
pleura, peritoneum, and pericardium, and this fluid is often blood-
stained.
In consequence of pressure upon the venous trunks in the axilla
there is often a swelling of the arm upon the affected side, dropsical
in character, known as lymphatic edema. The arm grows heavy, the
patient loses control of it, and the skin may become so distended by
effusion as to cause the limb to resemble a cast. This is due not
alone to pressure upon the veins but to involvement of the
lymphatics, and upon careful examination positive dilatation of the
lymphatic vessels may be noted. Pain is a usual accompaniment of
this form of edema.
2. Duct Carcinoma.—This appears especially about the time of the
menopause, when glandular structure has disappeared and only
ducts remain. It is common, without reference to cancer in these
instances, to find cystic dilatation of numerous ducts, which vary in
size from a mustard seed to that of a cherry. These are referred to by
Sutton and others as involution cysts. They are filled with mucoid
material and have a bluish tint. They occur usually upon the under
surface of the gland. Such cystic breasts are common, and when
appearing in diffused form may be easily mistaken for cancer. Pain is
not frequent. This condition is certainly a precancerous stage, since
the dilated ducts are often the starting points of cancer, and
occasionally of papillomatous or villous outgrowths from their walls.
Duct cancer implies the form which arises in these dilated ducts,
most commonly in the terminal branches, appearing ordinarily as a
single tumor, but sometimes as a mass of separate nodules.
Intracystic and intracanalicular growths of this character are often
found. When assuming the truly cancerous phases they may be
spoken of as duct cancers, otherwise as duct papillomas. They have
generally been referred to as intracanalicular fibromas. Duct cancers
are less tense than the preceding variety, and when situated near
the surface often discolor the skin. It is from these cases that there is
seen a more or less abundant discharge of fluid resembling bloody
milk. These tumors grow slowly, lymphatic involvement is late, and in
general they present the least malignant forms of breast cancer.
 PLATE XXVII
FIG. 1

Scirrhus Carcinoma of Breast. (Middle power.)

FIG. 2