In very slight cases of erectile tumour, or in nævus threatening to assume an aneurismal action, cold and pressure are sometimes, though very rarely indeed, sufficient for the prevention or removal of the disease. The most effectual remedy is excision, though this can very rarely indeed be had recourse to with safety; for when the disease is extensive, the vessels in its neighbourhood are much enlarged, and their action increased; so that any attempt to remove the tumour by the knife is followed by profuse, and often an uncontrollable, flow of blood. When excision is practicable, it ought to be accomplished by cutting very clear of the disease; the tumour, like every other, must be cut out, not cut into. If the incisions encroach on the substance of the tumour, or are made in the immediate neighbourhood of the diseased part, the tremendous bleeding which invariably ensues will convince the practitioner of the impropriety of his conduct, and rashness of the proceeding. Attempts have been made to arrest the progress of the diseased action, by tying the principal arterial trunks entering the tumour; but these have proved ineffectual, as might be expected, considering the unusually free and numerous inosculations which then exist. In a few instances, ligature of the carotid artery, on the same side with a tumour on the face or head, has put a stop to the disease; in the others, it has been unavailing.
When the tumour is so situated, or of such a size, as to render the expediency of excision doubtful, it may often be safely and expeditiously removed by ligature. In some cases the tumour is prominent, so that it readily allows of the application of a ligature around its base; in others, it is flat and broad; in which case, a long needle, or needles, armed with a double ligature, can be passed beneath it, and the ligatures can then be separated, and so disposed as to cause sufficient constriction of the entire mass.—Vide Practical Surgery, p. 331, 336. In many cases, incisions may be made with great advantage, either before or after introducing the ligatures; the diseased mass is thus more effectually included and strangled, and much pain and deformity are avoided. The disease, however, occasionally occupies such situations as are totally beyond reach. The application of potass has been recommended; and this caustic is certainly sufficiently powerful to destroy the diseased parts; but its use is attended with danger from profuse hemorrhage. Superficial nævi may occasionally be got rid of by the application of nitric acid, but it requires to be applied over and over again; and, after all, some more effectual means must probably be resorted to. Stimulating injections into the substance of the growth have been sometimes employed. Cures, it is said, have followed the use of setons, or the repeated puncturing and breaking up of the tissue with a needle. None of these means are to be depended upon. The cases are innumerable in which I have been obliged to employ the ligature in an effectual manner, combined or not with incision, where caustics, injections, puncturings, setons, and even imperfectly applied ligatures, had been previously resorted to in vain. Besides, in children there is as much resistance and crying, and as much anxiety in parents, produced by a slight operation, as by a more effectual one.20
OF INFLAMMATION OF VEINS.
Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly; in some cases it reaches the right side of the heart, producing most violent symptoms, and speedy dissolution.
Inflammation in the venous, as in the other tissues, may terminate in resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface agglutinated, causing obliteration of the canal to a greater or less extent. Suppuration also occurs, and the pus may be deposited in a cyst formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation.
The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable œdematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, causing sloughing of that tissue, or of the soft parts more deeply seated.
This disease generally follows an accidental wound or operation, as venesection or amputation; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many patients have died of this disease, induced by the application of a ligature to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints.
Inflammation of veins is a very unmanageable disease; the exhibition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation; the pain will also be much relieved by the application of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been employed, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its contents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious.
Inflammation of a vein is also occasionally followed by the sudden appearance of a purulent depôt in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the forearm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and, on examination, abscesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory explanation of these phenomena cannot readily be given.
It has already been noticed, that the softening of coagulated fibrin must not be confounded with suppuration. The fibrinous pulp has commonly been called pus, though erroneously; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is important; first, because many of the so-called cases of phlebitis are shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard.
There exists without doubt a capillary phlebitis, and the vast importance of inflammation, and its consequence in these vessels, will be estimated when their great extent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus.
Veins frequently become dilated or varicose; they assume a tortuous course, appear much enlarged, and present an elastic, soft feel, except in the situation of the valves, where they are more hard and incompressible: occasionally the tortuous windings form a bluish tumour of considerable size. The dilatation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less support. The limb is swollen and œdematous. The dilatation is generally supposed to be confined to the vessels near the surface, but it appears that the deep-seated ramifications are not exempt from the affection. When a dilated vein becomes inflamed, great pain is felt in the part; the vessel feels like a firm chord, its coats are much thickened, and its cavity proportionally contracted; lymph is effused, and by it the canal may be obliterated to a greater or less extent; a spontaneous cure is thus accomplished. In the lower limbs, the disease is often complicated with ulcers; and as long as the veins remain varicose, the ulcers are almost incurable, or if they are brought to cicatrise, the skin soon ulcerates again, and the disease is reëstablished. The coats of the vessel not unfrequently ulcerate, and blood is discharged in appalling profusion: such an occurrence may even prove rapidly fatal. Sometimes, though rarely, skin thinned by pressure from within gives way without previous ulceration, and profuse bleeding ensues.
The cause of this affection is obstruction to a free return of the blood; as by tumours, either natural or adventitious, from pregnancy, constipation, &c.; or by the tight application of a ligature round the limb, as of a garter. It often occurs in those who have been in the habit of great muscular exertion, the blood being thereby forced from the deep-seated veins into the superficial. This even occurs, though very rarely, in the upper extremity, and I have witnessed more than one instance of it. Here it is more readily got rid of. Dilatation of venous branches is met with in the scrotum, labium pudendi, lower part of the abdomen, in the neighbourhood of the anus, and at the lower part of the neck. The lower limb is, however, the most common seat of the disease: when the veins in this situation are dilated, the valves are insufficient to obstruct the calibre of the vessels, and consequently the lower and smaller ramifications have to sustain the column of blood in the superficial veins of the whole limb, its weight not being diminished by the support which, in the natural state of parts, is afforded by the valves; the disease is thus more and more aggravated. The left limb is generally the one affected; and this circumstance may probably be explained by the pressure of the sigmoid flexure of the colon on the left iliac vein.
In the majority of cases, the palliative treatment can only be adopted. The limb must be used as little as possible, and, if practicable, be kept in a state of complete rest; the veins must also be supported by the application of a bandage, or the wearing of a laced stocking. The Indian rubber bandage worn over the stocking or drawers answers fully as well as any other method. In some instances, the application of cold has been of advantage, by promoting the contraction of the dilated vessels. When pregnancy is the cause, it is needless to commence any method of cure, until the cause be removed; and the same remark is applicable when the affection arises from habitual constipation. The varices occasionally become inflamed, painful, and much swollen, with considerable œdema of the whole limb. Their contents become coagulated, and their coats thickened; in the end, the swelling abates and the vessels are closed. In certain cases, this spontaneous cure, a radical one, may be imitated by the surgeon; an escharotic being applied over the trunk of the vein at a healthy point, whereby inflammation is produced in the coats of the vessel, and obliteration of its cavity accomplished: the caustic which will be found most convenient and effectual, is the potassa fusa. The caustic may be made into a paste with soap; or a solid piece, of the size of a split pea, is placed over the vein, and there retained for a few hours by plaster or bandage. The vessel being obliterated, the lower venous branches necessarily pour their contents into those deeply seated; as they freely communicate with these, they readily empty themselves of their accumulated contents, and soon regain their calibre under the employment of bandaging. When the varicose veins are numerous, as is generally the case, the potass is to be applied to the healthy point of the larger trunk in which they terminate. But the practice is not unattended with danger, for the coats of the vessel may ulcerate in consequence of the application, and violent hemorrhage ensue; the degree of inflammation excited may be greater than that intended, and extend so as to give rise to suppuration in the vessel and the most alarming constitutional disturbance. These unfavourable results, however, must be of rare occurrence. Success has, however, followed the practice in innumerable instances.
A much preferable method, as being less painful and unattended with risk, is that of passing needles under the vessel, and twisting a piece of thick and strong silk round them. Two needles should be applied together, at an interval of about half an inch, at whatever points it is thought right to close the vein. Coagulation takes place in the included part, and also frequently for some distance below it; the coats of the vessel are thickened, and its canal closed. The needles are withdrawn before they begin to cut their way out by ulceration,—say at the end of from three to five days,—according as the parts become condensed. The needles suited to the purpose are soft, but tempered at the point, which is spear-shaped; the ends are cut off with pliers after the thread is fixed. Other operations have been performed on the veins, to procure a radical cure of varix; one or more ligatures have been passed round the vessel, as in the operation for aneurism; and the vessel has been divided, or a portion of it dissected out, and its cut extremities afterwards either compressed or secured. Such proceedings are now almost entirely abandoned.
OF TUMOURS.
A tumour is a swelling or new production, and not a part of the original composition of the body. Blood may have been effused, and the coagulated part, becoming organised, is increased in size by deposits from the vessels which enter it; or perhaps the blood, the coloured part of it at all events, is taken up and lymph is deposited, which, if not also removed, “undergoes further changes of a secondary nature, and remains a parasite or new structure.” Its structure and growth are modified according to the action which its own vessels assume, independently of the surrounding vascular system. The bloodvessels may enter this new growth by a narrow pedicle; or it may be of such a form as to present an extensive surface, by which it communicates with the surrounding parts, receiving vascular ramifications from them. As the growth of the tumour proceeds, the surrounding parts yield, are condensed, and form an envelope for the new formation; the neighbouring bloodvessels are excited to a greater degree of action, and more blood is poured into the vessels of the tumour; the action of these in turn is very vigorous, and the increase of the new growth is more and more rapid. They become, it would appear, dilated and tortuous. Morbid enlargement, or rather new productions, often attain an enormous size; some have weighed, when recent, upwards of 60 or 70 lbs. Tumours differ much in structure; and though their general appearance may not be dissimilar, one will scarcely be found exactly resembling another. In many cases, the external appearance proves no certain index of the nature of the tumour; sometimes, however, its feel and general external character lead the experienced surgeon to form a correct estimate of its internal structure. It is impossible, by any process of reasoning, to account for the different actions which these growths possess; and even minute anatomical investigation, either of healthy or morbid structures, has not as yet thrown much light upon the subject.
Tumours are divided into Solid and Encysted. The solid are generally enveloped by a dense cellular sheath of the surrounding cellular substance, yielding and becoming condensed in proportion as the tumour increases in size; this covering appears as a barrier between the healthy and diseased parts, shutting out the latter, as much as possible, from connection with the rest of the body, and preventing the former from participating in the injurious tendencies of the latter. Some tumours have no such limit, but extend in the direction where there is the least resistance, hold a free intercourse with the surrounding parts, and impart to them their morbid disposition and action; others are limited in their situation and communications, but prove dangerous or annoying from their bulk. Some grow rapidly, and prove troublesome in a few weeks or months; others remain without much increase for years, and produce little or no inconvenience. Occasionally tumours partly resemble the texture in which they grow; those of a fatty nature are frequently found to have their nidus in the adipose tissue; cartilaginous tumours project from the surfaces of bones or of a joint, are subsequently detached, and lie loose in its cavity; growths of a cellular structure internally, and invested by an apparently mucous lining, protrude from the surface of mucous membranes. Others differ, not only from the texture in which they are situated, and from which they derive their nutritive vessels, but also from every other part of the healthy structure. In one instance, a congenital tumour was found to be composed of an aggregation of numerous materials, many of them resembling the healthy textures of the body. But again, tumours are constantly met with, composed of matter which in no respect resembles any of the natural tissues of the body: those are what have been called heterologous formations.
The simple tumour is mere enlargement of a part, from the infiltration of solid matter deposited by its bloodvessels. There can be little doubt that the action which lays the foundation of such enlargement is inflammatory: in consequence of inflammation of the tissue, lymph is effused into the cellular substance during the progress of the incited action; and after it has subsided, the dilated and debilitated vessels probably do not regain their condition, as to size and vigour, but remain somewhat dilated, and continue to free themselves from portions of their contents; thus the cellular tissue is opened out in proportion as the infiltration advances, and the process may be occasionally accelerated by fresh attacks of subacute inflammatory action. The patient at first feels pain, heat, &c., as in an inflammatory tumour; these afterwards abate, and ultimately go off entirely; and during the increase of the swelling, little or no pain is experienced, unless when these subacute inflammatory attacks supervene, and then it is but slight; or unless the enlargement be resisted by an unyielding structure, and then it is acute and troublesome. The size and rapidity of increase in such tumours will vary according to circumstances; the vessels of the part soon regain their size and action, either by the efforts of nature or of art, so that the tumour will have attained no great size, and be stationary in its progress, being denied the materials necessary for its increase. If the morbid action be thus stopped, the absorbents will remove the newly-formed matter, and restore the parts to their healthy condition. But when the deposition proceeds in a superior ratio to absorption, the new matter becomes organised, and by means of its own vessels, secretes a substance similar to itself, whereby the increase of the tumour becomes more rapid, and the new structure may attain an enormous bulk. Thus the tumour is formed, not merely by dilatation of capillary vessels, and extension of its original tissue, but by the formation of new matter, which, becoming organised, assumes a secreting power. At first the former circumstance is the chief cause of the enlargement; but after the latter process has existed for some time, the tumour loses much of its resemblance to the primary tissue, assumes a more dense structure and a different action, and therefore cannot be designated a simple enlargement.
This species of tumour, or rather this enlargement which precedes the formation of a tumour, is chiefly met with in the cellular and glandular structures. Sometimes it is described under the term of œdema solidum. In the scrotum, where the cellular tissue is remarkably loose and extensile, such tumours attain a very large size. They are found in this country, though more frequently in warm climates. I removed one from this situation successfully, which weighed upwards of 44-1/2 lbs.; it had been of twelve years’ duration, and caused much inconvenience to the patient. It is sketched in the Practical Surgery, p. 341. It occurs in the mamma, apparently in consequence of suppression of the menstrual discharge; the gland becomes enlarged, there is no pain in the tumour, and it feels soft and doughy. When the subcutaneous cellular tissue is the seat of the disease, the tumour is often of considerable extent, but rarely forms a great protuberance. It sometimes is situated in the coverings of the nose, which, as they become enlarged, lose their natural colour, and assume a purple hue; the mucous follicles also are often much enlarged, and occasionally emit a profuse discharge of their secretions. It can be readily understood that in this situation the tumour is a source of much annoyance, from its partially obstructing respiration, and even vision, interfering with the functions of the parts and the comfort of the patient.
It has been already observed, that when simple enlargement exists for some time the structure changes. It becomes more dense, and assumes a peculiar action, independent of that of the surrounding parts. It has a harder and more firm feel, and all traces of the texture in which it was formed are destroyed. It may be considered as the next in order to the one already mentioned, both as to the simplicity of its structure and action; but in consequence of its action being independent of those of the neighbouring parts, and liable to change from even slight causes, it is very apt to degenerate into those tumours which are more complex and injurious.
ADIPOSE TUMOURS.
Another species of tumour seems to be composed almost entirely of fatty matter insinuated amongst extended and delicate cellular substance, and has been therefore termed adipose. It is surrounded by a cyst of dense cellular tissue, and to this it loosely adheres; its bloodvessels are few, and it is of an inactive and innocuous character. It is generally lobulated, and often attains a large size. It is not only irregularly prominent on its outer surface, but in its whole circumference, and its lobuli often insinuate themselves to a great depth amongst nerves, bloodvessels, and other important parts; owing to this circumstance they frequently prove a source of the greatest inconvenience from their bulk, for of themselves they are neither hurtful, nor possess any disposition to involve those parts with which they are in contact. This tumour is found only in the cellular and adipose tissues. From its loose connection with its envelope, it admits of ready removal by operation. A tumour of this kind is here represented, which, but for this circumstance, owing to its awkward situation under the tongue, could not by any possibility have been extirpated. It is fully larger than an orange, and had caused very great suffering. It is not so much lobulated as fatty tumours generally are. The adhesions of adipose tumours are, however, rendered firm and more numerous by pressure or external stimulants—in fact, by whatever induces inflammatory action in its substance or in its surrounding connections; and from this cause the extraction is often rendered exceedingly difficult. The skin becomes thickened and of a red hue, and the tumour itself is much more vascular. From this cause it is apt to assume a new mode of action, and to change in structure and in character, invariably for the worse. I have removed a few tumours, originally of this benign species, but which had apparently degenerated and assumed a malignant action. In one, distinct indurated bands radiating from a central mass of the same kind, are discernible. In two others, as a consequence of pressure, condensation and ultimate softening had occurred. The largest alluded to was removed from betwixt the shoulders of a soldier, and had borne the pressure of his knapsack for eight or ten years. It was attached by a thickish neck, presented the common lobulated appearance of adipose sarcoma; but its external surface, its feel, and section, were very different.
The patient does not complain of any pain or uneasiness in the tumour, unless inflammation be excited in it; then the pain and other symptoms are such as attend incited action, and the sensations which are afterwards experienced vary according to the character which the tumour assumes. Certain changes may occur in its texture, though not in its general character or disposition; thus osseous or earthy matter is occasionally deposited in some part of the tumour, while the surrounding adipose substance retains its appearance and density. Suppuration, it is said, has followed inflammatory action, excited in an adipose sarcoma.
OF FIBROUS TUMOURS.
Fibrous tumours are not uncommon, and are formed in various textures. In general they are composed of a substance of a dirty grey colour and considerable density, through which minute, firm, ligamentous fibres ramify; in some cases irregularly, in others radiating from the centre of the tumour. The new formation is surrounded by condensed cellular tissue, to which it intimately adheres, and does not mingle irregularly with the surrounding parts; in this respect differing from malignant tumours, which occasionally contain fibrous matter. It cannot be considered of an equally innocuous nature with those already described, but is still, in its original state, not of a malignant disposition. After some time, the consistence and structure of such tumours vary: some are of a loose texture, and contain cells; others are hard, and intermixed with cartilaginous matter, or even with bone. In general, the tumour is slow in its progress, though it may attain a very large size, as seen in the cut on the preceding page, if allowed to remain; occasionally its growth is rapid.
Besides those tumours which have been described, there is a number of others not of a malignant disposition, which are so various in their structure as to baffle all attempts to reduce them to a scientific classification. Some are composed of a homogeneous substance of almost cartilaginous consistence and a whitish colour; some consist of cartilaginous matter, mixed with substance of less density and of a different appearance; in some, fibrous matter is mixed with a homogeneous glandular-looking substance, partially softened. Some are almost entirely composed of osseous matter; others contain it in small proportion. It would be endless to enter into a minute detail of the structure of such tumours, for it may be said that their appearances vary with their number. In almost all tumours cysts are found, and the internal structure of some tumours consists almost entirely of cysts, or hydatids, as they have been called; in others, these only occupy certain parts, and compose but a minor feature in the structure. The sacs are generally lined with a delicate and smooth membrane, which is often vascular at various points; some contain a transparent and glairy fluid, albuminous or gelatinous; some bloody serum; some purulent, some curdy matter, or this mixed with a serous or purulent fluid; some pure blood; some a fluid like printer’s ink; and not a few are occupied by a dense elastic substance, which, on a section being made of the tumour, rises irregular and ragged above the cut surface. Some tumours are smooth; others lobulated or tuberculated.
OF ENCEPHALOID TUMOURS.
The tumour which comes next to be described is decidedly malignant. It is the Encephaloid, or Medullary Sarcoma. Although these tumours have been called encephaloid and medullary, it must not be understood that their intimate structure has any relation to that of the brain or marrow; for this reason the old term fungoid is perhaps a preferable one, since it leads to no false notion as to their nature, while it expresses a condition which at one time or other is remarkably characteristic of them. This tumour consists of a homogeneous matter, resembling the substance of the brain in colour and consistence It rarely has a distinct cyst; occasionally it is subdivided by membranous bands. It is always soft, though often more so in some parts than in others; portions of it being frequently so much softened and broken down as to resemble thick cream in consistence, and these are generally of a darker colour, from being mixed with a greater or less quantity of effused blood. Partial or universal softening only occurs after the tumour has existed for some time, for in its original state its structure and density are uniform throughout; and, on making a section of it, some few drops of blood may escape from vessels, the coats of which are of a very delicate nature. Some of these vessels seem to give way, in consequence of the process of softening, for we frequently meet with fluid blood, or masses of fibrin, in the midst of the pulpy matter; and, when the softening has been extensive, the blood is diffused throughout the whole substance of the tumour, so that it will appear to be chiefly, or entirely, composed of effused and degenerated blood, as here represented.
The mamma and testicle, and the contents of the orbit in children, are the most frequent seats of this disease; it not unfrequently occurs in the lymphatic glands, and few textures can be considered as exempt from it. The part at first enlarges slowly: but afterwards the disease advances with great rapidity, involving the adjacent parts. In general, the affection is not attended with much pain; the part has a spongy and elastic feel, and frequently presents an obscure sense of fluctuation, indicating that softening is more or less begun. The skin is tense, generally brownish, and is pervaded by large venous branches. This venous enlargement is always observable in the advanced stage of the disease, before or after ulceration has taken place; it is peculiarly evident in the eyelids, when the contents of the orbit are involved, and is to be attributed to obstruction of the circulation in the deeper vessels. The tumour is increased by the surrounding parts assuming a similar action, and being converted into a similar mass; and the disease also seems to be propagated by means of the absorbent system, and by the irritation conveyed along the vessels which emanate from the tumour, or from its immediate vicinity. Thus, when the testicle or mamma is affected, the lymphatic glands, both above and below the tumour, and the course of the absorbent vessels, are converted into an encephaloid mass, all traces of their glandular structure being completely destroyed. The same brain-like or cancerous matter is also found in the bloodvessels, large and small. When the disease has been of long duration, the superincumbent integuments appear tense, assume a purple colour, and ultimately ulcerate; a portion of the pulpy mass then protrudes, of a fungous appearance, the resistance being at that point removed, and the compressed matter relieving itself by the extension of a portion of its substance; the protruded portion afterwards becomes discoloured, and sloughs, to be speedily reproduced either by further dilatation, or by actual increase of the tumour; unhealthy pus is discharged, often mixed with blood, and occasionally slight hemorrhage occurs; the integuments become further ulcerated, assume a dull brown colour widely around, and are undermined, presenting a boggy feel.
Along with these local symptoms, there is a complete subversion of the system,—there being at first symptoms of constitutional irritation, afterwards those of hectic and extreme exhaustion. When the lympathic glands are diseased, the limb beneath is much swollen from œdematous effusion, the return of the blood and lymph being prevented; violent and excruciating pains are experienced in the course of the nerves of a limb; it also frequently loses its sensation, from those organs being either involved in the disease, or pressed on by the tumour. The vessels in the neighbourhood of the affected parts are materially altered, though they are seldom converted into encephaloid matter; the arteries are often completely obstructed by coagulating lymph for a considerable extent, and the coagulum not only occupies the principal trunk, but extends into the minute ramifications; and this explains why hemorrhage seldom occurs, even after ulceration of the tumour is far advanced; the veins also are frequently obstructed in a similar way; but in many cases they contain a soft and pulpy matter, exactly resembling the substance of the tumour. The fungus which protrudes after ulceration of the integuments sometimes bleeds, when it would appear that the hemorrhage proceeds from those bloody collections in the substance of the tumour already mentioned. According to my experience, when bloody points, or cysts containing bloody fluid, exist in a medullary or other tumour which has been removed, and if the diseased matter be reproduced, a bleeding fungus will almost certainly follow. This species of tumour occurs in all ages and in all situations, and during its progress evinces strong proofs of inveterate malignancy: if removed early, the disease may be arrested; but if the operation be long delayed, a tumour of a similar nature, and more extensive, will almost invariably be produced. In several instances I have removed encephaloid tumours, from the situation both of the mamma and testicle, and the disease did not return; but in the other cases the result has been as above stated. Encephaloid disease of the internal organs frequently supervenes on that of the external parts, and accelerates the patient’s dissolution; when in such situations they are beyond the reach of surgical art, and their existence is only, if at all, ascertained, in order to enhance the unfavourable nature of the surgeon’s prognosis.
OF MELANOID TUMORS.
The Melanoid tumour is rather of rare occurrence in the human subject; it originates in the cellular tissue, and most frequently attacks the internal viscera; sometimes it occurs in the eyeball, where it has been seen with the encephaloid disease, and occasionally melanotic matter is diffused amongst the cellular tissue throughout the whole body, even in that of the bones. The external surface of the tumour is generally of a shining and mottled appearance; internally it consists of a homogeneous black matter infiltrated into the cellular tissue, which is condensed, and in some cases distinctly increased in vascularity. The tumour, seldom of a large size, extends chiefly in a lateral direction. Occasionally it is pretty firm; in other instances it is soft, broken down, and semifluid. The melanotic matter is not always so deposited as to form a distinct tumour, but frequently seems to be sparsely infiltrated into the cellular tissue; and occasionally it is diffused in so minute a quantity as merely to tinge the part, or form dark streaks. Sometimes it is infiltrated in the substance of an organ, and sometimes it is effused on its surface; occasionally it is surrounded by a distinct delicate sheath; usually it is confined by no envelope, excepting the partial condensation of surrounding parts. In the skin it sometimes presents in a tubercular form. The tumour is said to be chiefly composed of albumen, mixed with a peculiar colouring matter. The disease mostly occurs in the trunk, seldom in the extremities; it is not uncommon in the orbit, and in the internal organs the melanotic deposits are generally both numerous and extensive. There is seldom pain, and the patient seems to suffer chiefly from lassitude and extreme debility, which gradually increase; anasarca frequently supervenes; the functions of the organs affected are much impeded, or even altogether destroyed, and thereby the sinking of the powers of life is accelerated according to the viscera affected and the extent of the disease. Melanosis occurs most frequently in advanced life, though it is not confined to it; whereas encephaloid attacks indiscriminately all ages.
OF CARCINOMATOUS TUMOURS.
The most malignant and intractable of tumours is the Carcinomatous. This term is applied to the disease in its occult state, whilst Cancer, a term pretty indiscriminately employed, may denote its condition after ulceration. The word scirrhus is often used synonymously with carcinoma; but the former has been, and still is, improperly employed to denote indurations and enlargements of structures in all situations, and has been altogether so much abused as to warrant its being erased from the nomenclature of diseases. Carcinoma seldom occurs before the age of thirty, and generally not till a later period of life; there are instances, however, of its appearance at a much earlier period. Very frequently it is not primary, but supervenes on adventitious formations originally of an innocuous character, and which might have long remained so. All tumours, though at first not of a hurtful tendency, are liable to assume malignant action, either from a constitutional cause, from external injury, or from latent disposition. When it occurs in newly-formed parts, the surrounding cellular substance is frequently condensed and thickened, so as to form a cyst round the tumour; and when it supervenes on chronic tumours, the cysts which enveloped these remain, for some time, as entire and distinct as formerly, though the character of their contents is remarkably changed. Afterwards the cyst may be contaminated with the same disposition as its contents, assume the same action, and be converted into a similar substance. When the disease is seated in the lymphatic glands, the cyst is at first distinct, and gradually disappears; whilst in this affection of the conglomerate glands a cyst is at no time perceptible, and the cancerous matter insinuates itself, and is lost, in the surrounding substance. The carcinomatous tumour is of great density, and communicates a peculiarly grating sensation and noise when cut. In its section there appears a central point, or nucleus, from which dense ligamentous bands of a white colour proceed towards the circumference, diverging in regular succession, as rays of light from a luminous body; or the larger bands subdivide into smaller ones, which follow a similar course with their parent trunk, or ramify regularly; or, from the first, follow an irregular and intricate course, uniting with and crossing one another, so as to present a retiform appearance. In general, the interposed substance is of a greyish colour, extremely dense, and generally homogeneous, though sometimes granular. Often the ligamentous bands are so numerous, and so intimately interwoven, as to leave little or no room for any intervening substance. Sometimes, and most frequently in the advanced state of the tumour, the greyish matter appears to have been broken down and removed, its situation being occupied by a glairy or turbid fluid, by a soft pulpy substance, or by blood; the parietes of such cysts are formed by the whitish bands, which sometimes appear to be much thickened, and coated with a membranous lining. The term gelatiniform cancer has been applied to that kind in which the reticulated texture is filled with glairy-looking fluid. Frequently, as has been already observed, the external cyst or covering becomes assimilated to the substance of the tumour, and the ligamentous bands then shoot forward into the surrounding tissues, more especially the cellular and adipose, establish a new footing for the disease, and thereby gradually enlarge the boundaries of the original tumour. All parts in its immediate neighbourhood become affected, and none withstand its morbid and destructive influence; bone, muscle, ligament, skin, and membrane, are successively or simultaneously involved; and even the bloodvessels and nerves. From what has been already said, it is almost superfluous to add that the tumour is most malignant, incessantly encroaching on the neighbouring parts, and imparting to them its own disposition; and this too frequently continues to exist after the removal of the primary source of the evil. The disease, in its commencement, occupies a minute and limited space, composed, it has been said, of enlarged and varicose capillaries, interspersed with the peculiar matter of cancer. It would even seem that these dilated aneurismal or varicose vessels, in morbid growths, are from the first gorged with what has been called heterologous matter. Judging from the imperfect account which has yet been given of them, it would appear, from the observations of Mr. Kiernan, that cancerous growths are entirely vascular in their early stages,—composed, in fact, of capillaries filled with cancerous matter, which shoot from the free surfaces of membranes in a flocculent or villous form, having no albuminous matrix, as has been commonly imagined in regard to adventitious growths generally; the progress of the cancerous tumour appearing to depend on the multiplication of the capillaries, their becoming remarkably varicose, tortuous, and dilated, the dilatation being accompanied by thinning, by more or less absorption of their coats, so as to allow of the escape partially of the accumulated matter from their cavities. Thus may be formed a tumour of unlimited extent. As the secerning vessels are excited to undue action in all cases where they have to form and supply preternatural growths, it is to be expected that they will in such cases become enlarged. Accordingly, the enlargement both of the smaller arteries and veins in tumours, generally, is a fact with which surgeons who have been in the habit of operating on such parts must be familiar. Farther, the enlargement of the capillaries in inflammation has been shown by the experiments of Hastings, and Thompson; and Mr. Gulliver, who informs me that he has seen pus in the capillaries of a suppurating surface, remarks, in regard to the observation of Professor Müller, as to the capillaries having only the diameter of a blood corpuscle, that these vessels become during suppuration sufficiently dilated to admit of rows of pus globules. Thus, during the formation of an ordinary product of inflammation, the capillary vessels are enlarged; and if excited to still further activity, and for a more protracted period, in the nutrition and formation of tumours, the minute vessels will become still more dilated, and filled with other materials than purulent matter. In a melanotic eye, which I lately examined with Mr. Dalrymple, there was a part in which the black matter seemed to be contained within the capillary vessels.
The cancerous tumour afterwards presents a stony hardness, is generally of a globular form, and irregular and unequal in its surface. At a still later period it gradually enlarges, in the way already mentioned, remains moveable for some time, but ultimately becomes fixed by the increased extent of its connections. By these circumstances it may, in general, be distinguished from the tumours which, from the first, occupy a wide space, and are firmly fixed by intimate connections with the surrounding parts. When the tumour has once been developed, its progress is slow and steady, being arrested, or made to recede, neither by the efforts of nature nor by the interference of art. Pain is generally complained of in the region of the tumour, and is of a lancinating kind, compared by the patient to the passing of sharp instruments through the part; occasionally, however, there is no pain in the new formation, and little inconvenience is caused by it. When the disease is left to itself ulceration occurs, frequently at an early period; but sometimes only after the tumour has been of long duration. The superimposed integuments appear stretched, change their natural colour, assume a dusky or livid hue, become attenuated, and ultimately give way; the breach of surface not being caused by tension and pressure, but by the parts having assumed an action similar to that of the tumour. The ulcerated point slowly enlarges, a thin ichorous fluid is discharged, the surrounding integuments are of a dusky red, and the margins of the ulcer are thickened, callous, everted. Whilst the destructive action proceeds in a lateral direction, it at the same time advances towards the more deeply-seated parts, the cavity becomes excavated, irregular, and ragged; and the parts seem to be destroyed partly by ulceration and partly by sloughing. The exposed surface seldom aims at reparation; and when it does, the granulations are greyish, hard, warty, and endowed with but little vitality; never investing the whole surface, but protruding from certain points, and presenting somewhat of a fungous character. The thin unhealthy discharge becomes profuse, and exhales a peculiarly fetid odour, highly offensive to the patient and attendants. By these means the ulcerated cavity may attain an enormous size, presenting a most disgusting and lamentable spectacle. If the patient bear up under the profuse discharge, the greater part of the original tumour may be destroyed by the ulceration, and some attempts may be made at cicatrisation; that is to say, the cavity may contract, and granulations be formed: but these are always unhealthy, and, in fact, carcinomatous, and often bleed profusely. New skin is seldom formed, the remaining parts resume their virulency, and the process of destruction again advances, surpassing the former both in extent and rapidity.
Along with these local symptoms and appearances, it can be readily understood that the constitution is, from the first, materially affected. The alimentary organs are deranged in function, the patient has a wan and sallow countenance, and is in general weak and much emaciated. After ulceration, the system is still more reduced by the discharge, the patient becomes hectic, and is often afflicted with diarrhœa; along with the other symptoms of extreme debility, the patient may become anasarcous, is affected with cough and dyspnœa, or by other symptoms indicating disease of some internal organ, and is ultimately carried off in a state of exhaustion.
The disease attacks various textures, but perhaps most frequently the mammary gland. The mamma generally diminishes in size from absorption of the fatty matter; the nipple is retracted, often to a great degree, and the surrounding integuments are of a purplish hue, and exude a sanious fluid; at length the nipple is completely destroyed by ulceration. In other instances the tumour is large, and there is a hard œdema of the integuments; the skin is thick, coarse, and of a dark red colour. The tumour soon adheres immoveably to the subjacent muscles and ribs, converting the contiguous portion of the former into a substance similar to itself. There may be other varieties in the appearances and symptoms of carcinoma; but the above are those which are most frequently observed, and are sufficient to denote the general character of this species of tumour, and to show its peculiar and inveterate malignancy.
Ulcers or swellings, at first simple, may assume a malignant action, either carcinomatous or of another kind; thus, in one instance, a simple ulcer, produced by a burn, assumed a foul and unhealthy aspect; and ultimately degenerated into a most malignant sore. Various malignant actions commence in glands of the conglobate or conglomerate kind, at first simply enlarged from irritation or injury. The female breast often becomes indurated from a blow, or from milk abscess, and remains for a series of years, half a lifetime perhaps, without any perceptible change in the enlargement and induration; but the tumour frequently is roused into activity at the critical time of life, and malignant action ultimately commences. The menstrual period ought to be particularly attended to in affections of the mamma more especially, but also in all tumours and ulcers; for both during and before it tumours become larger and more painful, the whole system appears to be excited, then relaxed, and all morbid actions seem to possess increased activity.
In this disease, as in soft cancer, as it has been called, (and they occasionally pass into each other,) the bloody masses, or sacs containing bloody fluid, are to be dreaded, and when they exist are to be considered as very unfavourable; for if, on the removal of a carcinomatous tumour, such appearances be found, the disease will certainly return; a new tumour, of even a worse character than the preceding, will be formed; a fungus will be protruded, and from this hemorrhage will occur.
The lymphatic glands, both above and below the tumour, generally enlarge early in the disease, become hard, and cut like cartilage, and with a grating noise. Frequently they become converted into a dense and fibrous substance, resembling carcinoma; sometimes they are softened and broken down at several points, and contain a purulent or bloody fluid. They enlarge, coalesce, and form irregular masses, which rise more and more above the surface; the superimposed integuments give way, and then occur those destructive ravages by ulceration and sloughing already described. The lymphatic vessels entering these tumours and emerging from them feel hard and wiry, as if thickened. The integuments in the neighbourhood of the tumours, and in the course of these absorbents, are of a blue colour, and the veins enlarged and tortuous; the limb below the enlargement swells and is œdematous. The absorbents often become affected months or even years after the removal of the original and exciting tumour; the immediate cause being taken away, yet the inherent disposition to malignant action is too often left, not to be eradicated. In fact, the disease generally returns, either in the original integuments, in the form of tubercles or buds, in the cicatrix, or in the glands; very frequently all are affected. It seems also to spring not unfrequently from fascia. Such enlargements of the glands have been said to arise, in the first instance, from irritation, and not from any participation in malignant action; and on this supposition, though in general extremely incorrect, cruel, bloody, and unnecessary operations have been performed.
Cancer seizes either the mucous or the cutaneous surface, with hardness and a warty excrescence; this ulcerates, and is surrounded by a hardened base. The process of destruction advances, and the ulcerated part presents the same appearances as those of a sore arising from a similar action in a deeply-seated carcinomatous tumour. The glands also enlarge, and assume the same aspect as if they had been the original seat of the disease. Some pathologists seem disposed to deny this, but apparently on no very sufficient grounds.
FUNGUS HÆMATODES
Has been much confounded with medullary sarcoma, but the two diseases are materially different. Fungus hæmatodes almost always supervenes on other morbid formations, when they have been ulcerated and exposed; and the particular formation which most frequently precedes is the medullo-sarcomatous; a bleeding fungus, however, occasionally protrudes from tumours of a different character, which, though they may have been at first simple, have degenerated, ulcerated, and assumed a malignant action. The disease certainly does not occur so frequently as some have asserted; for many, instead of limiting the application of the term to those fungous protrusions which bleed, honour with the appellation of fungus hæmatodes every growth which protrudes after the ulceration of a tumour, and every tumour which is unusually prominent, of soft consistence, and of a somewhat fungous appearance, although such have never shown any disposition to bleed, either spontaneously, or from irritation. But fungus hæmatodes, as the name implies, is truly a fungus which resembles blood; and as bloody or blood-like tumours are formed from the rupture of some vessel of rather a large size, and as they almost invariably evince a tendency to profuse hemorrhage, as a necessary consequence of the mode of their formation, the term is correctly applied only to those fungous growths which either have at one time emitted a discharge of blood, and exhibit symptoms of a recurrence of the hemorrhage, or which frequently pour out a quantity of blood, sometimes inconsiderable, but often profuse, and generally altogether uncontrollable. In short, the circumstances necessary to entitle a morbid formation to the appellation of fungus hæmatodes are a fungous structure and appearance, and hemorrhage proceeding from it to a greater or less degree, and with more or less frequency. Fungi are frequently met with, but there are certainly few hæmatoid fungi.
The excrescence is generally of a dark colour, resembling a mass of coagulated blood, but of more soft consistence, and its extremity has often a sloughy appearance. It is evidently organised; for, on being injured even in a very slight degree, hemorrhage ensues from the part which has been broken or contused, and frequently the growth bleeds spontaneously. At first the hemorrhage is in general slight, but is often repeated, becomes very profuse, and in most instances cannot be arrested. The vessels in the substance of the morbid mass are diseased in their coats, and have altogether lost their power of contraction; they give way either spontaneously or by laceration, and by their non-contraction they appear to serve merely as passive tubes, through which the blood is poured out by the active vessels which supply them; the latter are not exposed to any of the causes which tend to produce speedy obstruction of their canals, therefore continue to transmit their contained fluid through their subservient branches, and from this the uncontrollable nature of the hemorrhage can be accounted for; from the number of vessels which supply the new structure, and which are thus employed, it can be readily imagined that the hemorrhage will be profuse. In many instances, the application of firm pressure on the limb above the seat of the disease is even insufficient to arrest the flow of blood; and though this may, in some degree, be explained by supposing the continued stream to be venous, still it must be confessed that the disease appears connected with a peculiar hemorrhagic tendency. Frequently the fungus is found to communicate with, or rather to arise from, numerous cysts of a glossy appearance, from which also blood is copiously effused. The surrounding tissues are completely disorganised in the immediate neighbourhood, and also much altered in structure for a considerable extent around; the muscles, besides their disorganisation, have acquired a peculiar brown hue. Sometimes the hemorrhage does not seem to proceed so much from the fungus as from the subjacent cysts; for when a superficial incision or puncture is made into it, the bleeding is often inconsiderable, and only becomes alarming after masses of coagulated blood have been removed, and the cysts thereby exposed. Occasionally the fungus communicates with a cavity of enormous size, filled with blood, partly coagulated and partly fluid, and from the parietes of which the hemorrhage proceeds. When the disease has supervened on a medullo-sarcomatous tumour, the coagulated blood is mixed with a substance resembling the brain in a state of putrescence. It may supervene on polypous tumours, particularly of the antrum; and of this I have seen several instances. Sometimes it is produced after the removal of a tumour apparently not of malignant character, and in this case it frequently does not appear till the wound has almost cicatrised. When once established, it proceeds with all its virulency. The diseased parts may be removed as frequently as they appear; but they will be reproduced, and the disease will assume a still more frightful aspect, both in extent and malignity.
In consequence of the repeated and profuse loss of blood, the patient is gradually worn out, becomes hectic, is affected with nausea, vomiting, and indistinct articulation, with all the symptoms of extreme debility, and he generally sinks exhausted, or may be suddenly carried off by profuse hemorrhage.
The size of the bleeding fungus is extremely various, but it is rarely large; in fact, we frequently find that the most violent hemorrhage occurs from those of a small size; and in illustration of this, I shall briefly relate the following case. A man, aged forty, had been afflicted for some time with ulceration in the ham, and exfoliation of the posterior part of the femur. The sore healed; but about two years afterwards the cicatrix became ulcerated, and produced a very small fungus, resembling, in fact, a minute cluster of exuberant granulations: from this blood was effused in small quantity, and was easily restrained by the application of a bandage; but the hemorrhage returned at various intervals for upwards of a week, became extremely profuse and altogether uncontrollable. By this the patient was greatly exhausted, and amputation was rendered absolutely necessary. On examining the limb, the lower portion of the femur was found somewhat enlarged, its internal structure completely destroyed, and the periosteum on the inner side much thickened. On the posterior and inner part of the bone, about three inches above its articulation, there was a small fungous tumour of an irregular surface, and of soft consistence, resembling congealed tallow. From this excrescence the blood had been effused into a cyst formed amongst the muscles, and afterwards discharged externally. He recovered from the amputation, and remained well.
THE PAINFUL TUBERCLE.
Though of small size, and not possessed of malignant action or disposition, is a tumour of very great interest, on account of the excruciating pain with which it is accompanied. It is mostly situated in the subcutaneous cellular tissue, but not unfrequently in the intermuscular cellular substance; one tumour of this species which I have removed was so deep as to be in immediate contact with the sheath of the posterior tibial nerve. The tumour, generally of the size of a garden pea, rarely exceeds that of a cherry. It is invested by a dense ligamentous cyst, to which it intimately adheres; but occasionally the capsule is thin and cellular: in many instances its surface is perfectly smooth, in others it is slightly nodulated. It is not connected with any large nervous trunk; but minute nervous fibrillæ can occasionally be traced expanding on its surface, and apparently entering its substance. Internally it is composed of numerous whitish fibres, of considerable density, ramifying irregularly throughout its structure; and betwixt these is insinuated a firm substance, generally of a grey colour, and frequently of an almost cartilaginous consistence. Such is the structure most frequently observed; but in this morbid formation, as in all others, the appearances may be said to vary in almost every instance. Sometimes the fibres are indistinct, and of a yellowish or dirty grey colour; and the interfibrous matter is often found to vary in density and colour in different tumours, being at one time dense and almost transparent, at another opaque and cartilaginous, and sometimes rather soft, brownish, and occasionally tinged with blood. From attentive examination, it appears extremely probable that the enlargement is at first produced by infiltration of lymph betwixt the fibrillæ of a nervous twig, which becomes separated and inclosed by the deposit—that they afterwards increase in size—that the interfibrous matter is deposited in greater quantity, and is farther condensed—and that thereby the nervous filaments are still more separated and extenuated. In short, it would appear that the fibrous matter is nervous, though altered, and that the interposed substance is organised and condensed lymph. The tumour, at first extremely minute, enlarges slowly; when deep, it can only be obscurely felt, and its existence is with difficulty discovered by manipulation; but the attending symptoms are so peculiar, and so forcibly developed, as to lead the surgeon at once to an accurate diagnosis. When it is subcutaneous, the skin is rendered slightly prominent, and the size, density, and loose connections of the growth, are readily ascertained. The slightest pressure causes the most excruciating torments, and totally unmans the patient, even though induced by the most trifling movement of the adjoining muscles. From a fearful and well-grounded knowledge of this circumstance, the patient is extremely anxious to preserve the limb in a state of complete rest, and, in fact, he is often wholly unable to use it; although the part is completely set at rest, still he frequently suffers from paroxysms of severe pain, commencing in the tumour and shooting through the limb. The painful sensations are sometimes very much alleviated by gentle friction with the hand. The disease is most frequent in the extremities, and in the inferior more than in the superior.
The larger nervous trunks sometimes become diseased, being affected with an enlargement resembling the structure and appearance of the preceding tumour, and such enlargements are termed Neuromata. Occasionally a portion of a nervous trunk is thus enlarged, from a blow or wound; and sometimes there can be no cause assigned. Nerves when divided, become bulbous on that extremity towards their centre. In stumps this is well seen; whilst all the tissues entering into it, after a time shrink, and become more or less atrophied (bone, muscles, vessels, &c.), the extremities of the nerves swell out and present a bulbous appearance. When these tumours are connected to, and only covered by, integument, or when they are adherent to the ligamentous substance covering the bone, and become exposed to pressure, as in badly made stumps, the patient often suffers excruciating agony. The nervous trunk above is, in general, slightly enlarged, sometimes has a tortuous course; and in some instances the neurilemmal bloodvessels are considerably increased in size. The same symptoms exist, though in a less acute form, as in the painful tubercle.
OF POLYPUS.
A common species of tumour is that which is attached to a mucous surface, and is called POLYPUS. Polypi vary in structure and disposition; some are simple and benign, others are most malignant. The simple mucous polypus has a shining appearance, being invested by an extremely delicate membrane, in some degree resembling the mucous, and moistened by a fluid similar to the mucous secretion; it is of soft consistence and homogeneous structure. They are generally light brown, sometimes greyish, and in some degree diaphanous. They are connected to the mucous membrane by a narrow pedicle; generally occur in clusters, and are of pyriform shape; one or more are often suspended from one narrow base, and they seldom attain a large size. They possess but little vascularity, though occasionally minute vessels are seen ramifying pretty freely on their surface, and may be considered as almost devoid of sensibility. The malignant polypus, on the contrary, is always attached to the mucous membrane, and also to the subjacent parts, by means of a broad base; and its form and structure vary according to the particular action which it has assumed. Most frequently it is encephaloid, of an irregular form, and often presenting a cauliflower appearance, its surface being studded with numerous excrescences of medullary consistence and colour. Such tumours will be afterwards treated of, as occurring in different situations.
OF ENCYSTED TUMOURS.
Along with these have been classed the enlargements of bursæ, sheaths of tendons, &c., but with equal propriety might we include hydrocele and other collections in natural cavities. Encysted tumours are almost always situated superficially. The skin is distended, seldom inflamed, and often contains enlarged bloodvessels, which give it a streaked appearance. They consist of an external cyst, which is in some instances extremely thin and delicate, in others dense, of considerable thickness, and composed of fibrous looking substance, occasionally it is almost cartilaginous; the internal structure may be said to be almost always more or less fluid, but varies much in consistence. The tumour is surrounded with condensed cellular substance, which is of greater or less thickness and strength according to the size of the tumour. Some of these tumours are supposed, and on good grounds, to be mere enlargements of the natural mucous follicles, in consequence of obstruction in their ducts, by hardened and vitiated secretion; the cyst, therefore, will be at first thin and delicate; its contents will resemble the natural secretion of the follicle, and in many cases may be readily squeezed out. There is a black point on the most prominent part, marking the obstructed orifice of the follicle, and the sac is found at this point to adhere firmly to the skin. Even after all other marks of its original formation have disappeared, the situation of the orifice is sometimes indicated by small dark spots, by depression, or by a minute ulcer.
Encysted tumours, or wens, as they have been called, often appear to be hereditary; seldom occur single, and are met with under the surface of all parts of the body. They have been divided into different classes, according to the nature of their contents: Atheromatous; containing curdy matter; Meliceritous, containing a substance like honey; and Steatomatous, containing fatty matter, generally in a semifluid condition. But such terms are not adequate to express the nature of all encysted tumours; they are extremely various in their actions, and their contents vary according to the particular secretory action which the lining membrane of the cyst assumes; for the same reason, also, the contents of a tumour will differ in the different stages of its progress. Some contain a thin, fetid, brown fluid, mixed with solid particles, resembling half-dissolved fibrinous matter; in some the contents are serous, or sero-purulent,—in others they are gelatinous; whilst in those which have become inflamed from external irritation, the contents are altogether purulent, or contain a very considerable proportion of that fluid; not unfrequently the cyst is covered internally by a layer of calcareous matter, to which similar particles are loosely attached. Sometimes, in consequence of irritation, organisable matter is poured out on the inner surface of the cyst, adheres firmly to its inner surface, and is often disposed in concentric laminæ.
Sometimes, though rarely, the most prominent parts of the tumour ulcerate, and on the exposed surface is deposited a substance of semifluid consistence and gelatinous appearance, which afterwards increases in density, and ultimately assumes all the characters of horn. This hard excrescence in some instances increases only to a slight degree, and afterwards remains stationary; in others it attains a large size, and occasionally assumes a curved or tortuous form, like that of the horns of inferior animals. Horns are generally met with on the forehead, and the scalp may be said to be their seat. The largest which I have seen, measured seven inches in length, and two in circumference; but others have been removed still larger.
In many encysted tumours, hairs grow from the internal membrane of the cyst, often numerous, and are generally found in those situated on the eyelids; in some the hairs are destitute of bulbs, lie loose within the tumour, and are often rolled into a globular form. The adhesions of these tumours are in general very slight and easily broken up, but when seated amongst tendons, or in unyielding parts, they are often extremely firm. Violent inflammatory action may follow injuries of the tumours, or the making of even minute openings into them; suppuration occurs, the discharge is thin, fetid, and often bloody; there is much pain, and frequently severe constitutional irritation. Occasionally a fungus, bleeding or not, is protruded through the aperture; more frequently, however, the opening heals, and the tumour remains as before. External injuries sometimes appear to check the secreting action, and to excite the absorbents to remove the morbid growths, and this with or without rupture of the cyst. Thus, in the case of an encysted tumour the size of a hen’s egg, on the external lateral ligament of the knee joint, free and pretty rough manipulation was necessary to ascertain its nature and exact situation; in consequence of which, the tumour gradually disappeared, and no traces of it remained twelve days afterwards. Others of less size, I have known to disappear in a much shorter period.