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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]