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.
[Illustration]
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.