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 seropurulent,—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.
[Illustration]
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.
OF TUMOURS OF BONES.
The vascular action of bones, in their healthy state, is feeble, but,
as in other feeble parts, it is easily excited, and disease of an
obstinate and unyielding nature is apt to follow.
The morbid growths vary much in texture. The most frequent are the
osseous, or those of the same structure with the original bone;
but even these differ much in the density and arrangement of their
particles: they have been termed _exostoses_. They may be of great
density, and are then called the hard, or ivory; these never attain a
large size, seldom exceed that of a bean, have a smooth and polished
surface, and are of a flattened and hemispheroidal form, their greatest
circumference being at the base; they occur in many of the bones, but
generally in those of the cranium and face.
Others, being of a more loose and spongy texture, have been called
cancellated. These are commonly formed by the bones of the extremities,
and often attain a very considerable size; they grow from the
periosteum, or from the outer surface of the bone, and are then
covered by an expansion of this membrane. Sometimes they adhere by a
narrow neck, and expand into a bulbous form, so that they can be very
readily removed by operation, and are very apt to be broken off by
external injury. Others have a broad and firmer attachment, and are of
an irregular shape, often projecting in the form of a large spicula,
and at other times assuming a somewhat stalactical appearance. Such
frequently prove the source of much inconvenience, by impeding the
motions of the muscles, or disturbing the functions of any adjoining
organ. They possess no malignant disposition, but are under the same
laws, though perhaps in a less degree, with their parent trunk.
On making sections of exostoses, and of the bones from which they
arise, some appear to be mere enlargements or processes of the
parent bone, the cancellated tissue extending itself so as to form
the interior of the exostoses, whilst the exterior resembles a
proportionate extension of the outer lamina. Others are evidently
formed by the deposition of osseous matter externally to the outer
lamina, many being dense and compact throughout, others containing an
internal cancellated structure, but which is not continuous with that
of the bone, as it is separated by the natural outer lamina. Their
formation appears similar to that of the fœtal bones: a glutinous
matter is effused, becomes dense, and is converted into cartilage;
bloodvessels shoot into it, ramify throughout its whole structure in a
radiated form, and deposit osseous matter. This deposit increases, and
extends from a central nucleus towards the circumference; the cartilage
is in part absorbed, and the new structure becomes osseous, and similar
to the original tissue by the vessels of which it was formed. These
tumours, even when they have attained a large size, contain a mixture
of bone and cartilage, covered by a dense fibrous investment. The bony
matter is arranged in spicula, adhering to the surface of the shaft or
head of the bone, and projecting into the morbid mass: the spaces are
filled up by a cartilaginous substance. The growth is sometimes rapid,
and the tumour soon becomes troublesome from its immense size.
Frequently a bone is much enlarged throughout its whole extent, or the
greater part of it, and presents a cancellated texture: sometimes,
also, it is much thickened, and, at the same time, of great solidity;
but such enlargements cannot be considered as tumours of bones, or
exostoses, any more than those nodules of new osseous matter, which
are effused in consequence of inflammation of the osseous tissue. The
most frequent cause of exostoses appears to be external injury; their
progress is slow, attended with slight dull pain, and often accompanied
with no inconvenience; their existence can be readily ascertained,
a hard and immoveable body being felt where no bone exists in the
natural state of parts; but when the tumour projects into an internal
cavity, the diagnosis is rendered obscure. Most frequently, they remain
stationary, after having attained a certain size, and are productive
of little inconvenience, the surrounding parts having accommodated
themselves to the new formation. Occasionally, suppuration occurs in
the soft parts, the matter comes to the surface, and a troublesome
abscess is formed.
To this class of tumours would I confine the term exostosis, not
including those consisting of softer materials, and possessed of a less
benign action.
OF OSTEOSARCOMA.
[Illustration]