Part 17

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.