Part 18

The simple tumour is mere enlargement of a part, from the infiltration of solid matter deposited by its bloodvessels. There can be little doubt that the action which lays the foundation of such enlargement is inflammatory: in consequence of inflammation of the tissue, lymph is effused into the cellular substance during the progress of the incited action; and after it has subsided, the dilated and debilitated vessels probably do not regain their condition, as to size and vigour, but remain somewhat dilated, and continue to free themselves from portions of their contents; thus the cellular tissue is opened out in proportion as the infiltration advances, and the process may be occasionally accelerated by fresh attacks of subacute inflammatory action. The patient at first feels pain, heat, &c., as in an inflammatory tumour; these afterwards abate, and ultimately go off entirely; and during the increase of the swelling, little or no pain is experienced, unless when these subacute inflammatory attacks supervene, and then it is but slight; or unless the enlargement be resisted by an unyielding structure, and then it is acute and troublesome. The size and rapidity of increase in such tumours will vary according to circumstances; the vessels of the part soon regain their size and action, either by the efforts of nature or of art, so that the tumour will have attained no great size, and be stationary in its progress, being denied the materials necessary for its increase. If the morbid action be thus stopped, the absorbents will remove the newly-formed matter, and restore the parts to their healthy condition. But when the deposition proceeds in a superior ratio to absorption, the new matter becomes organised, and by means of its own vessels, secretes a substance similar to itself, whereby the increase of the tumour becomes more rapid, and the new structure may attain an enormous bulk. Thus the tumour is formed, not merely by dilatation of capillary vessels, and extension of its original tissue, but by the formation of new matter, which, becoming organised, assumes a secreting power. At first the former circumstance is the chief cause of the enlargement; but after the latter process has existed for some time, the tumour loses much of its resemblance to the primary tissue, assumes a more dense structure and a different action, and therefore cannot be designated a simple enlargement.

This species of tumour, or rather this enlargement which precedes the formation of a tumour, is chiefly met with in the cellular and glandular structures. Sometimes it is described under the term of œdema solidum. In the scrotum, where the cellular tissue is remarkably loose and extensile, such tumours attain a very large size. They are found in this country, though more frequently in warm climates. I removed one from this situation successfully, which weighed upwards of 44-1/2 lbs.; it had been of twelve years’ duration, and caused much inconvenience to the patient. It is sketched in the _Practical Surgery_, p. 341. It occurs in the mamma, apparently in consequence of suppression of the menstrual discharge; the gland becomes enlarged, there is no pain in the tumour, and it feels soft and doughy. When the subcutaneous cellular tissue is the seat of the disease, the tumour is often of considerable extent, but rarely forms a great protuberance. It sometimes is situated in the coverings of the nose, which, as they become enlarged, lose their natural colour, and assume a purple hue; the mucous follicles also are often much enlarged, and occasionally emit a profuse discharge of their secretions. It can be readily understood that in this situation the tumour is a source of much annoyance, from its partially obstructing respiration, and even vision, interfering with the functions of the parts and the comfort of the patient.

It has been already observed, that when simple enlargement exists for some time the structure changes. It becomes more dense, and assumes a peculiar action, independent of that of the surrounding parts. It has a harder and more firm feel, and all traces of the texture in which it was formed are destroyed. It may be considered as the next in order to the one already mentioned, both as to the simplicity of its structure and action; but in consequence of its action being independent of those of the neighbouring parts, and liable to change from even slight causes, it is very apt to degenerate into those tumours which are more complex and injurious.

ADIPOSE TUMOURS.

Another species of tumour seems to be composed almost entirely of fatty matter insinuated amongst extended and delicate cellular substance, and has been therefore termed adipose. It is surrounded by a cyst of dense cellular tissue, and to this it loosely adheres; its bloodvessels are few, and it is of an inactive and innocuous character. It is generally lobulated, and often attains a large size. It is not only irregularly prominent on its outer surface, but in its whole circumference, and its lobuli often insinuate themselves to a great depth amongst nerves, bloodvessels, and other important parts; owing to this circumstance they frequently prove a source of the greatest inconvenience from their bulk, for of themselves they are neither hurtful, nor possess any disposition to involve those parts with which they are in contact. This tumour is found only in the cellular and adipose tissues. From its loose connection with its envelope, it admits of ready removal by operation. A tumour of this kind is here represented, which, but for this circumstance, owing to its awkward situation under the tongue, could not by any possibility have been extirpated. It is fully larger than an orange, and had caused very great suffering. It is not so much lobulated as fatty tumours generally are. The adhesions of adipose tumours are, however, rendered firm and more numerous by pressure or external stimulants—in fact, by whatever induces inflammatory action in its substance or in its surrounding connections; and from this cause the extraction is often rendered exceedingly difficult. The skin becomes thickened and of a red hue, and the tumour itself is much more vascular. From this cause it is apt to assume a new mode of action, and to change in structure and in character, invariably for the worse. I have removed a few tumours, originally of this benign species, but which had apparently degenerated and assumed a malignant action. In one, distinct indurated bands radiating from a central mass of the same kind, are discernible. In two others, as a consequence of pressure, condensation and ultimate softening had occurred. The largest alluded to was removed from betwixt the shoulders of a soldier, and had borne the pressure of his knapsack for eight or ten years. It was attached by a thickish neck, presented the common lobulated appearance of adipose sarcoma; but its external surface, its feel, and section, were very different.

The patient does not complain of any pain or uneasiness in the tumour, unless inflammation be excited in it; then the pain and other symptoms are such as attend incited action, and the sensations which are afterwards experienced vary according to the character which the tumour assumes. Certain changes may occur in its texture, though not in its general character or disposition; thus osseous or earthy matter is occasionally deposited in some part of the tumour, while the surrounding adipose substance retains its appearance and density. Suppuration, it is said, has followed inflammatory action, excited in an adipose sarcoma.

OF FIBROUS TUMOURS.

Fibrous tumours are not uncommon, and are formed in various textures. In general they are composed of a substance of a dirty grey colour and considerable density, through which minute, firm, ligamentous fibres ramify; in some cases irregularly, in others radiating from the centre of the tumour. The new formation is surrounded by condensed cellular tissue, to which it intimately adheres, and does not mingle irregularly with the surrounding parts; in this respect differing from malignant tumours, which occasionally contain fibrous matter. It cannot be considered of an equally innocuous nature with those already described, but is still, in its original state, not of a malignant disposition. After some time, the consistence and structure of such tumours vary: some are of a loose texture, and contain cells; others are hard, and intermixed with cartilaginous matter, or even with bone. In general, the tumour is slow in its progress, though it may attain a very large size, as seen in the cut on the preceding page, if allowed to remain; occasionally its growth is rapid.

Besides those tumours which have been described, there is a number of others not of a malignant disposition, which are so various in their structure as to baffle all attempts to reduce them to a scientific classification. Some are composed of a homogeneous substance of almost cartilaginous consistence and a whitish colour; some consist of cartilaginous matter, mixed with substance of less density and of a different appearance; in some, fibrous matter is mixed with a homogeneous glandular-looking substance, partially softened. Some are almost entirely composed of osseous matter; others contain it in small proportion. It would be endless to enter into a minute detail of the structure of such tumours, for it may be said that their appearances vary with their number. In almost all tumours cysts are found, and the internal structure of some tumours consists almost entirely of cysts, or hydatids, as they have been called; in others, these only occupy certain parts, and compose but a minor feature in the structure. The sacs are generally lined with a delicate and smooth membrane, which is often vascular at various points; some contain a transparent and glairy fluid, albuminous or gelatinous; some bloody serum; some purulent, some curdy matter, or this mixed with a serous or purulent fluid; some pure blood; some a fluid like printer’s ink; and not a few are occupied by a dense elastic substance, which, on a section being made of the tumour, rises irregular and ragged above the cut surface. Some tumours are smooth; others lobulated or tuberculated.

OF ENCEPHALOID TUMOURS.

The tumour which comes next to be described is decidedly malignant. It is the Encephaloid, or Medullary Sarcoma. Although these tumours have been called encephaloid and medullary, it must not be understood that their intimate structure has any relation to that of the brain or marrow; for this reason the old term _fungoid_ is perhaps a preferable one, since it leads to no false notion as to their nature, while it expresses a condition which at one time or other is remarkably characteristic of them. This tumour consists of a homogeneous matter, resembling the substance of the brain in colour and consistence It rarely has a distinct cyst; occasionally it is subdivided by membranous bands. It is always soft, though often more so in some parts than in others; portions of it being frequently so much softened and broken down as to resemble thick cream in consistence, and these are generally of a darker colour, from being mixed with a greater or less quantity of effused blood. Partial or universal softening only occurs after the tumour has existed for some time, for in its original state its structure and density are uniform throughout; and, on making a section of it, some few drops of blood may escape from vessels, the coats of which are of a very delicate nature. Some of these vessels seem to give way, in consequence of the process of softening, for we frequently meet with fluid blood, or masses of fibrin, in the midst of the pulpy matter; and, when the softening has been extensive, the blood is diffused throughout the whole substance of the tumour, so that it will appear to be chiefly, or entirely, composed of effused and degenerated blood, as here represented.

The mamma and testicle, and the contents of the orbit in children, are the most frequent seats of this disease; it not unfrequently occurs in the lymphatic glands, and few textures can be considered as exempt from it. The part at first enlarges slowly: but afterwards the disease advances with great rapidity, involving the adjacent parts. In general, the affection is not attended with much pain; the part has a spongy and elastic feel, and frequently presents an obscure sense of fluctuation, indicating that softening is more or less begun. The skin is tense, generally brownish, and is pervaded by large venous branches. This venous enlargement is always observable in the advanced stage of the disease, before or after ulceration has taken place; it is peculiarly evident in the eyelids, when the contents of the orbit are involved, and is to be attributed to obstruction of the circulation in the deeper vessels. The tumour is increased by the surrounding parts assuming a similar action, and being converted into a similar mass; and the disease also seems to be propagated by means of the absorbent system, and by the irritation conveyed along the vessels which emanate from the tumour, or from its immediate vicinity. Thus, when the testicle or mamma is affected, the lymphatic glands, both above and below the tumour, and the course of the absorbent vessels, are converted into an encephaloid mass, all traces of their glandular structure being completely destroyed. The same brain-like or cancerous matter is also found in the bloodvessels, large and small. When the disease has been of long duration, the superincumbent integuments appear tense, assume a purple colour, and ultimately ulcerate; a portion of the pulpy mass then protrudes, of a fungous appearance, the resistance being at that point removed, and the compressed matter relieving itself by the extension of a portion of its substance; the protruded portion afterwards becomes discoloured, and sloughs, to be speedily reproduced either by further dilatation, or by actual increase of the tumour; unhealthy pus is discharged, often mixed with blood, and occasionally slight hemorrhage occurs; the integuments become further ulcerated, assume a dull brown colour widely around, and are undermined, presenting a boggy feel.

Along with these local symptoms, there is a complete subversion of the system,—there being at first symptoms of constitutional irritation, afterwards those of hectic and extreme exhaustion. When the lympathic glands are diseased, the limb beneath is much swollen from œdematous effusion, the return of the blood and lymph being prevented; violent and excruciating pains are experienced in the course of the nerves of a limb; it also frequently loses its sensation, from those organs being either involved in the disease, or pressed on by the tumour. The vessels in the neighbourhood of the affected parts are materially altered, though they are seldom converted into encephaloid matter; the arteries are often completely obstructed by coagulating lymph for a considerable extent, and the coagulum not only occupies the principal trunk, but extends into the minute ramifications; and this explains why hemorrhage seldom occurs, even after ulceration of the tumour is far advanced; the veins also are frequently obstructed in a similar way; but in many cases they contain a soft and pulpy matter, exactly resembling the substance of the tumour. The fungus which protrudes after ulceration of the integuments sometimes bleeds, when it would appear that the hemorrhage proceeds from those bloody collections in the substance of the tumour already mentioned. According to my experience, when bloody points, or cysts containing bloody fluid, exist in a medullary or other tumour which has been removed, and if the diseased matter be reproduced, a bleeding fungus will almost certainly follow. This species of tumour occurs in all ages and in all situations, and during its progress evinces strong proofs of inveterate malignancy: if removed early, the disease may be arrested; but if the operation be long delayed, a tumour of a similar nature, and more extensive, will almost invariably be produced. In several instances I have removed encephaloid tumours, from the situation both of the mamma and testicle, and the disease did not return; but in the other cases the result has been as above stated. Encephaloid disease of the internal organs frequently supervenes on that of the external parts, and accelerates the patient’s dissolution; when in such situations they are beyond the reach of surgical art, and their existence is only, if at all, ascertained, in order to enhance the unfavourable nature of the surgeon’s prognosis.

OF MELANOID TUMORS.

The Melanoid tumour is rather of rare occurrence in the human subject; it originates in the cellular tissue, and most frequently attacks the internal viscera; sometimes it occurs in the eyeball, where it has been seen with the encephaloid disease, and occasionally melanotic matter is diffused amongst the cellular tissue throughout the whole body, even in that of the bones. The external surface of the tumour is generally of a shining and mottled appearance; internally it consists of a homogeneous black matter infiltrated into the cellular tissue, which is condensed, and in some cases distinctly increased in vascularity. The tumour, seldom of a large size, extends chiefly in a lateral direction. Occasionally it is pretty firm; in other instances it is soft, broken down, and semifluid. The melanotic matter is not always so deposited as to form a distinct tumour, but frequently seems to be sparsely infiltrated into the cellular tissue; and occasionally it is diffused in so minute a quantity as merely to tinge the part, or form dark streaks. Sometimes it is infiltrated in the substance of an organ, and sometimes it is effused on its surface; occasionally it is surrounded by a distinct delicate sheath; usually it is confined by no envelope, excepting the partial condensation of surrounding parts. In the skin it sometimes presents in a tubercular form. The tumour is said to be chiefly composed of albumen, mixed with a peculiar colouring matter. The disease mostly occurs in the trunk, seldom in the extremities; it is not uncommon in the orbit, and in the internal organs the melanotic deposits are generally both numerous and extensive. There is seldom pain, and the patient seems to suffer chiefly from lassitude and extreme debility, which gradually increase; anasarca frequently supervenes; the functions of the organs affected are much impeded, or even altogether destroyed, and thereby the sinking of the powers of life is accelerated according to the viscera affected and the extent of the disease. Melanosis occurs most frequently in advanced life, though it is not confined to it; whereas encephaloid attacks indiscriminately all ages.

OF CARCINOMATOUS TUMOURS.