-No. 7.] LONDON, SATURDAY, Nov. 20, 1824.

SURGICAL LECTURES,DELIVERED BY

MR. ABERNETHY.

Theatre, St. Bartholomew’s Hospital.

LECTURE 7.

GENTLEMEN,I told you that I should have to say

something to-night on the subject ofTumours.

I shall begin with such as admit ofthe readiest illustration, as to the

manner in which they form, and suchas appear to possess the most simplestructure.

Pendulous Tumours.There are some tumours which hang

pendulous from the surfaces of mena-branes, being attached by very narrowbases to the structures from whichthey hang, by what in fact is a merepeduncle. The manner in which suchtumours form was first described byJOHN HUNTER, that great man towhom we aU owe so much. He found,on opening the abdomen, a spot ofextravasated blood lying upon thesurface of the peritoneum ; the bloodappeared recently coagulateci, andwas attached by a very narrow neck,of about half an inch in length, to thesurface on which it had been depo.sited ; he attempted to account torthe length of this attachment by sup-posing, that the coagulum of bloodhad adhered to the surface of the pe-ritoneum, and that by the movementsof the abdominal viscera, it had beenelongated in the way before described.Now there is no doubt but that ves-sels would have shot through thisnarrow neck and have organised the

clot of blood, which would, in thiswav, have continued to grow to an in-definite size. We have a tumour inthe museum, which hung pendulousfrom the front of the peritoneum ;produced without doubt in the waywhich Mr. HUNTER described. Theorganization, and the peculiar actions,had been so far perfected, that a lumpof fat was deposited in the centre ofthe tumour; whilst the neck remainedfibrous and vascular.

I believe that tumours form in allparts of the body in the same way. Þ

The jelly, or the coagulable part ofthe blood, becomes effused either bydisease or accident : vessels shoot intoit; it becomes completely organised,and what was before an inorganicconcrete, becomes a part of the living Z5system. The attachment of a tumourto a part is sometimes by a slenderpoint, and then all the vessels sup-plying the tumour must pass throughthat point; but in other cases, thevessels shoot into the tumour irre-

gularly at various parts. The tumourthus once organised seems to live andgrow by its own powers; the futurestructure which it may acquire seemsto depend on the operation of its own.vessels.Sometimes the structure of a tumour

is like that of the parts near which itgrows : fatty tumours frequently, ayegenerally, are found in the adiposestructure of the cellular membrane,whilst those which form in the jointsare frequently of an osseous or carti-laginous consistence. This, however,is not always the case, for you mayfind tumours composed of very diffe-rent materials from the parts by whichthey are surrounded. It appears thata tumour being once formed is a suf-ficient cause for its own continuanceand increase ; it irritates the con-

tiguous parts, and keeps up that in-creased action of vessels which isnecessary to its supply. - A tuuaorr,

226

having been once formed, increases,condenses the surrounding cellular

substance, and forms for itself a sortof capsule. It is connected to thesurrounding parts more or less firmly,according to the degree of irritationwhich it may excite.

I shall consider tumours as consti-

tuting an ’order in the class of localdiseases. This order may be subdi-vided into genera; and I shall firstspeak of the

Genus Sarcoma, or SarcomatousTumour.

It has been termed sarcoma fromits distinguishing characteristic, hav-ing a firm and fleshy feel. There are.several species of this kind of tumour.There is one species of this tumourwhich appears principally composedof the coagulable part of the blood,rendered very vascular by the growthof vessels through it, without havingany remarkable peculiarity in theirdistribution, and I have thereforecalled it

The common Vascular, or OrganisedSarcoma.

This tumour is of a firm and fleshyfeel ; it is one of the most simple inits nature, and it is probable thatmost tumours are at first of this kindof structure. It is met with in diffe-rent parts of the body ; in the tes-

tis, mamma, and absorbent glands.After it has acquired a considerablesize, the veins on its surface are re-markably large and have rather a

flattened appearance. Such tumoursgenerally grow till the skin ulceratesfrom the distension, and exposes thenewly-formed substance, which fre-quently sloughs and falls out. How-

ever, I always like cases, and I likethem because I consider that theyimpress the mind more forcibly thanmere words. It is said, that Historyis a mode of teaching philosophy by arecital of facts." To explain to youwhat I know of this sort of tumour,I will repeat the following case. Awoman was admitted into this hos-

pital with a large tumour on the innerside of her knee, which had so spreadover the tibia that it could not be felt.It continued to increase; the veinswere large, and had a net-like ap-pearance on the surface; it distended

the skin very much ; it ulcerated ; con-siderable inflammation and sloughingof the tuiuuur-fallowed, so as to leavea cavity in. it about the size of a pintbasin. A’copious fetid discharge fol-lowed and frequent haemorrhage. Thepatient was hectic from the irritationwhich it produced. What was to bedone ? Here was a large swelling ul-cerated; whether it had any connec-tion with the bone or not could not bedecided. The patient’s health wassinking, and it was considered neces,sary to amputate. I took the limbhome, injected it, and carefully dis.sected the swelling. I found that itdid not communicate with the boaeor with the joint ; there was a part ofa thin capsule remaining at the lower

, part of the swelling; but the principalbulk appeared to be made up of thecoagulable part of the blood, renderedhighly vascular. Now there was not

fault to be attached to the surgeon id’ this case ; the disease was not under-, stood, and you know that to err is

human. The next species is the

Adipose Sarcoma.This tumour is also formed, in the

first instance, by coagulable lymph,rendered vascular ; and the secretionof the fatty matter is the result of thepeculiar arrangements and actions ofthe vessels. It is generally found inthe cellular and adipose substance onthe trunk, but sometimes on the ex-tremities. These tumours are gene.rally contained within their cysts,which appear to be formed by a slightcondensation of the surrounding cellu-lar structure, unanfected by inflamma,tion. They. .sometimes arrive to a

very great size. Sir ASTLEY COOPERhas removed one which weighed 40lbs.,others have been removed which haveweighed 22 and 16lbs. They appear’to increase in a given ratio: they will-go on increasing for many years, but’they are not noticed much in the early.part of their career ; for supposing atumour of this kind, to be of the size ofa hazel nut, why if it should increaseone-third in, the course of’a’year, it.might not attract much:attention; ;.but,if it should be the size of my head, andincrease one-third in aiyear, egad12you, would see the alteration. plain.

li enough. The vessels of adipose tu-mours are neither large nor numerous;

11

227

they are readily torn, and the licemor-rhage is very slight. There is no tu-mour that can be removed with somuch dexterity and safety as this ; itis such as young men who wish to

distinguish themselves as operatorsshould always be on the look out for.You have a patient apply to you withswelling, you make an incision uponit, open the sac, put in- your finger,turn it round- between the capsule andthe tumour, and out it comes. A mancame to this hospital with a largeswelling on the thigh, which appearedto be beneath the fascia ; the mangave a very clear account of the case ;he said that it had been forming nearlyfour years; that he remembered itwhen no larger than an egg; that ithad gradually increased, but withoutpain. The surgeons here would notundertake the operation ; they wereuncertain as to the nature and con-nexions of the tumour ; it might arisefrom the bone, and so on. They allagreed that if the tumour burst thepoor man must lose his life. I recom-mended him to call upon differentsurgeons in London before he return-ed home, and gave him a list of per-sons on whom he might call. Mr.CLINE gave him more encouragementthan any other person, and the manwent into St. Thomas’s Hospital. Mr.CLINE divided the skin and fascia ofthe thigh, put in his finer, and thetumour was easily turned out ; therewas very little difficulty attending theoperation ; no hæmorrhage followed ;the wound healed, and the patient didvery well.

This kind of tumour has sometimesa lobzslcuecl appearance; it appears tobe made up of a great many little

lobules, connected together by celtu-lar membranes, and these give it anirregular feel on the surface. Suchtumours are sometimes separated withdifficulty; they form adhesions to thesurrounding parts by their capsules,which also become thickened. Some-times there arecross bands oj’ cellularstructure, which give great troublewiten you are trying to get out thetumour. To show you that adhesionsof the capsule to the surroundingparts sometimes occasion difficultiesI will tell you a case.,A man had a tumour of this sort

which hung down from his rump ; it

gave him little pain, and he continuedto thump upon the swelling each timethat he sat down. It increased verymuch in size, and he wished to haveit removed. Mr. LoNG performed theoperation ; he made an incision uponthe swelling, but found great difficultyin separating -the skin from its surface.Ah ! thought he, it is thus " bad begun,but worse remains behind." But what-was to be done ? Why he was in theboat, and must go on ; he did go on;and after a little further dissection heseparated the skin, but expected tomeet with more trouble afterwardsd .He pulled the tumour on one side toget at it better, when out it came,.such a bundle of’ it, made up of littlelobules, like a bunch of grapes. (Alaugh.)

. There is a species of sarcoma, re-sembling the structure of the pancreas,which I have called

Tlte Pancreatic Sarcoma.

It appears to be made np of irre-gularly-shaped masses, connected to-gether by a fibrous substance, like thepancreas, and also resembles it in-colour. It is found more frequentlyin lymphatic glands than in the cellu-lar substance ; very often in and aboutthe female breast, particularly be-tween it and the axilla, where thereis an absorbent gland found, and some-times it appears as if the gland wasconverted into this kind of structure ;but I have frequently found it sur-rounded by a capsule, vclicla has in.duced me to think that it is a distincttumour. Such tumours increase verygradually, not tending to inflammation,or suppuration. They are generallyremoved after having acquired a cer-tain size, on account of the anxietywhich they produce if allowed to re-main.A lady applied to me, having a tu-

mour of this kind between the breastand axilla of the size of a goose egg,and as it had produced serious alarm,..I was requested to remove it, whichI did. When I cut into the tumour,I found it composed of the structurewhich I have described. I went backto the lady and said, " Madam, youmay make yourself perfectly easy, itis not cancer, and it will never re-turn." Dr. BoUTTATZ, of Moscow,has given an account of a tumour of

228

this kind, which grew from a part .which could not be supposed to beglandular. He says, that when tra-velling in Italy, he saw a man with alarge tumour hanging over the sideof the face, and that he was inducedto examine it. It was seven incheslong, and three inches and a half incircumference : it had been formingseveral years, and he persuaded theman to have it removed. He foundthat it grew beneath the conjunctivaof the lower part of the globe andlower lid, and protruded between thelids. He cut through the conjunctivavery carefully and removed it, andmuch to his surprise the cornea, evenwhere it had been covered by thetumour, remained transparent. Hehas given a good plate of the tumour,and his description of its substancecorresponds very closely with thatwhich I have called pancreatic. Onewould almost have thought that thedoctor had some dealings with theold one to have described a tumourso exactly, if he had not seen it ; all Iknow is, that there is a very great si-milarity in our descriptions of the tu-mour, as much so as you will find in thedescription of any other tumours. Ithad the ordinary characters of suchswellings; it was slow in its progress,not prone to inflammation, nor dis- ’,posed to ’suppurate.The next species of sarcomatous tu- i

mour which I shall mention is the

4Cystic, or Cellular Sarcoma. ,

It is a tumour made of little cells orcysts, and may be named therefore thecystic, or cellular sarcoma. There aresome varieties of this tumour. It oc-curs frequently in the testis and ovary.In one kind of this disease the testismay be enlarged to six times its natu-ral size ; made up ofannmber of cells,containing ase1’ousjluid, perhaps aboutthe size of small grapes ; it occl1rs fre-quently from a blow, and the sides ofthe cysts are occasionally very vas-cular, so as to admit of’ being injected.ir CHARLES BLICKE removed a tu-mour of this kind from the face ofa boy ; it was found to consist of anumber of cells, containing a serousauid.

In the testis, these cysts are foundto contain occasionally a caseous sub.stance.i it is like cheese in consistence;

has an unctuous appearance, and isof a yellowish cast. The sides of thecyst are generally vascular, but thecysts vary in size. Mr. RAMSDEN reomoved a testicle which contained thematerial I have just described.

Of the Mammary Sarcoma.This is a kind of tumour which very

much resembles the structure ofmam.mary glands, or udders. If you cutinto it, you will find that it is ofa firmwhitish appearance, like udder, andI have therefore been induced to nameit mammary sarcoma. Sometimes ithas a brownish, or reddish tint. Ithink, on the whole, that this diseasedstructure is verv liable to desenerateinto an intractable ulcer, which willcommunicate the disease to the partsin its immediate neighbourhood. Thisused to be a very frequent occurrencewhen Mr. ALANSoN’s mode of healingthe parts by adhesion, after the re-

moval of the tumour, was first intro-duced. I recollect a case in whicha tumour of this kind hung down onthe inner side of the thigh of a female,and from one of the labia pudendi.The tumour was examined carefullyto ascertain that there was no hernia init, and Sir CHARLES BLICKE removedit by making an incision on each sideof its base, and separating its attach-ment. The edges of the skin were

brought together, but it left a nasty,fretful, ragged ulcer. which healedvery slowly. This tumour appearedto possess no distinct capsule, but ex.tended itself gradually into the sur-,rounding parts. I have placed thhspecies of tumour in this part of thearrangement, because it appears to

hold a middle place between such asare mild in their character and suchas have a malignant tendency. Ithasbeen said, what a lamentable thing itis that the number of practitionersshould have increased so much of lateyears; but diseases have certainlyvery much increased also. Such dis-eases as were very rare when I wasa young man are now very common,and that which I have just been de-scribing may be considered as an ex-ample. I shall speak now of the

Pulpy, or Medullary Sarcoma.This is a disease which has been

very frequently found in the testicle,

229

and has been therefore called the softcancer of the testicle. But it is not

cancer, and it is found in other partsof the body, therefore it has no rightto either of these terms. I have calledit medullary sarcoma, because thesubstance of which the tumour is com-posed very much resembles the pulpymedullary structure of the brain. Icannot explain the nature of thisdisease better than by giving you thefollowing case :A man had a swelling in his left

testicle, which supervened upon anattack of gonorrhœa ; the testicle be-came very much enlarged, but occa- ’,sioned no trouble, excepting thatwhich arose from its bulk. About a I

year afterwards a gland enlarged inthe left groin, and in two years there iwere several enlarged in each groin ;I think four. These continued to en-large very much, and if I say that ’,they were as large as good turnips,I shall not exceed the mark ; I do not IImean to say that they were as largeas some turnips which I have heardof, as being a yard in circumference,but I say that they were as large asordinary sized turnips. (A laugh.)One of these grew faster than the I

rest, distended the skin, and burst. IThe exposed tumour inflamed and isloughed till it came entirely away.The sloughing exposed its vesselsthey gave way, and a profuse hæ-

morrhage followed. Now, in hæmor-rhage arising from a surface like this,it would be of no use to be pickingout little vessels with a forceps er

tenaculum, for if you were to put aligature on such, it would cut throughthe vessel, and the haemorrhage wouldreturn; but you should take a bit oflint, fold it into a little compress, putit upon the surface, and make pressureon it with your finger. The bloodcannot flow then; the lint adheres ina short time to the bleeding surface,and when you begin to feel it stick-ing, you may take away your fingervery carefully. If hæmorrhage shouldreturn, the same method must beadopted. The sloughing of this glandrelieved the distended skin ; granu-lations shot out, and the part cica-trized. A similar occurrence hap-pened in the right groin, and againin the others, when the patient, wornout by irritation and exhaustion, died.

Now the ulceration of the skin arisingfrom distension merely, and the sub-sequent healing of the ulcer,: showthat it is different from cancer, whiehcommunicates diseased action to thesurrounding parts. Neither has it thehardness nor the disposition to ulce-rate, which distinguish cancer. Thisdisease is readily propagated in thecourse of the absorbents, and their

glands readily assume this diseasedaction. This was shown in the dis-section of the case I have just recited ;the glands in the pelvis were enor-mously swollen; the glands in theloins were also enlarged, as were

those even in the chest.This disease sometimes extends

itself by the absorbents. even in a

direction retrograde to the course ofthe absorbed fluids; and I think itmust do this by imparting an irritationto the vessels, as well as by furnishinga matter ; it may, by being absorbed,communicate disease to the glands inthe direct course of absorption ; butthe absorbents below may also becomediseased. The following case wiltshow this:—A boy was brought to thishospital with a tumonr on the front ofhis thigh; it had been growing severalmonths, till it reached the size ofan orange. The glands in the groinswelled; the limb became cedema-tous ; the boy’s health declined, andhe died. It was found on dissection,that the glands within the pelvis werevery much enlarged, as were also theglands in the ham ; they appeared tobe of the same kind of structure asthe original tumour.There are two kinds of pulpy mate-

rial found in these tumours ; one iswhitish, of a milky, or more duskyhue ; the other of a reddish colour, orrather of a brownish red. We havespecimens of each kind in the Museum.

Of tlee 2’uberetelaEeci Sarcoma.This species of sarcoma is princi-

pally made up of a collection of small,fine, roundish tumours, of different

colours, connected together by cellu-lar substance. These tubercles varyin size from a pea to a horse-bean, ofa brownish red, or of a yellow tint.I have most frequently observed thesetumours in the lymphatic glands, par-ticularly of the neck. I attended a

gentleman who had a cluster of these

230

.tubercles in his arm-pit; it was aboutthe size of an egg, and its surface wasirregular; this led me to examineother parts of his body, and I foundthat the glands above the collar-bone,in the side of the neck, were also en-larged ; and on further inquiry, Ifound that he had another tubercle inhis groin. I was consulted in thiscase to give my opinion about sendingthe patient to the sea side. I met the

physician who had been attendinghim, and I said that I really did notthink the patient could live manyweeks ; that it would be of no useto remove the tumour, for if I didit would appear again; and that Idid not see of what use it would beto a man to send him to the sea sideafter that; it would be only removinghim from his friends, and perhapsmany conveniences which he mightprocure at home. I saw him again atthe end of a fortnight, and these tu-bercles had multiplied over the skinboth in front and on the back part ofhis body ; they were hard and pain-ful, and I think I shall never forgetwhat he said to me : " I am lying,Sir, upon hobnails, and every. one ofthem is sensitive." The disease in-creased ; the skin peeled off in sloughsfrom the surface of the glands in thea-xilia, and in about five weeks fromthe time I saw him he died.

Of the Carcinomatous Sarcoma.This kind of tumour, on account of

its peculiar hardness,is called scirrhus,while it remains free from ulceration.After such a tumour has ulcerated, ithas been called cancer. I shall con-tiuue to use the word carcinoma forthe first stage, and ulcerated cai-ci-noma for the second; and as this dis-ease is not so peculiarly hard in everyinstance as to tnerit the term scirrhus,and however indurated it may be, itmust, be regarded as a fleshy tumour;I -have termed it carcinomatous sar-coma. It sometimes acquires for itselfa slight capsule, but more generally itappears to be a new formation. Theboundaries of the disease cannot beclearly ascertained ; it- begins in a

small spot, and extends in all directionslike rays from a centre. It may bedistinguished by this circumstancefrom other diseases, which at their com-mencement appear to involve the whole

of the part in which they are found.It is generally slow, but unremittingin its progress ; and it excites the con-tiguous parts, whatever may be theirstructure, to the same diseased actions.In the medullary sarcoma, the diseaseis propagated along the course of theabsorbents, but it does not excite thediseased action in the surroundingparts. In the tuberculated species,the ulceration, as far as I have seen,does not spread along the skin, butdestroys only that part which coversthe diseased glands.The circumstance of a disposition

remaining in the surrounding parts toassume this diseased action, pointsout the propriety ofremoving a portionof those structures immediately sur.rounding the diseased part. Verymuch has been said and written oncancer, and you should read Vl-hathasbeen written. It is impossible, in alecture-room, to give you a detailedaccount of cancer. But I know nobetter definition of this disease thanhas been given by Dr. BAILLIE. Hesays, the diseased part is peculiarlyhard, that there are intermixed firmwhitish bands, which extend in alldirections from the middle towardsthe circumference of a carcinomatoustumonr, like rays from a centre. Itwas this appearance which, there is nodoubt, obtained for it the name ofcancer. These diseased parts, project-ing out of the surrounding structures,should be carefully dissected out-in anoperation for the removalof a carci-nomatous tumour. There is ne remedyfor it but the knife ; to forbear tooperate, is to consign the patient tomisery.The ulceration and self-destroying

process of cancer is so horrible, thata patient gets rid of a quantity of dis-ease upon easy terms, by having itremoved bythe knife. 011 ! a ean-cerous sore is dreadful ; its edges arethickened, and the surface secretes athin irritating ichor ; the sore openslike a flower, as Mr. HUNTER used tosay. This ichor is so, irritable, thatDr. CRnwrortD was led-to make someexperiments to ascertain its nature,and he said that it contained bydt’o-su!-phuret of ammonia ; he recommendedchlorine as an application calculatedto remove the fætor of the discharge;carbonic acid gas has been used with

231

the same intention, and various me-tallic preparations. Narcotics werefound to be the best applications,and they are also the only medicineswhich allay the sufferings of the pa-tient. In my next Lecture I shallconclude the subject of tumours.

LECTURESON THE

PRINCIPLES AND PRACTICE

OF PHYSIC,

BY DR. ARMSTRONG.

Theatre of Anatomy, Webb Street.

LECTURE 6.

DR. ARMSTRONG briefly recapitu-lated the phenomena of inflammation,and the pathological conditions on

which these phenomena depend, andthen proceeded to the piincipal di-visions, and to the immediate andremote effects of inflammation.

GENTLEMEN,Inflammation is acute, szeb-acute,

and chronic, As in these Lectures Ishall often use these terms, it is rightthat I should attach a definite mean-ing to each ; and, indeed, it is my in-tention to explain, as I proceed, everysuch term as I may have occasion to

adopt. If ever 1 forget to do so, I

hope that you will demand an expla- Ination , for if I have a definite idea,I can find a word to express it; butif I have not a definite idea, I wi)l notattempt to conceal it, but at once ac-knowledge to you my ignorance onthe subject in question. By acute in-flammation, I mean the highest degreeof inflammation, which arises sud-

denly, advances svithrapidity, and ter-minates in a few days, if left to itself.By sub-acute inflammation, I mean alower degree of inflammation thanthe acute, which arises less suddenlyand severely, has a more protractedcourse, and, if left to itself, does notterminate,in the first week, but runson to the second or third week. Wheninflammation is acute or snb-acnte,it is , attended by fever, which is

higher in the former, and there is lesslocal disturbance in the latter. Bythe term chronic inflammation, I meanan inflammation which begins andgoes on very slowly, and which isgenerally unattended by -fever for aconsiderable time after its formation.When inflammation is acute or sub-acute, the system is attacked, as itwere, by storm ; -an alarm is excitedthroughout the whole, or, to speakless figuratively, a considerable dis-turbance, called fever, is produced ;but when inflammation is chronic, it

begins and proceeds so very in-

sidiously, that litt!e or no generaldisturbance arises for some time.

I shall have occasion also to use theterms active inflammation. and passiveinflammation. When inflammation isactive, it is attended by a very highdegree of fever, by a remarkably hotskin, and by either a full expandedpulse, or a smaller, but a hard con-tracted pulse, feeling like wire or

whip-cord beneath the finger. Butwhat I mean by passive inflammation,is that attended by a subdued or

masked form of fever, in which theheat upon the surface is scarcelyhigher than natural, and in which thepulse is remarkably soft and compres-sible, the heart’s action being reallydiminished in natural force, while thecapillary vessels of some part remainengorged. We have an example ofthe active and passive inflammation insome cases of typhus fever, the activeat the commencement, and the passiveat the end. At the former period,the skin is in such cases intensely hot,and the pulse expanded, while someorgan is acutely inflamed; this statecontinues for five or six days; thenthe heat begins to fall on the surface,the pulse becomes subdued, the mus-cular power prostrate, and the tongueglaze(1 and brown. Now in what doesthis change consist ? There is alwaysa remarkable deficiency of force inthe action of the heart, whatever maybe its frequency. In active inflam-mation, the heart’s action is increased,;but in the passive it is diminished.This distinction between active andpassive inflammation is of the greatestimportance in the practice of physic.If you were to treat an active -inflam-mation in the same manner as a pas-sive one, yon would be extremely un-