Elements of Surgery

by Robert Liston

OF TUMOURS.

A tumour is a swelling or new production, and not a part of the original composition of the body. Blood may have been effused, and the coagulated part, becoming organised, is increased in size by deposits from the vessels which enter it; or perhaps the blood, the coloured part of it at all events, is taken up and lymph is deposited, which, if not also removed, “undergoes further changes of a secondary nature, and remains a parasite or new structure.” Its structure and growth are modified according to the action which its own vessels assume, independently of the surrounding vascular system. The bloodvessels may enter this new growth by a narrow pedicle; or it may be of such a form as to present an extensive surface, by which it communicates with the surrounding parts, receiving vascular ramifications from them. As the growth of the tumour proceeds, the surrounding parts yield, are condensed, and form an envelope for the new formation; the neighbouring bloodvessels are excited to a greater degree of action, and more blood is poured into the vessels of the tumour; the action of these in turn is very vigorous, and the increase of the new growth is more and more rapid. They become, it would appear, dilated and tortuous. Morbid enlargement, or rather new productions, often attain an enormous size; some have weighed, when recent, upwards of 60 or 70 lbs. Tumours differ much in structure; and though their general appearance may not be dissimilar, one will scarcely be found exactly resembling another. In many cases, the external appearance proves no certain index of the nature of the tumour; sometimes, however, its feel and general external character lead the experienced surgeon to form a correct estimate of its internal structure. It is impossible, by any process of reasoning, to account for the different actions which these growths possess; and even minute anatomical investigation, either of healthy or morbid structures, has not as yet thrown much light upon the subject.

Tumours are divided into Solid and Encysted. The solid are generally enveloped by a dense cellular sheath of the surrounding cellular substance, yielding and becoming condensed in proportion as the tumour increases in size; this covering appears as a barrier between the healthy and diseased parts, shutting out the latter, as much as possible, from connection with the rest of the body, and preventing the former from participating in the injurious tendencies of the latter. Some tumours have no such limit, but extend in the direction where there is the least resistance, hold a free intercourse with the surrounding parts, and impart to them their morbid disposition and action; others are limited in their situation and communications, but prove dangerous or annoying from their bulk. Some grow rapidly, and prove troublesome in a few weeks or months; others remain without much increase for years, and produce little or no inconvenience. Occasionally tumours partly resemble the texture in which they grow; those of a fatty nature are frequently found to have their nidus in the adipose tissue; cartilaginous tumours project from the surfaces of bones or of a joint, are subsequently detached, and lie loose in its cavity; growths of a cellular structure internally, and invested by an apparently mucous lining, protrude from the surface of mucous membranes. Others differ, not only from the texture in which they are situated, and from which they derive their nutritive vessels, but also from every other part of the healthy structure. In one instance, a congenital tumour was found to be composed of an aggregation of numerous materials, many of them resembling the healthy textures of the body. But again, tumours are constantly met with, composed of matter which in no respect resembles any of the natural tissues of the body: those are what have been called heterologous formations.

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.

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.