TUMOURS

ARE outgrowths which differ from hypertrophies in never serving any useful purpose. This difference may be illustrated by the uterus, which hypertrophies during gestation, but often forms a tumour of exactly similar tissue to its own, often described as polypus. Tumours are usually divided into benign and malignant, the latter class including cancer alone; and with these two subdivisions the terms analogous and heterologous correspond. These epithets are convenient but not strictly accurate. They are also talked of as " continuous when formed amidst tissue like themselves; "discontinuous" when isolated by other structures. Paget's classification is as follows:

I. Cystic tumours—

A. SIMPLE OR BARREN.

1. Serous, 2. Synovial, 3. Mucous,

4. Sanguineous,

5. Oily,

6. Colloid,

7. Seminal.

B. COMPOUND OR PROLiferous.

1. Complex cystic,

1. Serous cysts, which occur in any part of the body where areolar tissue exists; for from the cells of this, or perhaps its areolæ, they have their origin. The cyst is lined with tesselated epithelium, and filled with a fluid usually like the serum of the blood; but it may be stained of different tints by its hæmatin, may contain some of its solids, frequently cholesterin, and may be

come solid on removal, owing to the presence of fibrin. No better example could be adduced than "hydrocele of the neck," as described by O'Beirne. 2. Synovial cysts, which are either enlargements of original bursæ (“housemaid's knee"), formation of new ones (“ bunions"), or distension of the cells of synovial sheaths about tendons (ganglion). They contain synovia, albumen being more abundant in the latter case, and little cartilaginous bodies, like melon seeds or half-boiled rice, are often found within them, especially about the wrist. 3. Mucous cysts result from the distension of a mucous cavity or cocal gland-duct, consequent on obstruction of its orifice. Ranula is an example. 4. Saguineous cysts most resemble the serous, save that they are filled with blood, which is either poured out as the result of injury to a cyst previously containing serum, or the enlargement of a vessel in a nævus. One the size of a goose-egg, in the posteriorinferior triangle of the neck, was lately treated by my colleague, Dr. Quinlan, in St. Vincent's Hospital. 5. Oily cysts are very rare, but have been found connected with the sebaceous or lactiferous ducts, and filled with pure oil. 6. Colloid cysts occasionally occur in the kidney or thyroid, and contain a jelly-like matter very similar to that found in the cells of colloid cancer; and 64 parts of albumen per 1,000 may be obtained from such matter. 7. Seminal cysts, or encysted hydroceles," are, as was explained by Müller, most commonly distensions of that tubular remains of the Wolffian body which lies above the epididymus, and which is sometimes named "the organ of Giraldés." They are by others supposed to be dilatations after obstruction of the seminal ducts, or effusions of fluid between the albugineal and serous layers. They, however, contain spermatozoa, which Paget believes they themselves generate; he mentions one which held 46 ozs. of fluid.

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Compound or Proliferous Cysts have the power of producing within themselves organised structures. 1.

Complex cystic, which usually grow in the ovary and generate within the parent cyst several others—often in hundreds, and, within these again, often tertiary cysts. Beale has found the epithelium occasionally ciliated. 2. Cysts with glandular or other vascular growths are exemplified in the "sero-cystic sarcoma," which Brodie described in the breast. The vascular mass produced in the interior may so completely fill the sac as to produce an almost solid tumour, which, according to Hodgkin, were always formed in this way originally from a cyst. Still further urging outwards, it may burst the skin and protrude as a fungous mass. This intracystic mass may be glandular, corresponding to the gland with which it is connected, or may be composed of cellular matter much resembling granulations. No tumours are more difficult to diagnose from cancer. 3. Cutaneous cysts produce within them various matters which are normally connected with the skin-they may be congenital or formed after birth. Congenital ones are scarcely ever found except near the eyebrow, often dipping deep into the orbit, and containing fatty matter and ill-developed hairs with the free ends split into many fibres. Of those formed after birth the scalp is by far the most frequent seat, and here they are familiarly known as wens." Sir A. Cooper looked on these as obstructed sebaceous follicles, and believed a dark mark always indicated the original duct. Tablets of cholesterin are often present, and may be tested by giving a blue tint, passing to brown, with iodine and sulphuric acid. Cysts containing cutaneous matters may occur in the ovary, where they generate these contents very perfectly; so that at one time they were supposed to be the remains of a partly absorbed foetus: they have been also occasionally observed in the testis, kidney, and even within the skull. It is remarkable that there is a strong hereditary tendency to their production. 4. Dentigerous cysts occur mostly in the ovary, or may be congenitally formed in

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other situations. Teeth, even to the number of 400, have been found within them, and occasionally also hair, epidermis, &c. Those occurring about the jaws are tooth saccules, from which the teeth were never protruded.

II. Solid Tumours and Out-growths.-1. Fatty tumours are likewise known as lipoma and steatoma. Those which are continuous occur in the subcutaneous fatty tissue, of which they are a local increase, and are well distinguished by their scalloped edge, projecting into the surrounding areolar tissue, and their soft "pillowy" feel. Others may occur even where no adipose tissue normally exists, and are covered with a capsule which dips into and lobulates the fatty mass. These are known by the skin over them dimpling when squeezed. The microscope discovers fat-cells larger than normal, especially in the softer tumours; others of them are shrivelled and some occasionally contain beautiful crystals of the fatty acids.

2. Fibro-cellular tumours, which consist of areolar tissue usually in a distended or dropsical state, owing to the pendulous form most of these out-growths possess. Of these covered by mucous membrane, simple polypi, as those of the nose, rectum, or bladder, are good examples; and they have a ciliated, columnar, or tesselated epithelium, according to the situation from which they spring.

Dr. O'Ferrall published, in 1847 ("Dublin Journal"), a masterly account of pendulous tumours which he had observed in St. Vincent's Hospital and in consulting practice. I shall quote his description of the appearances on section, and refer to his memoir, which contains all we know on the history, diagnosis, and treatment of these important growths: The general appearance of the section of pendulous tumours is that of areolar tissue, more or less hypertrophied, and containing in its meshes a limpid secretion. The whole has a

pearly or whitish semi-transparent appearance, when of the simplest kind. In the living state this section would, no doubt, be more or less vascular, and present a very different hue. The granulations which spring from these tumours, when the skin has given way, have invariably the red, fleshy tint of a highly organized part. To the tissues already named, and which constitute the simplest form of pendulous tumour, may be added others, which give it a special character. Thus the cellular tissue may contain adipose substance in quantity sufficient to give it the character of a fatty tumour. I have seen several examples of this kind, and shall relate the particulars of the most remarkable instances further on. The cellular tissue may be occasionally the basis of an accidental erectile formation. The tumour in such cases has the uneven purple colour of the nævus, and is capable of great reduction in its volume when compressed between the fingers. A section of these tumours shows the numerous apertures of vessels divided in different directions with respect to their axes."

Fibro-cellular tumours often occur about the labia or scrotum, and have been mistaken for elephantiasis of those parts; but they are more discontinuous, and are separated and lobulated by firm areolar tissue. Elephantiasis is more painful, fissured and excoriated, and is produced by recurring attacks of erythematous inflammation. Such tumours yield gelatin, and albumen from the serum which soaks them, on analysis. They have no malignancy. Dr. Beatty and I removed a large one from the left labium of a lady two years since; six months after she was found to labour under scirrhus of of the os uteri, but the scar of the operation remained still perfectly healthy. 3. Fibrous tumours consist of white fibrous tissue, often glistening and tendinous. The fibrous polypus of the uterus is the type of such outgrowths in most particulars; but as its tissue is identical with that of the womb itself, the term fibro-muscular