Chapter VII: Part 7

In consequence of aneurism, the circulation of blood in the vessel is obstructed; hence the collateral branches above the tumour become enlarged, and through them the circulation is continued; by their anastomosis with collateral branches which arise below the seat of the tumour, a portion of the fluid is brought back into the canal of the original artery. The circumstance of collateral enlargement used to be distinctly enough demonstrated in amputation, one of the old cures for the disease.

The tumour may be suddenly increased by a portion of the parietes giving way, and the blood being propelled into the cellular tissue, which becomes thereby condensed, and supplies the deficiency in the original sac; diffuse is thus superadded to the true or encysted aneurism.

The disease is generally accompanied with great pain, the neighbouring nerves being much stretched by the enlargement of the tumour, as in the axilla or ham; in these situations also the limb below the aneurism is much swollen from the compression of the absorbents and veins and consequent infiltration into the cellular tissue. Diffused aneurism from wounds, and the other species of the disease, will be afterwards treated of.

The peculiar degeneration of the coats of the vessels has been already stated to be the predisposing cause of aneurism; and the disease may be directly caused by over-excitement of the circulation, or by an over-exertion of the muscles. It is more frequent in males than females.[14] In men somewhat advanced in life the arteries get hard and rigid, whilst at the same time the muscles are strong, the general health good, and the whole frame stout and active; so that the patient is capable of violent muscular action, such as the arteries are ill able to bear, and consequently the internal coat of a vessel yields, and lays the foundation for an aneurism.[15] The lower limbs being chiefly subject to such exertions, aneurism in them is most frequent;[16] and for the same reason it is said to be common in those who ride much on horseback. Degeneration of the coats of the vessels in the superior extremity is extremely rare. This is another reason why spontaneous aneurism seldom assails them.

_Treatment._—In internal aneurism the only indication which can be followed, with any chance of success, is to favour the occurrence of a spontaneous cure, by abstracting all stimuli, mental and corporeal, by enjoining complete rest, by keeping the patient on low diet, and by repeated bleeding. Thus the force of the circulation is diminished, and coagulation, it is said, promoted; by this practice aneurisms, the progress of which defies external means, are occasionally, though very rarely, cured. Ice and other cold applications to external aneurisms, or those which have made their way to the surface, have been recommended to induce coagulation, but their use is not unattended with danger; for they may, in some stages, so far diminish the vitality of the coverings as to cause sloughing, and fatal hemorrhage.

In the treatment of aneurisms exterior to the great cavities, important improvements have been made in modern times. No success can be expected to follow palliative and temporizing measures, and a cure can result only from operation. Formerly it was the practice to lay open the aneurismal tumour, to search for the extremities of the artery opening into the cavity, and to secure them by a ligature, or close them by pressure, styptics, or both. In some few instances this method had permanent success; but in the majority the operation proved wholly abortive, and not unfrequently fatal. It was necessarily tedious in its performance, and attended with much danger, the blood being discharged in great profusion immediately after the opening of the sac, and the extremities of the vessels being with great difficulty detected and secured. Besides, the vessels in the immediate neighbourhood of the tumour having generally undergone the degeneration already mentioned, were incapable of taking on any healthy action; the application of ligature on a vessel thus circumstanced could consequently be productive of no advantage. From this method having almost invariably proved unsuccessful, practitioners in those days generally preferred amputation, when the tumour was so situated as to allow it; and when the disease occupied a situation in the limb so high as to prevent amputation, the case was deemed incurable, and the patient abandoned to his fate. But amputation was accompanied with circumstances almost equally alarming with those attendant on division of the sac: the hemorrhage was very great; for as a consequence of obstruction to the free passage of the blood in the aneurismal vessel, the circulation was chiefly carried on by the collateral anastomosing branches, which were thereby so much enlarged, as, on their division, to pour out blood with a profusion resembling that of arteries of the second or third magnitude. Continued pressure was employed as a less hazardous method of cure, but was equally inefficacious; and was also attended with danger, from the risk of sloughing. If the practice ever proved successful, it was only after a tedious perseverance in its use, and long confinement of the patient.

The operation of applying a ligature on the vessel at a distance from the tumour, and thus intercepting or weakening the flow of blood into the cavity, so as to allow complete coagulation to take place, is of comparatively modern invention, and is the one now practised with almost invariable success. To John Hunter without doubt belongs the merit of proposing and putting it in practice; it has been claimed also for the celebrated Desault. This operation has been variously modified. Some have advocated the temporary application of a ligature, conceiving that the effects produced will be as complete and permanent when it has been allowed to remain only for a certain time, as when it is left undisturbed and ultimately separated by nature. Such a theory, however, has proved to be incorrect in most of the instances in which it has been reduced to practice on the human subject; and the operation is at best very uncertain, and not to be relied on. Others have employed a double ligature, and some of the Continental surgeons have applied a great many; some were tightened, others left loose, and looked upon as ligatures of reserve to be tightened, should hemorrhage take place, an occurrence likely enough to follow their clumsy and unsurgical proceedings. A thick broad ligature like tape has also been used, from an ill-grounded apprehension that all the coats of the artery would be cut completely through by the tight application of a thin and firm one. With the same view, a roll of linen or plaster has been interposed betwixt the noose and the vessel, and this practice has been advocated even by good surgeons—as Scarpa. Such complications can do no good, and may do much mischief. The artery must be greatly detached from its surrounding connections before the numerous and flat ligatures can be applied, in consequence of which its coats will be apt to slough or ulcerate, and hemorrhage occur. When, from any cause, the vessel has been detached to a greater extent than is sufficient for the passing of one ligature, two ought undoubtedly to be used, and one applied close to each extremity where it is attached to the surrounding parts.

Again, it has been proposed, after the application of a double ligature, that the vessel should be cut through betwixt the two deligated points; it being supposed that in this way the closure of each extremity will be more rapid, the cut ends retracting, and being, in fact, in the same circumstances as the extremities of arteries which have been tied on the face of a stump. Mechanical contrivances have also been invented for the compression of the artery,—such as the serrenœud and presse artere; these, however, are clumsy, insufficient, and often injurious.

The single ligature, when properly applied, is the most safe, and preferable to any other, for arresting permanently the flow of blood in a vessel. In its application, the artery must not be separated from its connexions farther than is barely sufficient for the passage of the armed needle beneath it; but the external incision ought to be free, in order that this may be readily effected, and that the operation may be easily and speedily performed. By the firm application of a single ligature, the vessel is rendered impervious; the internal and middle coats are divided, so that the ligature only encircles the outer or cellular one, which resists the influence of any moderate degree of force by which it may be tightened. The blood coagulates above the deligated point,—the coagulum is of greater or less extent, in proportion to the vicinity of a collateral branch, and is of a conical form, the apex of the cone pointing to the free portion of vessel. Incited action in the vessel takes place at the deligated point; the divided margins of the internal and middle coats secrete lymph, by which they adhere, and so obliterate the canal of the artery. Lymph is also effused on the external surface, and in this deposit the ligature becomes imbedded. The direct influx of blood into the aneurismal sac is thus intercepted, and time is allowed for coagulation of the blood which it contains; the artery for a considerable distance below the ligature becomes ultimately converted into a firm and impervious chord. The coats of the vessel above the ligature are much thickened, and the internal membrane is occupied with the transverse rugæ occasioned by projecting fasciculi of the fibres, which are always apparent after obstruction of an artery. If this operation be properly conducted, success must almost uniformly follow. Before determining on its performance, however, the state of the arterial system ought to be examined as carefully as possible; for not unfrequently the degeneration of the coats is almost universal, and therefore an artery, or even arteries, may be diseased at more points than one; and if this aneurismal diathesis exist, the patient may be found to labour under an internal aneurism of the aorta. In such a case, an operation could not with propriety be undertaken for the cure of the external aneurism; there might be no inconsiderable danger of the patient’s death being suddenly accelerated by the operation, the sac of the internal aneurism giving way perhaps during its performance: such a circumstance has actually occurred.

Ligatures composed of animal substance, such as catgut, have been proposed as preferable to all others, on the supposition that they would be absorbed, and occasion less irritation; the fallacy of any such theory has already been adverted to. After the ligature has been applied for some time, it induces ulceration of the external coat which it envelopes, by which means it becomes detached from the vessel; acting as a foreign body, and causing a slight degree of suppuration, it makes its way by nature to the surface and is discharged. The period at which it separates may be said to be from the tenth to the twentieth day; sometimes sooner, seldom later. If, however, much of the surrounding parts have been extensively included along with the vessel, a longer period will probably elapse before the separation of the ligature. One end only of the ligature should be cut away close to the artery, the other being left hanging from the external wound; perhaps it is even safer to leave both, unless a third knot is made upon it; thus the extraneous body, when detached, can be gently pulled at so as to hasten the separation: this must be done with very great caution. When both ends are cut short, and the knot closed in, there is a risk of secondary hemorrhage, from the ligature causing formation of matter round it, perhaps detaching the vessel from its connections, and causing ulceration of its coats.

The operation ought to be performed at as early a period of the disease as possible. Some recommend that it should be delayed in recent cases, with the view of allowing sufficient time for the anastomosing vessels to enlarge, in order that the circulation may be more vigorous in the smaller branches after obstruction of the principal vessel. Such delay prolongs the patient’s sufferings, which are in many cases extremely acute, and the precaution is altogether unnecessary, as has been amply proved by experience. On the same principle, the previous application of pressure to the vessel has been recommended; but few surgeons, if any, are now afraid of trusting to the resources of Nature when the principal vessel of a limb is obliterated, and that suddenly, without previous dilatation of the anastomoses. Cases are on record, in which the abdominal aorta has been completely obstructed by a natural process, without much impeding the inferior circulation; and in one remarkable instance of this description, the inconvenience was so slight that the disease was not suspected during the life of the patient, the lower limbs retaining their usual size and activity. In plethoric habits it may sometimes be prudent to abstract blood, even more than once, previously to the operation.

When the ligature is placed immediately below a collateral branch of considerable size, a bloody coagulum is not formed, though adhesion may occur; but if the excited action should extend to the collateral branch, and its canal become thereby obliterated, a coagulum is speedily deposited. In consequence of the enlargement of the anastomosing branches, and the increasing circulation in them, pulsation generally returns in the tumour, to a slight degree, some days after the operation. This, however, is by no means a sign that the operation has been ineffectual; for the renewed pulsation almost always disappears in the course of a very short time. In one instance only have I found it assume a more permanent and troublesome aspect; in that case, it recurred about ten months after the performance of the operation, but speedily disappeared under the careful use of a compress and bandage.

On account of the aneurismal diathesis, it occasionally happens, that after the cure of one aneurism, another appears in a different situation; in two instances, I operated on both thighs, at a considerable interval, successively and successfully, for popliteal aneurism, in the same patients.[17]

When the tumour is so situated as not to admit of the application of a ligature between it and the heart, it has been proposed to place the ligature on the distal side of the aneurism, upon the supposition that coagulation will occur within the sac in this case as after the common operation.[18] The practice has been made trial of, but its expediency appears very doubtful; neither has the success attendant upon it been such as is generally supposed: the _post mortem_ examinations have been very unsatisfactory in some of the cases. The application, indeed, of a ligature in that situation can seldom be of any advantage, the artery being already obliterated, in aneurisms of some standing, a long way beneath the tumour; and it is, perhaps, from this circumstance that, in such operations, great difficulty has been experienced in securing the vessel, and that it has been thought necessary even to pass a needle under a thick mass, somewhat in the situation of the artery. It would appear, in some instances, that the artery when pervious had even remained untouched, not being even exposed by the burrowing process employed by some of the operators; and that if any vessel was tied, it was not the trunk in which the disease existed. It would appear that a very correct diagnosis had not been formed in some of the cases.

The appearance of the vessel after the application of a ligature above the tumour has been already shown. The obliteration of the sac proceeds, in some cases, very rapidly; it assumes a harder feel, decreases, and disappears; being connected with the vessel by means of a dense impervious chord, to which condition that portion of the artery has been reduced. The anastomosing vessels enlarge more and more, carry blood freely from above to below the ligature, and thence to below the tumour; some even passing to the latter situation directly from above the ligature. Along with the muscular and other branches, the neurilemmal vessels also become enlarged, and compress the nervous filaments; and to this are to be attributed the annoying pains which sometimes occur in a limb after the operation for aneurism. The enlargement of the arteries of the neurilemma can be distinctly shown by dissection.

Immediately after the operation, the circulation in the limb cannot be so vigorous as before; its temperature is consequently diminished, and it possesses less power of resisting the influence of stimuli. The limb ought to be kept only moderately warm; for if too much heat be applied, there is a risk of gangrene. The temperature afterwards rises, and soon gets above the natural standard; the blood, from obstruction in the internal parts, being chiefly determined to the surface. After the collateral circulation has been completely established, the limb regains its natural temperature.

Secondary hemorrhage is occasionally a consequence of this operation; nor is it to be wondered at, should one ligature only be used, seeing that this is often clumsily applied; the cellular tissue being lacerated, and the vessel detached from its connections by the use of blunt instruments, directors, and silver knives. When many ligatures are employed and foreign substances placed in the wound, the patient can scarcely be expected to escape profuse bleeding. If, however, the operation by single ligature be properly performed, and the coats of the artery be sound at the deligated point, the occurrence of secondary hemorrhage must be rare. It generally supervenes when the ligature is about to separate: at first there is a thin bloody discharge, afterwards the quantity of blood is more copious; it is evacuated at first in a gentle and continued stream, but afterwards _per saltum_, and in profusion. The discharge not unfrequently stops for a short time, but, on the circulation being excited, it again returns; and the patient soon dies, unless active measures be practicable, and immediately resorted to. Compression can be of no use; nor can astringents, nor venesection, which I have actually seen practised in such cases. The application of a ligature betwixt the heart and the open point of the vessel affords the only chance of saving the patient; the surgeon must interfere, and do what is in his power—he cannot look on and see the patient bleed to death.

Occasionally the aneurismal sac deviates from its usual structure and appearance. Sometimes osseous or calcareous matter is found deposited, to a greater or less extent, in the substance of the parietes of the sac, or between the laminæ of fibrin which it contains. The tumour may also occupy unexpected situations, occurring after fracture of the bones and laceration of an artery, and perhaps from more slight external injuries. A disease of bone, somewhat resembling aneurism in that tissue, will be afterwards noticed.

OF ANEURISM BY ANASTOMOSIS.

This disease is generally seated in the external cellular tissue. It has been supposed to attack occasionally the internal organs; and a case is related in which it was situated in the cellular tissue, between the vagina and rectum. Frequently the congenital marks of children, termed Nævi, degenerate into this disease: occasionally, though very rarely, it occurs in sound skin and in adults. A good case of this kind will be found in the _Practical Surgery_, p. 336. When the cutaneous tissue is involved, the colour of the tumour is a dark red, or inclining to purple; it is irregular on its surface, and has a soft, spongy feel. Often it is raised distinctly above the surrounding parts; at other times it is flat, scarcely prominent, and seems to enlarge chiefly in a lateral direction. The skin is then frequently unaffected; pulsation, in some instances, is perceived; often, however, the tumour is of an inactive character, affords no pulsation, and, on being handled, feels like a doughy, elastic intumescence, appearing to be composed of a congeries of distended vessels, in which the blood circulates slowly, and resembling varix. The tumour is formed by enlargement, tortuosity, and increased activity of the capillary and other vessels; in some cases the arteries are chiefly affected, in others the veins. That such is its structure, can be distinctly proved by dissection; the vessels are found enlarged to many times their natural size, and their coats are much attenuated; it is certainly not cellular, as some have supposed. The tissue is similar to that of the cavernous and spongy bodies of the penis, and has hence been named erectile. A natural structure of the same kind is met with in the lower animals in different situations. The tumour is much increased on the general circulation being hurried, as by crying in children, by fits of passion, by the excitement of ardent liquors or venery, and during or before the menstrual discharge. On such occasions the surface frequently gives way, hemorrhage ensues, and is often profuse; in females it sometimes takes the place of the regular discharges. The tumour, in general, increases rapidly in size, and bleeds from time to time; now and then, however, it becomes stationary, even in circumstances where it could hardly be expected, and remains so during the remainder of the patient’s life. Again, in children, the surface of the tumour is not unfrequently ulcerated, even to a great extent, without hemorrhage occurring; when such is the case, the ulceration for the most part extends, with surrounding induration and condensation of the parts. The whole or part of the adventitious tissue may thus be destroyed; the parts cicatrise, and a spontaneous cure is sometimes accomplished. In other cases, though the disease is not extensive, frequent and most violent hemorrhage occurs. A hemorrhagic tendency also occasionally occurs in affections of a different nature,—a trifling sore pouring out blood on the slightest touch. In some constitutions, leech-bites, trifling punctures, or the extraction of a tooth, have been followed by dangerous hemorrhage. The disposition very often exists in many members of the same family, and is sometimes hereditary. Great trouble has been experienced in staying the bleeding; large vessels have been tied without effect, and some patients have even perished notwithstanding every exertion on the part of the attendants. It becomes a difficult matter to treat surgical diseases in such constitutions: openings cannot be made with the knife for the evacuation of matter or any other purpose. A good case will be found in the _Lancet_, 1838-39.[19] The same patient again presented himself with a very large and deep abscess of the hip, which was opened by caustic, though nearly one inch and a half from the surface. It is not easy to account for this disposition to bleed so profusely, or from slight causes. The blood is in a diseased state, probably as in the patient here referred to, in whom it contained pus globules, and coagulated slowly; there is probably also a want of tone in the vessels themselves. Many such cases are on record. The cause, or causes, of aneurism by anastomosis are also unknown.

In very slight cases of erectile tumour, or in nævus threatening to assume an aneurismal action, cold and pressure are sometimes, though very rarely indeed, sufficient for the prevention or removal of the disease. The most effectual remedy is excision, though this can very rarely indeed be had recourse to with safety; for when the disease is extensive, the vessels in its neighbourhood are much enlarged, and their action increased; so that any attempt to remove the tumour by the knife is followed by profuse, and often an uncontrollable, flow of blood. When excision is practicable, it ought to be accomplished by cutting very clear of the disease; the tumour, like every other, must be cut out, not cut into. If the incisions encroach on the substance of the tumour, or are made in the immediate neighbourhood of the diseased part, the tremendous bleeding which invariably ensues will convince the practitioner of the impropriety of his conduct, and rashness of the proceeding. Attempts have been made to arrest the progress of the diseased action, by tying the principal arterial trunks entering the tumour; but these have proved ineffectual, as might be expected, considering the unusually free and numerous inosculations which then exist. In a few instances, ligature of the carotid artery, on the same side with a tumour on the face or head, has put a stop to the disease; in the others, it has been unavailing.

When the tumour is so situated, or of such a size, as to render the expediency of excision doubtful, it may often be safely and expeditiously removed by ligature. In some cases the tumour is prominent, so that it readily allows of the application of a ligature around its base; in others, it is flat and broad; in which case, a long needle, or needles, armed with a double ligature, can be passed beneath it, and the ligatures can then be separated, and so disposed as to cause sufficient constriction of the entire mass.—Vide _Practical Surgery_, p. 331, 336. In many cases, incisions may be made with great advantage, either before or after introducing the ligatures; the diseased mass is thus more effectually included and strangled, and much pain and deformity are avoided. The disease, however, occasionally occupies such situations as are totally beyond reach. The application of potass has been recommended; and this caustic is certainly sufficiently powerful to destroy the diseased parts; but its use is attended with danger from profuse hemorrhage. Superficial nævi may occasionally be got rid of by the application of nitric acid, but it requires to be applied over and over again; and, after all, some more effectual means must probably be resorted to. Stimulating injections into the substance of the growth have been sometimes employed. Cures, it is said, have followed the use of setons, or the repeated puncturing and breaking up of the tissue with a needle. None of these means are to be depended upon. The cases are innumerable in which I have been obliged to employ the ligature in an effectual manner, combined or not with incision, where caustics, injections, puncturings, setons, and even imperfectly applied ligatures, had been previously resorted to in vain. Besides, in children there is as much resistance and crying, and as much anxiety in parents, produced by a slight operation, as by a more effectual one.[20]

OF INFLAMMATION OF VEINS.

Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly; in some cases it reaches the right side of the heart, producing most violent symptoms, and speedy dissolution.

Inflammation in the venous, as in the other tissues, may terminate in resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface agglutinated, causing obliteration of the canal to a greater or less extent. Suppuration also occurs, and the pus may be deposited in a cyst formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation.

The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable œdematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, causing sloughing of that tissue, or of the soft parts more deeply seated.

This disease generally follows an accidental wound or operation, as venesection or amputation; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many patients have died of this disease, induced by the application of a ligature to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints.

Inflammation of veins is a very unmanageable disease; the exhibition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation; the pain will also be much relieved by the application of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been employed, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its contents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious.

Inflammation of a vein is also occasionally followed by the sudden appearance of a purulent depôt in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the forearm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and, on examination, abscesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory explanation of these phenomena cannot readily be given.

It has already been noticed, that the softening of coagulated fibrin must not be confounded with suppuration. The fibrinous pulp has commonly been called pus, though erroneously; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is important; first, because many of the so-called cases of phlebitis are shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard.

There exists without doubt a capillary phlebitis, and the vast importance of inflammation, and its consequence in these vessels, will be estimated when their great extent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus.

Veins frequently become dilated or _varicose_; they assume a tortuous course, appear much enlarged, and present an elastic, soft feel, except in the situation of the valves, where they are more hard and incompressible: occasionally the tortuous windings form a bluish tumour of considerable size. The dilatation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less support. The limb is swollen and œdematous. The dilatation is generally supposed to be confined to the vessels near the surface, but it appears that the deep-seated ramifications are not exempt from the affection. When a dilated vein becomes inflamed, great pain is felt in the part; the vessel feels like a firm chord, its coats are much thickened, and its cavity proportionally contracted; lymph is effused, and by it the canal may be obliterated to a greater or less extent; a spontaneous cure is thus accomplished. In the lower limbs, the disease is often complicated with ulcers; and as long as the veins remain varicose, the ulcers are almost incurable, or if they are brought to cicatrise, the skin soon ulcerates again, and the disease is reëstablished. The coats of the vessel not unfrequently ulcerate, and blood is discharged in appalling profusion: such an occurrence may even prove rapidly fatal. Sometimes, though rarely, skin thinned by pressure from within gives way without previous ulceration, and profuse bleeding ensues.

The cause of this affection is obstruction to a free return of the blood; as by tumours, either natural or adventitious, from pregnancy, constipation, &c.; or by the tight application of a ligature round the limb, as of a garter. It often occurs in those who have been in the habit of great muscular exertion, the blood being thereby forced from the deep-seated veins into the superficial. This even occurs, though very rarely, in the upper extremity, and I have witnessed more than one instance of it. Here it is more readily got rid of. Dilatation of venous branches is met with in the scrotum, labium pudendi, lower part of the abdomen, in the neighbourhood of the anus, and at the lower part of the neck. The lower limb is, however, the most common seat of the disease: when the veins in this situation are dilated, the valves are insufficient to obstruct the calibre of the vessels, and consequently the lower and smaller ramifications have to sustain the column of blood in the superficial veins of the whole limb, its weight not being diminished by the support which, in the natural state of parts, is afforded by the valves; the disease is thus more and more aggravated. The left limb is generally the one affected; and this circumstance may probably be explained by the pressure of the sigmoid flexure of the colon on the left iliac vein.

In the majority of cases, the palliative treatment can only be adopted. The limb must be used as little as possible, and, if practicable, be kept in a state of complete rest; the veins must also be supported by the application of a bandage, or the wearing of a laced stocking. The Indian rubber bandage worn over the stocking or drawers answers fully as well as any other method. In some instances, the application of cold has been of advantage, by promoting the contraction of the dilated vessels. When pregnancy is the cause, it is needless to commence any method of cure, until the cause be removed; and the same remark is applicable when the affection arises from habitual constipation. The varices occasionally become inflamed, painful, and much swollen, with considerable œdema of the whole limb. Their contents become coagulated, and their coats thickened; in the end, the swelling abates and the vessels are closed. In certain cases, this spontaneous cure, a radical one, may be imitated by the surgeon; an escharotic being applied over the trunk of the vein at a healthy point, whereby inflammation is produced in the coats of the vessel, and obliteration of its cavity accomplished: the caustic which will be found most convenient and effectual, is the potassa fusa. The caustic may be made into a paste with soap; or a solid piece, of the size of a split pea, is placed over the vein, and there retained for a few hours by plaster or bandage. The vessel being obliterated, the lower venous branches necessarily pour their contents into those deeply seated; as they freely communicate with these, they readily empty themselves of their accumulated contents, and soon regain their calibre under the employment of bandaging. When the varicose veins are numerous, as is generally the case, the potass is to be applied to the healthy point of the larger trunk in which they terminate. But the practice is not unattended with danger, for the coats of the vessel may ulcerate in consequence of the application, and violent hemorrhage ensue; the degree of inflammation excited may be greater than that intended, and extend so as to give rise to suppuration in the vessel and the most alarming constitutional disturbance. These unfavourable results, however, must be of rare occurrence. Success has, however, followed the practice in innumerable instances.

A much preferable method, as being less painful and unattended with risk, is that of passing needles under the vessel, and twisting a piece of thick and strong silk round them. Two needles should be applied together, at an interval of about half an inch, at whatever points it is thought right to close the vein. Coagulation takes place in the included part, and also frequently for some distance below it; the coats of the vessel are thickened, and its canal closed. The needles are withdrawn before they begin to cut their way out by ulceration,—say at the end of from three to five days,—according as the parts become condensed. The needles suited to the purpose are soft, but tempered at the point, which is spear-shaped; the ends are cut off with pliers after the thread is fixed. Other operations have been performed on the veins, to procure a radical cure of varix; one or more ligatures have been passed round the vessel, as in the operation for aneurism; and the vessel has been divided, or a portion of it dissected out, and its cut extremities afterwards either compressed or secured. Such proceedings are now almost entirely abandoned.

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.