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CONTRIBUTIONS TO THE PRACTICAL SURGERY OF DISEASES OF CHILDHOOD.
575 his right hand for the introduction of the brush or other 25 per cent. of adults he got a perfect. view of the larynx easily at the first examination ; in about 5 per cent. it was impossible instrument. But how does the throat bear the contact of the mirror? to see the larynx at all ; in the remainder he succeeded more Does not its introduction excite retching and cough and dys- or less completely after repeated examinations. In children pnoea, and other unpleasant sensations? These questions are from two years of age and upwards the proportion of failures often asked by those who have had no experience of laryngo- is much greater. (To be continued.) scopy; but those who have experience are unanimous in declaring that, in the great majority of cases, none of these unpleasant results attend the introduction of the mirror into the fauces. In some instances, however, we meet with difficulties CONTRIBUTIONS in the use of the instrument. I will briefly refer to some of these, TO THE and will give sorne hints as to the best mode of meeting them. have some a throw the PRACTICAL SURGERY OF DISEASES OF First, then, persons propensity to tongue forcibly upwards towards the roof of the mouth; and CHILDHOOD. they do this with a provoking pertinacity just as the mirror is introduced between the This the teeth. BY T. HOLMES, M.A. CANTAB., being position of tongue offers a serious impediment to the introduction of the SURGEON TO THE HOSPITAL FOR SICK CHILDREN, AND ASSISTANT-SURGEON TO ST. GEORGE’S HOSPITAL. mirror, and the obstruction is greater in proportion to the size of the rebellious tongue. It is usually a result of nervousness on the part of the patient, and is sure to be made worse by any III.-ON CONGENITAL INNOCENT TUMOURS, THEIR DIAGNOSIS appearance of petulance in the operator. The better plan is to AND TREATMENT. the to endeavour reassure the patient. Sometimes occupation I HAVE been struck lately by the rather frequent occurrence of holding his own tongue has a good effect by diverting his the of his and while he is in own attention, holding tip occasionally, my experience of a congenital affection which I cannot tongue, you may depress the dorsum with a spatula or with find described in books, and which I should suppose might your finger. In ’some instances, after making one or two at- easily lead a surgeon, unaware of the existence of the disease, tempts, it is better to defer examination to a future day. After into a serious error of diagnosis, and which therefore it may be two or three sittings, there is usually less nervousness, and the worth while to describe, together with the cases upon which tongue comes more under control. p)r. Watson, after hearing this lecture, told me that in the the description is founded. The disease to which I refer is a case of patients who have this tendency to arch up the tongue, solid tumour, developed before birth, and sometimes growing and so to prevent the examination of the fauces, he directs them with great rapidity in the early days of life, so as to threaten to practise by sitting in front of a looking-glass with the mouth to fatal, either by exhaustion, or by its pressure on organs prove open. The inspection of the tongue, while they are endeavourin the neighbourhood. As, however, it wants all the essential to the is found of its movements, power ing acquire controlling characters of cancer, I should propose to apply to it the name to be a great assistance.] Another impediment to the examination of the larynx results of the congenital innocent tumour. The situations in which, up from unusual sensitiveness of the fauces, so that the touch of to the present time, I have met with these tumours have been the mirror excites contraction of the pharynx and retching. in the neck (three times), on the nape and back of the head, in This excessive sensibility is common when the fauces are in a the orbit, and in the pharynx. I must speak doubtfully, howstate of inflammatory congestion ; so that, seeing the throat gorged and red, we may anticipate a difficulty in the examina. ever, of the last named instance, for reasons which will be tion of the larynx. ’1 here are two modes of lessening the sen- ’: apparent when I come to describe the case. sibility of the throat in such cases. One is, to direct the patient Now, as all these six cases (or five if we exclude the doubtful to keep a lump of ice in his mouth for ten or fifteen minutes own practice in the course of four have occurred in before the examination, and as the ice melts to swallow the one) I cannot believemy that the disease is a very rare one. years, cold water. Another, and I think a more effectual plan, is to From what I have seen o. it, I think the prospects of cure by put twenty drops of chloroform on a handkerchief and let him operative interference at an early period are very good, for the inhale it for a minute : I have found this successful in quieting disease appears to have no charac er of malignancy except rapid the most irritable throats, and that without rendering the but this last feature is in some cases extremely marked, growth ; patient in the least degree drowsy or uncomfortable. The’ so that it soon becomes too late to do anything, as my first case bromide of potassium, when swallowed or used as a gargle, has will prove, and it is this which constitutes to my mind the iralong been supposed to have the effect of lessening the reflex portance of recognising the disease. the but in the few in I have of cases which sensibility fauces, I have characterized the disease above as a "solid tumour," tried it for this purpose it has appeared to be quite inert; but both terms of this definition would in many cases be obSemeleder states, too, that he has not obtained the desired jected to. Cysts are very common in these tumours, and in result from this salt. maay of them the cysts form the greater part of the whole It will usually be found that the repeated introduction of mass. Probably some of cystic" tumnurs which M r. Csesar the fancial mirror at intervals of a day or two has the effect Hawkins describes in those" his paper in the " Medico Chirurgical of lessening the sensibility of the throat, so that after a short Transactions," vol. xxii., on "A Peculiar Form of Congenital time the most sensitive throat becomes tolerant of the mirror. Tumour of the Neck," were of the same kind with those which I have found that patients labouring under acute laryngitis I am here denominating solid tumours. In fact, I regard the and other organic diseases which are attended with much suf presence of cysts as an accidental circumstance, although a fering usuajiy bear the examination well, and often better than very frequent one, and as caused merely by the mode of growth others who have but trifling ailments, or none at all. The man of the tumour.* The is not a trivial one, but involves who is threatened with suffocation will submit to any proceed- the whole treatment otquestion the disease. If we believe the tumour ing which affords him hope of relief, and the distress in his to be essentially cystic, we naturally hope to cure it by oblilarynx is so great that he is scarcely conscious of the trifling terating the cyst or cysts-a point to which Mr. Hawkins’s irritation caused by the faucial mirror; so true is it that treatment will be found to be mainly directed. If, on the con" Where the greater malady is fixed trary, we regard the cysts as merely an accidental formation The lesser is scarce felt." in a solid tumour, no treatment can be efficacious which does Enlargement of the tonsils may render the examination of not deal with the latter. Still more, if we regard the disease the larynx difficult or impossible. A small mirror may be as essentially cystic, we can hardly imagine that it would be used when the enlargement is not excessive; but if the tonsils very dangerous to life ; for should our measures directed to the are so much enlarged as nearly to touch each other, a laryngoobliteration of the cysts fail of success, yet the cysts might be scopic examination is impracticable. of a moderate size by repeated evacuation, and this meaThe epiglottis is sometimes very long, and projects obliquely kept sure would be a palliative, if not in the end a radical cure. My downwards and backwards, so as to make it impossible to throw of this congenital tumour in the neck is, the light beneath it, and to get a view of the larynx. The experience, however, * arch of the epiglottis, too, is sometimes so contracted as to obI hope the reader will not misunderstand me as throwing doubt on the diagnosis in Mr. Hawkins’s cases. Some of them were, no doubt, truly cystic struct the entrance of the light. Semeler’ler* ives as the result of his experience that in about tumours ; others which Mr. Hawkins did not treat, or did not treat to a termiuses
en-
*
Die bat’no-kopte und there verwerthung tnr die Artzliche Praxis. Von Dr.Friedrich Semeleder. Wien, 1863.
nation, may have been instances of the graver disease which I am now describing—viz., rapidly growing solid tumours, with cysts accidentally deve-
loped in them.
576 that it is a most formidable and a rapidly fatal disease in many cases, and that when the solid portion is growing it must be dealt with promptly and radically, or the time for treatment
mentions a case (p. 2o4) in which a proposal had been made to dissect out the tumour under the idea of its being fatty. As Mr. Hawkins observes, the existence of collections of fluid distinguishes most cases ; but there may be no such collections (as in Cases 4 and 6*), or they may be only small (as in Case 5*), when, if seated in the deep parts of the tumour, they would not be recognised. The most important step in the diagnosis has been made when the surgeon has assured himself that he is dealing with a congenital innocent tumour. Whether the tumour is or is not removable must be ascertained by careful examination of all its connexions, rather than by opinions formed beforehand of its structure; though it is no doubt true that a fatty tumour would be more likely to be isolable than I may just one composed of more rapidly growing elements. take occasion to remark that the presence of cysts or of limited collections of fluid does not absolutely preclude the idea of its being a fatty tumour ;t and that in Case 3 below, although there were other elements present, so that the disease could hardly be called a fatty tumour, yet fat formed by far the largest part of its structure. The histories of the following cases will, I hope, illustrate sufficiently the disease in question. The three cases which I shall relate in the present paper are those which 1 have met with in the neck ; in the sequel, which will appear shortly, I will describe those that have occurred to me in other regions of the body, and give references to such other cases of this disease which I have seen or read of.
will soon be past. With respect to the formation and the contents of these cysts in congenital tumours, I cannot do better than quote Mr. Hawkins’s lucid and accurate remarks : " The numerous cysts which compose the tumour are formed in the common cellular tissue; each separate cyst, it is to be presumed, being like the single serous encysted tumour, met with in many parts of the body, at every age. Why such numbers should be formed at once before birth does not appear, unless it arise from the peculiarly lax and watery nature of the cellular membrane in the a foetus, especially, perhaps, in the neck, where I believe such tumour to be more common than elsewhere." (p. 239.) " The fluid in most of the cysts was transparent, with scarcely any trace of coagulable matter, but in others the contents were of every shade of red, even as dark as venous blood, but without any coagulum, and evidently only coloured secretion." (p. 238.) The only alteration which I would venture to suggest in the above is to speak of the cysts not as composing, but as forming )0tt’< of the tumour. I shall have occasion to speak of some instances in which the tumour contained no cysts, or extremely few; and I believe that in most cases the solid part of the tnmour, and not the cysts, is the essence of the disease. It is reasonable to believe that the formation of the cysts is somehow connected with obstruction to the circulation caused by the invasion of the cellular spaces by the growth of the solid tumour. CASE 1. Congenital tumour of the neck rapid growth and The disease being allowed to be essentially of a solid character, result.-An infant a few weeks 01<1 was bruught to me fatal is it correct to describe it as a tumour ? At a late period of the Portsmouth. It was born with a large tumour in the complaint all the tissues around are so far infiltrated and de- neck, which had been pronounced incurable. On examination, all of a tumour is lost; generated that appearance of the neck two large cysts, I found in the anterior originally the disease commences in a distinct formation, whichseparated by a distinct triangle from each other, and with depression and This I shall be circumscribed removed. by incisions, may decided evidence of communication. The parts around show to be the case in some instances at any rate, and I believe them were somewhat consolidated, and the cysts rested upon it As is to so in all. the disease a solid base. The whole mass lay evidently below the cervical -’t’ with confounded two maybe things diagnosis, muscle. and dipped partly chiefly-viz., degenerated noevus and cancer. Either error is fascia, Under these circumstances, I was unwilling to run the risk of of considerable practical moment. If we looked upon the attempt to extirpate the tumour without having first tried had become arrested and con- an case as one in which a the and injecting the cysts. upper solidated, we should not be alive to the chief practical point in to contain bloody fluid ; it was the history of the disease-viz., that the tumour is one of rapid growth which demands prompt interference, otherwise the powers of nutrition will be diverted from their natural Then the child was f L d Wh seen and the child will fall into a condition of languor and six weeks afterwards) the growth had attained to (about again The error of mis. an enormous size, reaching from the sternum to the chin, and taking such a tumour for a cancer leads in the same direction, from the spinal column to beyond the middle line. Under these but by a different route; for here the surgeon will probably abthe only question was whether it was possible circumstances, stain from operation, which he will be fruitless, to ren ove it. I procured the opinion of several surgeons, some of whom thought it possible that the infani might live through of bestowing on it a life of perfect the operation, but most thought otherwise. All allowed that not difficult if the surgeon is the necessarily fatal. I put the case fairly before the mother, stating the great probability that an attempt to remove the tumour would prove immediately fatal; but offered cases their hard lobulated feel, and perfect independence of the at the same time, since the child could not survive long, to circulation, distinguish them from nævus, especially if they are seen at a very early age, when a neavus of any large size conld in the country shortly afterwards. There was no opportunity hardly be reasonably expected to have passed through all its fora ’’post-mortem examination. stages of growth and arrest. But in some instances, as in CASE 2. CongenitaL tumour of the neck, proving rapidly Case 4,’ the skin adheres to the tumour, and shows traces of was a case of very much the same kind, except naevus, and then more care is required in weighing the various fatal.-This that before I saw the child (at the age of six weeks) the tumour and if be in there cysts appearances, especially any symptoms attained such a size that it was impossible to think about part of the tumour. But the great practical consideration is, had that the mass is growing rapidly. This proves both that the its removal ; it reached down to the sternum, and projected tumour is not a transformed nævus, and that it must be re- up underneath the lower jaw into the mouth, where a large the tongue resembling a ranula. The mother moved, since the weakly condition of a young infant cannot cyst lay under anxious that an operation should be performed extremely afford to support a rapidly-growing tumour. was As to the diagnosis from cancer, the congenital occurrence of (being indeed eager to get rid of the child, which was illegitibut the removal of the tumour would have been an the tumour, and the otherwise perfect health of the child, will As, however, the disease would necesusually suffice. Without denying what is stated by so eminent absolute impossibility. sarily soon prove fatal, it was determined to attempt to destroy an author as Dr. Walshe, that cancer occurs congenitally, I of it with arrows of caustic, somewhat on M. Maisonmay be allowed to say that the published evidence of the fact principle. The sloughing and suppuration thus prois slight, and that the affection may be at any rate regarded as duced seemed only to hasten the fatal event. The diseased a very uncommon one ; so that in any case of doubt, it would that be fair to give the child the benefit of doubt, and rather to mass was found to fill up the whole side of the neck and com. risk the performance of an unsuccessful operation than allowa pletely surround the oesophagus. The cysts were large and child to die who might possibly be saved. But we must remem- numerous, and the solid part contained such numerous and ber that if the tumour is growing rapidly, it must be attacked various cell-forms as to bear some resemblance to cancer. CASE 3. Congenital tumour of the neck extirpated with sucat once, if at all. Mr. Hawkins points out that the cystic tumour in the neck cess.-The patient, a boy eight years of age, had been for some bears also a considerable resemblance to fatty tumour, and time an out-patient at the Hospital for Sick Children on account This case will be found in the sequel to this paper.These cases will be found in the sequel. t Mr. T. Smith has recorded two o cases in which fatty tumours contained t A reference to several cases of cancer developed before birth may be found in Dr. Walshe’s work " On the Nature and Treatment of Cancer" (1846), cavities, the result of old abscess. (Path. Soc. Trans., ix" 384.)
from
defined
but
no
under the sterno-mastoid
effect of punctming found one was with tapped, and The lower iodine.
nvus
The
tobe in notinseem injected cyst didrefill communicationwith it. Thetaken did not the next few cyst out of object, d weeks thegrowth had attained to Then the was taken exhausagain tion thatwill in noIona time prove fatal Theerror ex mistion that will m no longtime provefatal. expect to
in fact,be it might notonly savethechildfromanearly while, death, but the meansis usually health. The diagnosis aware of thegeneral history of congenitaltumours. Many of these tumoursare quiteseparatefrom theskin, and in these
disease was
make the attempt. She declined, however,and thechild die .
_
mate),
portions neuve
-
p. 146. large
-
577 of a congenital tumour on the right side of the neck, which had commenced latterly to grow. As the fact of growth was in-
he was taken into the house in order to have the tumour removed. Two large cysts, containing perfectly pellucid fluid, lay immediately under the skin just beneath the ear, and
dubitable,
(a) To lessen the supply of fatforming or respiratory materials.-These substances are fat, starch, and sugar : the first entering the circulation as fat, but probably not deposited in
the tissues, except it be in excess of the wants of the system ; the second being chiefly transformed into sugar and its allies, overlapping the mastoid process. They were in communica- and probably only into fat when digested in excess of the imtion. Lying underneath was an ill defined mass, which filled up mediate requirements of the respiration ; and the third entering the whole of the posterior triangle, extending back towards the blood as sugar, and forming fat only under the same conthe spine, and raising up the sterno mastoid muscle in front. ditions as starch. Hence the whole question is centred in that It reached down to within about two inches of the clavicle. It which demands how much of these substances is required by could be felt by placing the finger under the anterior edge of the body, and to what extent we may allow of a deficient supthe sterno-mastoid muscle, but could not be traced forwards so ply so as to draw upon the stock accumulated in the system. far as the sheath of the vessels, nor was there any evidence of This varies with the activity of the respiratory process; and pressure on the jugular vein. There was no interference with that, partly with the constitution of the individual, and chiefly swallowing or respiration. The evacuation of the cysts made with the amount of bodily exertion made. A fat man in good little difference in the size of the mass, and they soon filled health is generally one who enjoys life and takes matters easily. again. The tumour extended backwards as far as the edge of He may not eat much, but he selects his food and enjoys it. the trapezius muscle. It seemed slightly movable. The ope- He digests his food, takes a nap after dinner, retires to rest ration for its removal was a tedious one, occupying half an hour early, and sleeps profoundly; and when awake, prefers an df careful dissection, since it was necessary to separate the arm-chair or a cushioned carriage to a rough trot on horseback tumour carefully from the muscles (scaleni, levator scapulæ, or a walk over the hills on a windy day. It is also remarkable and splenius) forming the floor of the neck, to divide a great how warmly he clothes generally. Hence he makes good use of part, though not the whole, of the sterno-mastoid, and to dissect his food, resists loss of heat by offering a good non-conductor the superficial part of the tumour cautiously from the thin skin. in the layers of fat and the woollen clothes, and hy preventing In the latter proceeding some fragments of the cyst-walls were too great evaporation at the surface by perspiration ; and althe postman, probably left behind, and in the deeper dissection a few of the though he may envy the lightness and activity ofthe postman’s cysts were accidentally opened; but no morbid tissue could be he does not make the exertion required to go distinguished in the wound after the removal of the tumour daily round. With little muscular exertion and loss of heat, from its bed. A large crucial wound was thus left, which such a person needs less carbon (respiratory food) than others; healed very kindly in about four weeks without any bad symp- and whilst the estimate of different observers gives from 5 oz. tom. There was no contraction. The anterior border of the to 13i oz. as the quantity of carbon actually leaving the lungs, eterno-mastoid remained quite natural, and the movements of and whilst my experiments (see " Health and Disease as influthe head were perfectly free. On examining the tumour, its enced by the Cyclical Changes in the Human System") show solid part was seen to resemble udder in appearance and con- that at rest it is about ’7 oz., with moderate exercise 8½ oz., sistence ; and, under the microscope, showed nothing except and with the work of the labouring man llioz., it is probable that the quantity need not exceed 7 oz. to maintain the daily some fibrous tissue, a few free nuclei, and a very large quantity of fat. There were a large number of cysts, most of them of weight, and might be reduced to 5 oz. temporarily with a view small size, scattered through the tumour, and containing fluid to reduce the weight. Hence a considerable reduction in the quantity of food may of various colour--some of them almost pure blood ; in fact, be made with v-dvantage, provided it be effected slowly, be one which was opened during the operation was at first taken for a large vein. The tumour is preserved in the museum of kept within due limits, be patiently persevered in, and the the Hospital for Sick Children. The cystic portion of it bears effects be carefully watched at short intervals; and from the but a small proportion to the solid, since the cysts are small, foregoing it will be seen to be of little importance whether any though numerous; but the two superficial cysts, which were one of these sources be cut off, or whether the diminution be in the largest, are not seen in the preparation. The lobe which all three alike. But it is essential to bear in mind that in prolay superficial to the sterno-mastoid is pedunculated, and thus portion as the resources of the body in fat have been drawn upon, easily distinguishable from the larger mass which lay below the tinte will come when the supply of food must be increased. that muscle. In the substance of the tumour is a small, round, (b) Increase in the muscular activity of the system. -My insolid body, easily distinguished from the surrounding mass, and quiries into the effect of exactly measured degrees of exertion in all probability an enlarged gland.* As the operation was are the only ones on record.* They show that, taking the performed less than half a year ago, it would be premature to lying posture as the minimum and as the unit of comparison, speak confidently about the reproduction of the tumour; but walking at the rate of one mile atper hour is 1 9 ; at two miles, four miles, 5. The effect of nothing could be more gratifying than the immediate result of 2.76 ; at three miles, 3 -22 ; and the operation. cantering on horseback with a rough horse is 3’16 ; and of trot(To be continued.) ting, 4. The effect of moderate rowing is 3 -33 ; and of moderate swimming, 4 33. The numbers will represent both the relative effect upon the body in the consumption of fatty and fat-forming matters in any given time, and the greater number of hours during which a given gentle exercise must be continued DIETARY IN DISEASE. to render the effect equal to the severer exercise. For example, one hour’s walking at the rate of four miles per hour would BY EDWARD SMITH, M.D., F.R.S., F.R.C.P., cause as large a consumption of fat as nearly three hours’ walkASSISTANT-PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, BROMPTON. ing at one mile per hour; and one hour on the treadwheel is equal to four hours of gentle walking. Hence we have almost as powerful an agent in exertion as in fasting; but in employNo. IV. ing it we must proceed by slow degrees, and maintain the OB E SIT Y. exertion, keeping always well without the limit of failure of the heart’s action and general exhaustion. (Concluded from p. 546.) It is curious to know how much fat is consumed by different 2. WHEN excess of fat really exists, the aim must be to re- modes of exertion per hour. Thus, one hour of lying still when duce the use of substances which form fat, so that it shall be asleep at night consumes 0 31 oz, of fat ; one hour of lying somewhat below the daily wants of the system, and to so in- awake in the daytime, 046oz.; one hour of standing, 0-55oz.; one hour of walking at the rate of two miles per hour, 1 ’1 oz.; crease muscular exertion that the respiratory function shall be increased in activity, and, a sufficient quantity of fuel not being ditto at the rate of three miles per hour, 1 6 oz.; one hour of the treadwheel (if continuous). 2 75 oz. Hence 1 Ib. supplied from without, the deposited fat shall be consumed. working of the fat of the body, in the absence of food, would be conAll this must be done, and yet the full vigour of the system sumed by less than six hours’ labour at the treadwheel, by ten must be maintained. hours of walking at three miles per hour, and by fourteen hours and a half of walking at two miles per hour. If we further * Mr. Hawkins points out the occasional presence of enlarged glands in estimate that 10 oz. of carbon are required by the body daily these tumours, in his account of the case which he examined after death, p. 238. with only moderate exertion, and that by the food we supply r have also noticed their existence in Case 6. I mention this to show that the only 5 oz., there will be a consumption of 8 oz. of the fat or presence of enlarged glands in such tumours is an accidental circumstance on which no weight need be laid in the diagnosis. Apart from other con* siderations, it would not justify a suspicion that the disease was malignant. Edinburgh Medical and Surgical Journal, Jan. 1859.
en-
*
Die bat’no-kopte und there verwerthung tnr die Artzliche Praxis. Von Dr.Friedrich Semeleder. Wien, 1863.
nation, may have been instances of the graver disease which I am now describing—viz., rapidly growing solid tumours, with cysts accidentally deve-
loped in them.
576 that it is a most formidable and a rapidly fatal disease in many cases, and that when the solid portion is growing it must be dealt with promptly and radically, or the time for treatment
mentions a case (p. 2o4) in which a proposal had been made to dissect out the tumour under the idea of its being fatty. As Mr. Hawkins observes, the existence of collections of fluid distinguishes most cases ; but there may be no such collections (as in Cases 4 and 6*), or they may be only small (as in Case 5*), when, if seated in the deep parts of the tumour, they would not be recognised. The most important step in the diagnosis has been made when the surgeon has assured himself that he is dealing with a congenital innocent tumour. Whether the tumour is or is not removable must be ascertained by careful examination of all its connexions, rather than by opinions formed beforehand of its structure; though it is no doubt true that a fatty tumour would be more likely to be isolable than I may just one composed of more rapidly growing elements. take occasion to remark that the presence of cysts or of limited collections of fluid does not absolutely preclude the idea of its being a fatty tumour ;t and that in Case 3 below, although there were other elements present, so that the disease could hardly be called a fatty tumour, yet fat formed by far the largest part of its structure. The histories of the following cases will, I hope, illustrate sufficiently the disease in question. The three cases which I shall relate in the present paper are those which 1 have met with in the neck ; in the sequel, which will appear shortly, I will describe those that have occurred to me in other regions of the body, and give references to such other cases of this disease which I have seen or read of.
will soon be past. With respect to the formation and the contents of these cysts in congenital tumours, I cannot do better than quote Mr. Hawkins’s lucid and accurate remarks : " The numerous cysts which compose the tumour are formed in the common cellular tissue; each separate cyst, it is to be presumed, being like the single serous encysted tumour, met with in many parts of the body, at every age. Why such numbers should be formed at once before birth does not appear, unless it arise from the peculiarly lax and watery nature of the cellular membrane in the a foetus, especially, perhaps, in the neck, where I believe such tumour to be more common than elsewhere." (p. 239.) " The fluid in most of the cysts was transparent, with scarcely any trace of coagulable matter, but in others the contents were of every shade of red, even as dark as venous blood, but without any coagulum, and evidently only coloured secretion." (p. 238.) The only alteration which I would venture to suggest in the above is to speak of the cysts not as composing, but as forming )0tt’< of the tumour. I shall have occasion to speak of some instances in which the tumour contained no cysts, or extremely few; and I believe that in most cases the solid part of the tnmour, and not the cysts, is the essence of the disease. It is reasonable to believe that the formation of the cysts is somehow connected with obstruction to the circulation caused by the invasion of the cellular spaces by the growth of the solid tumour. CASE 1. Congenital tumour of the neck rapid growth and The disease being allowed to be essentially of a solid character, result.-An infant a few weeks 01<1 was bruught to me fatal is it correct to describe it as a tumour ? At a late period of the Portsmouth. It was born with a large tumour in the complaint all the tissues around are so far infiltrated and de- neck, which had been pronounced incurable. On examination, all of a tumour is lost; generated that appearance of the neck two large cysts, I found in the anterior originally the disease commences in a distinct formation, whichseparated by a distinct triangle from each other, and with depression and This I shall be circumscribed removed. by incisions, may decided evidence of communication. The parts around show to be the case in some instances at any rate, and I believe them were somewhat consolidated, and the cysts rested upon it As is to so in all. the disease a solid base. The whole mass lay evidently below the cervical -’t’ with confounded two maybe things diagnosis, muscle. and dipped partly chiefly-viz., degenerated noevus and cancer. Either error is fascia, Under these circumstances, I was unwilling to run the risk of of considerable practical moment. If we looked upon the attempt to extirpate the tumour without having first tried had become arrested and con- an case as one in which a the and injecting the cysts. upper solidated, we should not be alive to the chief practical point in to contain bloody fluid ; it was the history of the disease-viz., that the tumour is one of rapid growth which demands prompt interference, otherwise the powers of nutrition will be diverted from their natural Then the child was f L d Wh seen and the child will fall into a condition of languor and six weeks afterwards) the growth had attained to (about again The error of mis. an enormous size, reaching from the sternum to the chin, and taking such a tumour for a cancer leads in the same direction, from the spinal column to beyond the middle line. Under these but by a different route; for here the surgeon will probably abthe only question was whether it was possible circumstances, stain from operation, which he will be fruitless, to ren ove it. I procured the opinion of several surgeons, some of whom thought it possible that the infani might live through of bestowing on it a life of perfect the operation, but most thought otherwise. All allowed that not difficult if the surgeon is the necessarily fatal. I put the case fairly before the mother, stating the great probability that an attempt to remove the tumour would prove immediately fatal; but offered cases their hard lobulated feel, and perfect independence of the at the same time, since the child could not survive long, to circulation, distinguish them from nævus, especially if they are seen at a very early age, when a neavus of any large size conld in the country shortly afterwards. There was no opportunity hardly be reasonably expected to have passed through all its fora ’’post-mortem examination. stages of growth and arrest. But in some instances, as in CASE 2. CongenitaL tumour of the neck, proving rapidly Case 4,’ the skin adheres to the tumour, and shows traces of was a case of very much the same kind, except naevus, and then more care is required in weighing the various fatal.-This that before I saw the child (at the age of six weeks) the tumour and if be in there cysts appearances, especially any symptoms attained such a size that it was impossible to think about part of the tumour. But the great practical consideration is, had that the mass is growing rapidly. This proves both that the its removal ; it reached down to the sternum, and projected tumour is not a transformed nævus, and that it must be re- up underneath the lower jaw into the mouth, where a large the tongue resembling a ranula. The mother moved, since the weakly condition of a young infant cannot cyst lay under anxious that an operation should be performed extremely afford to support a rapidly-growing tumour. was As to the diagnosis from cancer, the congenital occurrence of (being indeed eager to get rid of the child, which was illegitibut the removal of the tumour would have been an the tumour, and the otherwise perfect health of the child, will As, however, the disease would necesusually suffice. Without denying what is stated by so eminent absolute impossibility. sarily soon prove fatal, it was determined to attempt to destroy an author as Dr. Walshe, that cancer occurs congenitally, I of it with arrows of caustic, somewhat on M. Maisonmay be allowed to say that the published evidence of the fact principle. The sloughing and suppuration thus prois slight, and that the affection may be at any rate regarded as duced seemed only to hasten the fatal event. The diseased a very uncommon one ; so that in any case of doubt, it would that be fair to give the child the benefit of doubt, and rather to mass was found to fill up the whole side of the neck and com. risk the performance of an unsuccessful operation than allowa pletely surround the oesophagus. The cysts were large and child to die who might possibly be saved. But we must remem- numerous, and the solid part contained such numerous and ber that if the tumour is growing rapidly, it must be attacked various cell-forms as to bear some resemblance to cancer. CASE 3. Congenital tumour of the neck extirpated with sucat once, if at all. Mr. Hawkins points out that the cystic tumour in the neck cess.-The patient, a boy eight years of age, had been for some bears also a considerable resemblance to fatty tumour, and time an out-patient at the Hospital for Sick Children on account This case will be found in the sequel to this paper.These cases will be found in the sequel. t Mr. T. Smith has recorded two o cases in which fatty tumours contained t A reference to several cases of cancer developed before birth may be found in Dr. Walshe’s work " On the Nature and Treatment of Cancer" (1846), cavities, the result of old abscess. (Path. Soc. Trans., ix" 384.)
from
defined
but
no
under the sterno-mastoid
effect of punctming found one was with tapped, and The lower iodine.
nvus
The
tobe in notinseem injected cyst didrefill communicationwith it. Thetaken did not the next few cyst out of object, d weeks thegrowth had attained to Then the was taken exhausagain tion thatwill in noIona time prove fatal Theerror ex mistion that will m no longtime provefatal. expect to
in fact,be it might notonly savethechildfromanearly while, death, but the meansis usually health. The diagnosis aware of thegeneral history of congenitaltumours. Many of these tumoursare quiteseparatefrom theskin, and in these
disease was
make the attempt. She declined, however,and thechild die .
_
mate),
portions neuve
-
p. 146. large
-
577 of a congenital tumour on the right side of the neck, which had commenced latterly to grow. As the fact of growth was in-
he was taken into the house in order to have the tumour removed. Two large cysts, containing perfectly pellucid fluid, lay immediately under the skin just beneath the ear, and
dubitable,
(a) To lessen the supply of fatforming or respiratory materials.-These substances are fat, starch, and sugar : the first entering the circulation as fat, but probably not deposited in
the tissues, except it be in excess of the wants of the system ; the second being chiefly transformed into sugar and its allies, overlapping the mastoid process. They were in communica- and probably only into fat when digested in excess of the imtion. Lying underneath was an ill defined mass, which filled up mediate requirements of the respiration ; and the third entering the whole of the posterior triangle, extending back towards the blood as sugar, and forming fat only under the same conthe spine, and raising up the sterno mastoid muscle in front. ditions as starch. Hence the whole question is centred in that It reached down to within about two inches of the clavicle. It which demands how much of these substances is required by could be felt by placing the finger under the anterior edge of the body, and to what extent we may allow of a deficient supthe sterno-mastoid muscle, but could not be traced forwards so ply so as to draw upon the stock accumulated in the system. far as the sheath of the vessels, nor was there any evidence of This varies with the activity of the respiratory process; and pressure on the jugular vein. There was no interference with that, partly with the constitution of the individual, and chiefly swallowing or respiration. The evacuation of the cysts made with the amount of bodily exertion made. A fat man in good little difference in the size of the mass, and they soon filled health is generally one who enjoys life and takes matters easily. again. The tumour extended backwards as far as the edge of He may not eat much, but he selects his food and enjoys it. the trapezius muscle. It seemed slightly movable. The ope- He digests his food, takes a nap after dinner, retires to rest ration for its removal was a tedious one, occupying half an hour early, and sleeps profoundly; and when awake, prefers an df careful dissection, since it was necessary to separate the arm-chair or a cushioned carriage to a rough trot on horseback tumour carefully from the muscles (scaleni, levator scapulæ, or a walk over the hills on a windy day. It is also remarkable and splenius) forming the floor of the neck, to divide a great how warmly he clothes generally. Hence he makes good use of part, though not the whole, of the sterno-mastoid, and to dissect his food, resists loss of heat by offering a good non-conductor the superficial part of the tumour cautiously from the thin skin. in the layers of fat and the woollen clothes, and hy preventing In the latter proceeding some fragments of the cyst-walls were too great evaporation at the surface by perspiration ; and althe postman, probably left behind, and in the deeper dissection a few of the though he may envy the lightness and activity ofthe postman’s cysts were accidentally opened; but no morbid tissue could be he does not make the exertion required to go distinguished in the wound after the removal of the tumour daily round. With little muscular exertion and loss of heat, from its bed. A large crucial wound was thus left, which such a person needs less carbon (respiratory food) than others; healed very kindly in about four weeks without any bad symp- and whilst the estimate of different observers gives from 5 oz. tom. There was no contraction. The anterior border of the to 13i oz. as the quantity of carbon actually leaving the lungs, eterno-mastoid remained quite natural, and the movements of and whilst my experiments (see " Health and Disease as influthe head were perfectly free. On examining the tumour, its enced by the Cyclical Changes in the Human System") show solid part was seen to resemble udder in appearance and con- that at rest it is about ’7 oz., with moderate exercise 8½ oz., sistence ; and, under the microscope, showed nothing except and with the work of the labouring man llioz., it is probable that the quantity need not exceed 7 oz. to maintain the daily some fibrous tissue, a few free nuclei, and a very large quantity of fat. There were a large number of cysts, most of them of weight, and might be reduced to 5 oz. temporarily with a view small size, scattered through the tumour, and containing fluid to reduce the weight. Hence a considerable reduction in the quantity of food may of various colour--some of them almost pure blood ; in fact, be made with v-dvantage, provided it be effected slowly, be one which was opened during the operation was at first taken for a large vein. The tumour is preserved in the museum of kept within due limits, be patiently persevered in, and the the Hospital for Sick Children. The cystic portion of it bears effects be carefully watched at short intervals; and from the but a small proportion to the solid, since the cysts are small, foregoing it will be seen to be of little importance whether any though numerous; but the two superficial cysts, which were one of these sources be cut off, or whether the diminution be in the largest, are not seen in the preparation. The lobe which all three alike. But it is essential to bear in mind that in prolay superficial to the sterno-mastoid is pedunculated, and thus portion as the resources of the body in fat have been drawn upon, easily distinguishable from the larger mass which lay below the tinte will come when the supply of food must be increased. that muscle. In the substance of the tumour is a small, round, (b) Increase in the muscular activity of the system. -My insolid body, easily distinguished from the surrounding mass, and quiries into the effect of exactly measured degrees of exertion in all probability an enlarged gland.* As the operation was are the only ones on record.* They show that, taking the performed less than half a year ago, it would be premature to lying posture as the minimum and as the unit of comparison, speak confidently about the reproduction of the tumour; but walking at the rate of one mile atper hour is 1 9 ; at two miles, four miles, 5. The effect of nothing could be more gratifying than the immediate result of 2.76 ; at three miles, 3 -22 ; and the operation. cantering on horseback with a rough horse is 3’16 ; and of trot(To be continued.) ting, 4. The effect of moderate rowing is 3 -33 ; and of moderate swimming, 4 33. The numbers will represent both the relative effect upon the body in the consumption of fatty and fat-forming matters in any given time, and the greater number of hours during which a given gentle exercise must be continued DIETARY IN DISEASE. to render the effect equal to the severer exercise. For example, one hour’s walking at the rate of four miles per hour would BY EDWARD SMITH, M.D., F.R.S., F.R.C.P., cause as large a consumption of fat as nearly three hours’ walkASSISTANT-PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, BROMPTON. ing at one mile per hour; and one hour on the treadwheel is equal to four hours of gentle walking. Hence we have almost as powerful an agent in exertion as in fasting; but in employNo. IV. ing it we must proceed by slow degrees, and maintain the OB E SIT Y. exertion, keeping always well without the limit of failure of the heart’s action and general exhaustion. (Concluded from p. 546.) It is curious to know how much fat is consumed by different 2. WHEN excess of fat really exists, the aim must be to re- modes of exertion per hour. Thus, one hour of lying still when duce the use of substances which form fat, so that it shall be asleep at night consumes 0 31 oz, of fat ; one hour of lying somewhat below the daily wants of the system, and to so in- awake in the daytime, 046oz.; one hour of standing, 0-55oz.; one hour of walking at the rate of two miles per hour, 1 ’1 oz.; crease muscular exertion that the respiratory function shall be increased in activity, and, a sufficient quantity of fuel not being ditto at the rate of three miles per hour, 1 6 oz.; one hour of the treadwheel (if continuous). 2 75 oz. Hence 1 Ib. supplied from without, the deposited fat shall be consumed. working of the fat of the body, in the absence of food, would be conAll this must be done, and yet the full vigour of the system sumed by less than six hours’ labour at the treadwheel, by ten must be maintained. hours of walking at three miles per hour, and by fourteen hours and a half of walking at two miles per hour. If we further * Mr. Hawkins points out the occasional presence of enlarged glands in estimate that 10 oz. of carbon are required by the body daily these tumours, in his account of the case which he examined after death, p. 238. with only moderate exertion, and that by the food we supply r have also noticed their existence in Case 6. I mention this to show that the only 5 oz., there will be a consumption of 8 oz. of the fat or presence of enlarged glands in such tumours is an accidental circumstance on which no weight need be laid in the diagnosis. Apart from other con* siderations, it would not justify a suspicion that the disease was malignant. Edinburgh Medical and Surgical Journal, Jan. 1859.