Lectures on tumours, delivered in the theatre of the Royal College of Surgeons of England / by James Paget, F.R.S.

James Paget

Date:: 1851

Credit: Lectures on tumours, delivered in the theatre of the Royal College of Surgeons of England / by James Paget, F.R.S. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

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$formed of overgrown hair follicles ; others are of distinct antogonous origin. Some ranulse are probably ibrmcd by dila- tation of the submaxillary duct, ob- structed by calculi or otherwise ; othei-s by anornial development of distinct cysts, or possibly of a bursa between tiie muscles of the tongue.* Some cysts in the niain\uary' gland are certainly dilated portions of ducts; others are, from their origin, anormal transformations of the elementary structures of the glaud. But, in each of these cases, it may be impossible, when the cyst is fully formed, to decide what was its mode of origin—whether by growth of parts once normally formed, or by transl'or- matiou of elementary and rudimental structures. Of the three modes of formation of cysts to which I liave referred,, the first two, namely, that which is accomplished by expansion of areolar spaces, and that by dilatation and growth of ducts or vesicles, scarcely need an explanation.f But for the third method of formation a more detailed accoiuit is required ; and this I will now endeavour to give. The general structures of the cysts thus formed may be best studied in those that are so commonly found in the kidneys, or the mammary or thyroid gland, or in any instance of an ordinary serous cyst. Sucli a cyst, when large enough for naked-eye examination, is usually constructed of fine, well-fonned fibro-cellular tissue, of which the filaments are commonly mingled with nuclei, or nucleus-fibres, and are variously interwoven in a single, or in many sepa- rable layers. The membranous walls thus formed are, in general, rather firmly con- * See Fleischmann, in Schmidt's Jahrbuclier, 1841, li. 32, and Krerichs, Uuber Gailert- Oder Collold^eschwiilsle, Gotiiiifreii, 1847, p 37. t Indeed, if it were not tor some convenience in surgical practice, we should not retain most of the cvsts thus formed in the list oftiiinouis; for their fjrowtli appears, iti most instance.s, to be due only to the accnmulat on of the contents of tlie obstructed tube or sacculus, beint;; exactly adjusted to this accuirulatioii, and cnni- mensurate with it. Tims it is in the cases of ranula with olistiuction of the submaxillaiy duct, and the similar di;iitations of the pan- creatic duct ; in the cystiform dilatation of the obstructed Fallopian tube; in the dilated hair- follicles; in bursa;; and In someoihi'rs. These arc all conventionally reckoned anion!? cysts as arraiis^ed with tumours: but several of the like kind are never so reckoned ; such as the cyst- like gall-bladder, dilated vvitn thin nuicus. wlicu the cystic duct is completi iy obstructed ; the dilatation of the uterus, tilled with serum after closure of its external orilice ; the distended sheath of a rfn ■■ ■ and others. Convenience and common usa^-c liave decided wliat cysts may be (grouped with those wiiirh alone, we mav an- ticipate, will be classed with tumours when p.'itho- logy beromes more accurate and strict. Conve- nience alone, also, decides (or the omission, from so vajfue a class as this, of the sacs or cap- nected with the adjacent parts, so tliat tlie cyst cannot easily be removed entire ; and from theSe parts they derive the blood- vessels that usually ramify copiously upon them. Tiiey are usiiaUy, also, lined with epithelium, which, so far as I know, is always of the tesselated form, and may consist, according to Kokitansky, of either nuclei or nucleated cells.* I am not awa^re that minute examinations have been made of the modes of earliest formation of any of the cysts of this kind, that are common subjects of surgical con- sideration ; hut there can be little doubt that, in their formation, they resemble the cysts of the kidney and other internal oi-gans. In these orgems the origin and progress of cysts have been pi-ofoundly studied by Eokitansky ;t and 1 shall best describe them by giving an abstract of some of the observations which he has recently published. They confirm and gi'catly extend tlie results obtained by the similar investigations of Frerichs,+ and they fully establish the accuracy of the observations on the cystic degeneration of the kidney which were made by Mr. Simon,§ to whom pathology is indebted for the first sure step in this rich path of inquiry. They may be repeated in almost any portion of a granular kidney containing cysts, or in a choroid plexus with cysts ; but, I believe, the process may be best traced in the cystic disease of the embryo- nic chorion—the hydatid mole, as it lias been called. || In a portion of such a granular and cystic kidney, nests, as Eokitansky calls them, of delicate vesicles, from a size just visible to that of a millet-seed, may be seen imbedded in a reddish grey or whitish substance. These diifer in size alone from the larger cysts to which one's attention would be sooner attracted ; and, on the other side, it is shnply in size that they differ from, many mucli smaller. For if a portion of such a nest be examined with the microscope, one finds, together with the debris of the kidney, variously sales that are formed round foreign bodies and solid tumours, and of the sacs' that yiay be lormed on the free surfaces of extravasated blood or inllammatory exudation. * Kokitansky says (Ueber die Cyste, p. 4) there IS often no einthcliuin in the larger cysts, and their iinuT l:iyer is a nucleated structure- less or striated blastema, exteri ally splittiu- into hbres in the direciion of the Ion ' axis of the oval iiucli-i It ci iitiiiiis. Epiihelial cells, ap- parently al ered so us to resemble very lar-e exudation-cells, are cominonly found in the tenacious contents oC bur,-ic. t Ueber die Cyste. VVicu. 1850. t Ueber (Jallert- oder Cilloulijeschwiilste. § ()n Subacute liillammairiui of the Kid- nev, in the Meilico-Chirui(,ncal Transactions. vol. XXX. ' li Mettenheinier, in Miiller's Archiv. iJTiO.$

Lectures on tumours, delivered in the theatre of the Royal College of Surgeons of England / by James Paget, F.R.S.

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