and having originated without apparent cause, had existed for several years.

The severe measure of amputation has not unfrequently been resorted to in the treatment of this disease. Dr. Smith relates at length the particulars of a case in which Chelius amputated the leg of a female for a tumour in the ham which was of a neuromatous character. It extended from the popliteal space nearly half way up the back part of the thigh, was the seat of intolerable pain, and had resisted every variety of treatment which had been employed for several years in the endeavour to disperse it.

"The tumour, which was of about the size of a pine-apple, was found to be a neuroma connected with the sciatic nerve, which, along with the femoral artery and vein, corresponded to its anterior or deep surface; and from its lower extremity proceeded the posterior tibial nerve and several small branches, destined for the gastrocnemius muscle and the integuments, but the peroneal and communicating or external saphenus arose above the tumour, and ran along its external surface, the fibres of the peroneal being separated from each other where the nerve crossed the middle third of the tumour, to which it was connected by a loose cellular structure. The tumour, though everywhere solid, was not of the same consistence throughout; in some parts, especially below, the feeling of elasticity was so great, that it might readily have been supposed that in these situations fluid existed; other portions possessed nearly the firmness of cartilage. The investment of the tumour consisted of an external capsule, seemingly formed by the condensation of the surrounding cellular tissue, and beneath this of a membranous expansion continuous with and apparently composed of the distended sheath of the sciatic nerve. A section of the morbid growth exhibited a lobulated structure, of different degrees of consistence, but nowhere presenting any of the characters of malignant disease." (p. 3.)

Several similar cases are recorded; among others, one in which M. Louis amputated the arm for neuroma of the median nerve.

From the examination of these and similar facts, Dr. Smith concludes that the first and the last of these operations, viz. excision of a portion of the nervous trunk and amputation, can be performed in almost every instance with success; and with respect to the remaining one, he remarks, "that there may be cases in which it may be practicable, and perhaps prudent, without sacrificing the nervous trunk by division, to dissect out the tumour from the nervous fibrilla which surround it."

Having thus described the general characters of neuromatous tumours, their varieties, pathology, and treatment, our author proceeds to consider each class rather more in detail.

He commences with giving an account of cases in which these morbid growths have existed in considerable numbers in the same individual, including two remarkable examples which fell under his own observation.

Occasionally throughout the nervous system, alike upon the largest trunk and the smallest peripheral nerve, implicating both the par vagum and the phrenic, and not excepting the sympathetic system, there are developed tumours in vast numbers, which occasion neither pain, lesion of innervation, nor any other inconvenience. These growths were considered by Knoblauch as accessory ganglia, indicating an original vice of conformation-" Vitia primæ conformationis habendi, et vera ganglia sunt;" but this opinion is almost certainly an erroneous one. Two very remarkable examples of this form of neuroma are related by Schiffner,

in the fourth and sixth volumes of the 'Oestreich. Med. Jahrbücher.' They occurred in brothers, cretins afflicted with the worst form of that disease. A vast number of the principal cerebro-spinal nerves all over the body were enlarged, and had tumours developed in their course. In one of the two cases, the superior cervical ganglion of the right side, and the inferior ganglion on the left, had not escaped the disease; and in the other case the sympathetic nerve was also involved. There is another remarkable example of the affection related by Knoblauch, as occurring in the practice of Bischoff, which we pass over to arrive at the cases which came under Dr. Smith's notice, and to which most of the lithograph plates refer.

We extract entire the first of these cases.

"John M'Cann, 35 years of age, was admitted into the Richmond Hospital, under the care of Dr. Hutton, in 1840, having a large tumour on the right side of the neck, of a globular form, and equal to a moderate-sized cocoa-nut in magnitude; it extended from the mastoid process to within a short distance of the sternoclavicular articulation. It presented an uniform surface, and admitted of being moved freely in the transverse direction, but could neither be pushed upwards nor drawn downwards; the external jugular vein grooved its surface, the integuments did not adhere to it, nor (although it obviously extended deep into the neck) did it appear to have contracted a close adhesion to any important part; the larynx was not displaced, nor was there any interference with the functions of respiration or deglutition. It was solid throughout, and had existed for upwards of fifteen years, but had never been painful, nor was it now (although of so large a size) the source of much inconvenience to the patient, whose general health was not impaired.

"A second tumour, about as large as a walnut, existed underneath the left side of the tongue; it likewise was solid, and free from pain, but its presence was the source of much annoyance to the patient when eating. He could not, with any degree of accuracy, state at what period the tumour commenced to form, being unaware of its existence until it had attained such a size as to interfere with the

motions of the tongue. In consequence of the size of the tumour in the neck, and its relations to the larynx and great vessels and nerves, as well as from an apprehension of its being of a malignant character (notwithstanding its slow growth and freedom from pain), it was not deemed advisable to attempt its removal, more especially as the existence of the sublingual tumour appeared to confirm the opinion which had been formed respecting the nature of the disease. The patient, therefore, left the hospital shortly after he had been admitted, and resumed his business in the country, that of a cattle-driver, an occupation which exposed him to the inclemency of the weather, not only during the day, but frequently also in the night-time.

"In 1843 he was again taken into the hospital, having, upon the day previous to his admission, been found by Dr. Adrien, lying upon the side of the road, and complaining of pain in the left hip. Upon examining the part, a large solid tumour was discovered upon the back of the thigh, which the man stated had been growing for nearly two years. It extended from the fold of the nates to the inferior third of the thigh, and exceeded in magnitude the head of the patient; it admitted of being moved from side to side, and, although more prominent in some parts than in others, its general surface was smooth. Several large veins ramified beneath the integuments, which were not adherent to the tumour. The patient suffered no acute pain, the chief inconvenience of which he complained being referable to the existence of so large a tumour in such a situation.

"His general health had, however, undergone a material alteration since the period of his first admission into the hospital; he was now pale and greatly emaciated. He had no relish for his food, nor did he sleep at night; yet he made no complaint of any particular distress, nor could he assign the cause of his restless

ness; he had neither diarrhoea nor perspiration; his pulse was quick and weak, but respiration was undisturbed. In this condition he lingered for a few months, generally pining and wasting away, and, towards the end of the year, died with hectic symptoms and without pain, but emaciated in the last degree. The tumour in the neck had neither enlarged nor undergone any alteration since 1840, the date of his first admission, nor had the inconvenience arising from the sublingual tumour increased. It was the opinion of all who saw the case, that this immense tumour on the back of the thigh was of a malignant character, and its appearance was looked upon as establishing the correctness of the diagnosis which had been originally formed regarding the nature of the cervical tumour.

It

Upon the day succeeding that upon which the patient died, I made a careful examination of the body. Independently of the tumours that have been already mentioned, several others were now discovered, which had escaped notice during life, although most probably some of them had existed when the man was first admitted into the hospital. The largest was situated upon the posterior part of the right thigh, immediately beneath the lower margin of the gluteus maximus muscle. was of an oblong form, and considerably larger than a lemon. There was one upon the outer side of the right arm, near its centre, of the size of a pigeon's egg, and another upon the point of the right fore-arm, immediately above the carpus, nearly as large as a hen's egg; they all admitted of being moved in a lateral direction. The intercostal spaces upon each side, as well as the abdominal parietes and right inguinal region, presented numerous tumours about the size of large peas.

"Upon laying open the cavity of the abdomen, the first object which attracted my attention was a white, solid, oblong tumour, situated in the right iliac fossa, between the iliacus internus muscle and the outer margin of the psoas magnus. It was three inches and a half in length, and one in breadth.

"It was connected with the anterior crural nerve, several filaments of which, separated from one another, were opened out upon its anterior surface; these filaments were themselves enlarged, and presented numerous smaller tumours.

"Upon tracing the nerve upwards, it was found that all the branches entering into the composition of the lumbar plexus were greatly increased in size, some of them being nearly three quarters of an inch in diameter; this enlargement commenced where the nerve issued from the intervertebral foramina. The anterior crural nerve measured three quarters of an inch in diameter from the lower extremity of the tumour down to its point of exit from the pelvis. Three tumours, each as large as an almond, existed upon the pelvic portion of the musculocutaneous or external cutaneous branch of the plexus, and the trunk of the nerve in the interspace was as large as that of the ulnar in its normal state at the elbow. The anterior division of the nerve was hypertrophied, and studded with tumours throughout the whole of its course along the anterior and external region of the thigh. The branches of the anterior crural presented similar appearances; the long saphenous nerve in particular being crowded with tumours from its origin to the foot. There existed upon the anterior and lateral regions of the right lower extremity upwards of 150 tumours. The nerves of the front of the left lower extremity were similarly affected, and presented, from the lumbar plexus to the knee, more than 130 tumours. They were all of an oblong shape, the smallest being about the size of grape-stones, while the largest exceeded an almond in magnitude. Upon the surface of many of them delicate nervous filaments were distinctly visible, running from above downwards.

"The right sciatic nerve presented, at the lower margin of the gluteus maximus, an oval tumour, five inches in length, and three and a half in breadth; the principal portion of the nerve lay upon its anterior surface, but numerous filaments, widely separated from each other, traversed its lateral aspect; it was inclosed in a capsule formed by the distended neurilemma. From the lower extremity of the tumour down to the popliteal space, the trunk of the nerve varied from three quarters of an inch to an inch and a half in diameter, and each of its component fibres presented a series of oval or oblong tumours, several of which were as large as an

almond. The anterior and posterior tibial nerves were in like manner studded with small tumours. The total number discovered upon the right sciatic and its branches exceeded seventy.

"It was, however, upon the left sciatic that the most remarkable example of neuroma hitherto recorded was observed. One immense tumour occupied the posterior surface of the nerve, from the lower margin of the gluteus maximus to within four or five inches of the centre of the popliteal space. Its vertical diameter was eleven inches, and its transverse ten. The extent of its surface from above downwards measured fifteen inches, and from side to side one foot and a half. A dense capsule, formed by the neurilemma, invested its entire surface, to which, however, it did not adhere very closely, except in a few situations, where the connexion was intimate.

"The portion of the trunk of the nerve, which corresponded to the anterior aspect of the tumour, was spread out into a vast number of flattened fibres, which, following the convexity of the neuroma, formed a series of curved lines, diverging above, and at the lower extremity of the tumour reassembling to form the nervous trunk; these separated and flattened fibres were themselves the seat of more than fifty tumours, the largest of which was about the size of a grape, and upon the surface of some of them numerous fibrillæ could be traced. The trunk of the sciatic, at its origin from the sacral plexus, and for some distance below it, measured an inch and a half in diameter, and several oblong tumours were connected with the enlarged fibres. At the lower part of the popliteal space, there was found a tumour of the form and size of a lemon, connected by its deep or anterior aspect to the posterior tibial nerve, but the external popliteal and several other branches likewise crossed its surface; they presented a plexiform arrangement, and were all enlarged, some of them being equal to the branches of the sacral plexus in magnitude. The nerves of the leg were also of immense size, and covered with tumours throughout the entire of their course, from the popliteal space to the feet. The number of tumours which existed upon the left sciatic and its branches exceeded 200.

"Nerves of the right upper extremity. The nervous trunks which enter into the composition of the right brachial plexus commenced to enlarge immediately upon emerging from the intervertebral foramina, more especially the fifth and sixth cervical, to the trunk formed by the union of which there adhered a circular tumour, larger than a cherry; the neurilemma formed for it a loosely adherent capsule, the internal surface of which was smooth and glistening; the plexus itself, before giving origin to the nerves of the arm, presented several oblong tumours, which it was difficult to separate from each other. A perfectly oval tumour, as large as a hen's egg, sprung from the external root of the median nerve, which was flat, like a ribbon, and its fibres separated from one another; this tumour was in close relation to the brachial artery, and was inclosed in a dense, smooth capsule, continuous with the sheath of the nerve. The entire of the remainder of the median nerve presented numerous oblong swellings of various sizes, the most considerable of which was placed immediately above the carpus; it was pear-shaped, two inches and a half in length, and one and a half in breadth at its upper or widest part; it lay upon the front of the nerve, the separated fibres of which, as they ran over its surface, formed a series of curved lines, arranged like the divisions of a melon. The external and internal cutaneous, the ulnar, musculo-spiral, and circumflex nerves were all, in like manner, covered with tumours, more especially the circumflex, which presented one continuous mass of neuromatous swellings throughout the whole of the axillary portion of its course. Upon the musculo-spiral, besides numerous small tumours, there existed two of considerable size, one of which, as large as a grape, was situated near where the nerve reaches the external side of the humerus, while the other, which was of the size of a pigeon's egg, was placed near the elbow, between the brachialis anticus and the supinator longus. Upwards of 100 tumours were counted upon the nerves of the right upper extremity.

"Nerves of the left upper extremity. The branches joining the left brachial plexus were similarly affected, and presented bulbous enlargements in their course

across the neck. A pyriform tumour, nearly four inches in length, and two and a half in breadth, was connected with the lower and posterior part of the plexus. It involved the common origin of the musculo-spiral and circumflex nerves, but was more especially connected with the former, which, by the growth of the tumour, was deflected from its course, flattened, and its fibres separated; its capsule adhered so loosely to it, as to admit of being everywhere detached without the use of the scalpel, except towards the apex of the tumour, where the latter sprang from the plexus. Here the capsule was closely adherent and continuous with the neurilemma. Although upon this side the tumours were not so numerous as upon the opposite, yet no branch of the plexus was exempt from them. They were all of an oblong form, existed in the forearm as well as the arm, and were most numerously developed upon the internal cutaneous and musculo-spiral nerves; they numbered upwards of sixty. I may here observe, that, both in the upper and lower extremities, the tumours existed not only in the general sheath which invested the entire nerve, but that they were, in numerous instances, found upon the most delicate fibril that could be separated from the nervous trunk by an ordinary dissection.

Pneumogastric nerves. The pneumogastric nerve upon the right side was enlarged to an immense size throughout the whole of its course, from the base of the skull to the diaphragm; it exceeded the normal size of any nerve in the human body, with the exception of the great sciatic, and throughout the cervical and thoracic divisions of its course presented a most irregular and nodulated appearance; it resembled a large, tortuous, varicose vein. This remarkable condition was produced by a vast number of oblong tumours, varying from half an inch to one inch in length, occupying uninterruptedly the entire course of the nerve, and so closely connected to each other, that they could not be rendered distinct without a difficult and tedious dissection. One large, solid, globular tumour occupied nearly the whole of the cervical portion of the nerve, which, along with the carotid artery and jugular vein, corresponded to its deep surface. The tumour was five inches in length and four in breadth, loosely connected with the side of the larynx, and covered with a thick and adherent capsule. Upon the summit of this large neuromatous tumour, and connected with it by cellular tissue, a smaller one existed, which also sprang from the vagus nerve, and resembled somewhat in form the supra-renal capsule. The left pneumogastric was also enlarged from the angle of the gum to the commencement of its thoracic portion, and presented a series of tumours, the largest of which occupied the lower part of the cervical division of the nerve; one equalled an almond in size, and over its surface there ran a delicate fibre, separated from the trunk of the nerve; the latter resumed its normal size shortly after its entrance into the cavity of the chest.

Lingual nerve. Upon the under surface of the tongue, and towards its left side, there existed nearly twenty tumours, of a white and glistening aspect, and of various sizes, from that of a hemp-seed to that of a walnut; they were all connected with the smaller branches of the left hypoglossal nerve; there were none upon the trunk of the nerve, and but four upon its primary division. They were principally connected with the terminating branches, which could not in every instance be distinctly traced over the tumour to the muscles they were intended to supply. The branches connected with the two larger of the tumours, after a short course, spread out into a number of delicate filaments, which appeared to be lost upon the capsules which invested the tumour. Some of the smallest of the tumours were situated deep between the muscles, and in size, form, and relation to the fibres of the nerve, resembled very much the Pacinian corpuscles of the digital

nerves.

"Phrenic nerves. Upon the phrenic nerves in the neck nothing abnormal was observed; but in their course along the pericardium they each presented three or four small tumours, resembling grains of wheat in size and shape; the neurilemma was continued over them; the nerves between the tumours were of normal size. "Intercostal nerves. The anterior branches of the dorsal nerve upon each side