Pathological Anatomy.—­The wall of the cyst is composed of fibrous tissue closely adherent to or fused with the surrounding tissues, so that it cannot be shelled out.  There is no endothelial lining, and the fibrous tissue of the wall is in immediate contact with the colloid material in the interior, which appears to be derived by a process of degeneration from the surrounding connective tissue.  In the region of the knee the ganglion is usually multilocular, and consists of a meshwork of fibrous tissue, the meshes of which are occupied by colloid material.

It is often stated that a ganglion originates from a hernial protrusion of the synovial membrane of a joint or tendon sheath.  We have not been able to demonstrate any communication between the cavity of the cyst and that of an adjacent tendon sheath or joint.  It is possible, however, that the cyst may originate from a minute portion of synovial membrane being protruded and strangulated so that it becomes disconnected from that to which it originally belonged; it may then degenerate and give rise to colloid material, which accumulates and forms a cyst.  Ledderhose and others regard ganglia as entirely new formations in the peri-articular tissues, resulting from colloid degeneration of the fibrous tissue of the capsular ligament, occurring at first in numerous small areas which later coalesce.  Ganglia are probably, therefore, of the nature of degeneration cysts arising in the capsule of joints, in tendons, and in their sheaths.

Treatment.—­A ganglion can usually be got rid of by a modification of the old-fashioned seton.  The skin and cyst wall are transfixed by a stout needle carrying a double thread of silkworm gut; some of the colourless jelly escapes from the punctures; the ends of the thread are tied and cut short, and a dressing is applied.  A week later the threads are removed and the minute punctures are sealed with collodion.  The action of the threads is to convert the cyst wall into granulation tissue, which undergoes the usual conversion into scar tissue.  If the cyst re-forms, it should be removed by open dissection under local anaesthesia.  Puncture with a tenotomy knife and scraping the interior, and the injection of irritants, are alternative, but less satisfactory, methods of treatment.

Ganglia in the substance of tendons are rare.  The diagnosis rests on the observation that the small tumour is cystic, and that it follows the movements of the tendon.  The cyst is at first multiple, but the partitions disappear, and the spaces are thrown into one.  The tendon is so weakened that it readily ruptures.  The best treatment is to resect the affected segment of tendon.

The so-called “compound palmar ganglion” is a tuberculous disease of the tendon sheaths, and is described with diseases of tendon sheaths.

CHAPTER XI

INJURIES