Some of these warts were vascular, and were covered with secretion, whilst others had a grey colour, and presented a more loosely fibrous texture; some few of these latter were partly detached, apparently possessing little or no vitality. The patient said that, occasionally during the progress of the disease, masses of warty growths would become loose and fall off. The surface bled occasionally when the dressings were removed. The patient suffered constant severe pain; she dreaded to have the arm uncovered, and begged to be relieved of the burden. The fœtor of the discharge was scarcely corrected by chloride of lime.

Considering the extent and seeming incurability of the ulcer, the sufferings of the patient, and the crippled state of the limb, amputation appeared to me the only resource, and in this opinion my colleagues agreed. The limb was removed by double flap operation in the upper-third of the arm, so as to avoid including in the stump any portion of the cicatrix. The wound healed by the first intention, excepting at the point where the ligatures passed out; one ligature remained a long time, and delayed her dismissal from the hospital.

The disease had not penetrated deeper than the integument of the forearm; there was, however, one point where it was doubtful if the subjacent tissue was not beginning to be affected.

the following manner :-A portion of the margin of the ulcer became more extensively indurated, thickened, and raised; increased pain was felt in the part, which slowly ulcerated, the destruction being co-extensive with the previously altered texture. The surface of this fresh ulceration had a foul greyish aspect, which seemed to be due to the deposit in the diseased portion of the cicatrix. The ulcer then remained in a quiet state for an uncertain period, when another portion of the circumference, either adjacent to or remote from the part previously diseased, became similarly affected, and underwent the same changes. During the period she was under observation the ulcer extended in this manner in a direction toward the knee and the outer side of the thigh. Two or three times the whole surface, which had generally a florid appearance, presented a foul grey surface, the general health being at the same time affected; in the course of a day or two this surface would clear off, and the sore regain its former appearance.

Treatment had no effect upon the progress of the disease. The various applications made to the ulcer afforded some relief to the patient; more, however, apparently, from a mental influence than from any direct effect upon the disease. Opium afforded much comfort. Donovan's solution was given. The surface was too extensive to be removed by caustic or the knife. She left the hospital in March, 1851, and I subsequently lost sight of her, as she soon afterwards went to America with her family.

The next case occurred in the practice of my friend Mr. Sicard, to whose kindness I am indebted for an opportunity of seeing the patient, and for being enabled to add the particulars.

A. C., aged 44, the mother of four children, a large leuco-phlegmatic person, was admitted into the hospital December 13th, 1850.* When a child she had been burnt on the posterior part of both lower extremities, but more especially on the left, in which there was a cicatrix extending from the hip to the ham, producing slight contraction of the knee-joint. About eight years since an ulcer had formed in the middle of the scar of the left thigh, which had slowly healed under E. R., aged 72, received a severe burn, fifty-two treatment. Five years ago it reappeared, and has conyears since, by which the left arm became crippled. tinued gradually increasing. When she was admitted The fingers and the thumb were so much injured that there was a large oval ulcer on the posterior surface of they mortified, and were removed. The surface of the the left thigh, yielding a thin offensive discharge. Its burn slowly healed, but during the next twenty years surface was coarsely granulated; the granular elevations repeated exfoliation of bone from the ulna took place. were florid, and the largest of them were about the size On these occasions, inflammation attacked the fore-arm, of a large pea, and had a rough appearance resembling and extended even to the upper-arm; a portion of the a flattened wart. These elevations were separated by covering of the arm became black, and separated, shallow grooves, which admitted the end of a probe. leaving an ulcer, from which either several small scales The edge of the sore was sinuous, raised, and everted, of bone, or a larger portion, were discharged. The and the adjoining texture in some places thickened and ulcer then healed, and remained so until more bone indurated to a slight extent. Before the patient entered was about to be discharged, and, in consequence, fresh the hospital I had seen the ulcer at intervals, at which inflammation was set up. At last, no more exfoliations periods it had presented the same aspect, excepting on took place, and then the cicatrix remained sound for one occasion, when it was less granular, and had rather twenty-nine years. About three years since, an ulcer a glazed appearance. On another occasion a slight formed in the cicatrix on the outer side of the arm, attack of erysipelas had taken place in the healthy skin away from the situation of the former ulceration; this about the hip. The pain was constant, but varied in became incrusted, and by constant addition to the base intensity, being generally proportioned to the more of the crust, a conical horny growth was formed, active or quiescent condition of the ulcer. During her which after a time fell off, leaving a healed surface residence in the hospital the disease slowly advanced in beneath. The part speedily re-ulcerated, and the same process was repeated. During one year and a half this occurred three times, and then the ulcer became permanent. The largest of these masses, which is preserved in the hospital museum, measures two inches,

* This case had only been a short time in the hospital, and the following one was only incidentally mentioned when this communication was read to the Society. I have, therefore, given a fuller account of them than was made at that time.

It is a matter of confessed importance in endeavouring Read at the Quarterly Meeting of the Bath and Bristol Branch, Dec. 17, 1951. to attain a correct knowledge of disease that, at the same time we are careful not to associate together disorders in their nature essentially different, we should guard against unnecessary distinctions, grounded on differences in the degree of development, or a few slight variations of external form. It is with the view of avoiding a distinction of this latter kind, which was apparently inferred, and which does not seem really to exist, that I have offered the foregoing remarks, and would suggest that the forms of disease before mentioned, which have been considered peculiar to cicatrix, should be regarded as epithelial cancer of that tissue; and thus a step, in simplifying our knowledge of disease, and as a consequence, in directing our remedial measures, will be gained.

nation. This crisis was followed by a sense of very great relief, with an almost total cessation of pain; and from that time the sickness never returned.

On the following day all pain had ceased; the abdominal tumour had entirely disappeared; and the liver had retreated nearly within its natural limits. Some slight tenderness in the epigastric region was all that mained of the truly formidable state of things that existed there the day before. The countenance was free from anxiety; the surface had recovered its natural warmth; and the pulse had fallen from 120 to 80. Hunger was now the chief complaint. The starved body was no sooner released from pain than it asserted, in its own emphatic way, its demand for the material needed to restore its natural proportions.

An alkaline mixture, containing equal parts of carbonate of magnesia and bicarbonate of soda, was now prescribed, with ten grains of compound extract of colocynth at night. The bowels did not move until the following day, after an enema. Some large and quite clay-coloured lumps were first voided, followed by more liquid matters, evidently tinged with bile. The evacuation was not examined so minutely, perhaps, as it should have been; but nothing like gall-stone was seen in it.

The remaining part of this singular history is soon told. From the first moment of relief the patient continued to mend, with scarcely an interruption. On the 4th of October he was strong enough to get up, and was, in all respects, convalescent. On the 29th of the same month he left the hospital, having gained six pounds in weight during the last fortnight of his stay. Two circumstances were, however, noted, a knowledge of which is important to the pathology of the case. The whole time the patient remained under treatment the stools were of a pale drab colour. They were not devoid of bile, but were only scantily tinged with it.

bile, through some obstruction in the course of the common gall-duct; and that the sac was, after all, a distended gall-bladder. One of the important points of the case consists, in fact, in showing that the concurrence of the circumstances here specified constitutes no bar to such a conclusion. It may be further added, that a little consideration suffices to show that the anomaly they seem to offer is more apparent than real. For, it is not too much to say, that this anomaly is at once explained by reference to the exactly analogous circumstances which are often observed in the case of retention of urine. In the one case, as in the other, the gland continues to separate from the blood the elements of secretion, so that the system is kept free from taint. In the one case, as in the other, these elements are cast out into the natural receptacle, which provides, by its gradual distension, for the gradually increasing accumulation. In both, again, the gland, as well as the bladder, yields to the distending power, and makes room, in its own way, for the fluid which the bladder has no longer space to hold. The parallel does not even terminate here, but extends to the mode in which that partial relief is obtained, by which alone, in many cases, rupture is averted; for there can be no reasonable doubt, that the bile which occasionally appeared in the matters vomited, in the case of John Morgan, had escaped from the gall-bladder by the same mechanism as that by which small instalments of urine distil from the over-distended urinary bladder in cases of retention there. The outward discharge of this bile, as proving communication between the biliary passages and the intestinal to be still extant, although obstructed, was, I need scarcely add, a fact of the first importance in regard to treatment. Very probably, too, it alone rendered the continuance of life possible for so long a period under such circumstances; for, failing the relief thus afforded, it is but too probable that the gall-bladder, tense as it was in spite of such relief, would have given way under the constantly-increasing distension.

In the absence of direct evidence the nature of the obstruction itself must of course remain a matter of conjecture. Judging from the circumstances amid which it arose, on the one hand, and the persistence of a partial communication on the other, the probabilities are, that it was caused by inflammation and swelling of the lining membrane of the duodenal and of the common gall-duct, propagated upwards from the gut. Micro

The other circumstance alluded to referred to the state of the kidneys. For the first four or five days the urine was distinctly albuminous. It was also very acid, and on being allowed to stand, threw down an abundant precipitate, which by examination with the microscope was ascertained to be almost wholly composed of lithic acid in large crystals. It contained, besides, some well-marked casts of the uriniferous tubes; and, as the specific gravity was never lower than 10.25°, the presence of albumen was supposed to depend on the existence of, perhaps, recent nephritis. This suppo-scopic examination of the stools might, perhaps, have sition was entirely confirmed by the sequel. On the 3rd of October the albumen had disappeared, and could never be detected again in subsequent examinations. Many important reflections occur to the mind in dwelling on this remarkable case. In the first place, the obscurity which at first hung over its nature, was, in regard to the immediate source of danger at least, entirely removed by the event; for, it is scarcely necessary to remark, that after the crisis which occurred on the night of admission, there could no longer be any doubt, notwithstanding the absence of jaundice, and the frequent presence of bile in the ejecta, that the abdominal enlargement was caused by retention of

thrown some light on this question, but want of time and other circumstances prevented my having recourse to it.

The great length of time the obstruction lasted tells much against the notion that spasm was much, though it might have been partly, concerned in it. any of the circumstances of the case, however, among which I may mention the characters of the urine, coupled with what we know of the pathology of this class of affections, renders it not improbable that the irritant action of an excess of acid in the upper part of the primæ viæ might have played an important part in the phenomena. The continued deficiency of bile in the stools, after the

obstruction had given way, would admit of various

interpretations. It might possibly have been owing to OBSERVATIONS ON HYDATID DISEASE

an early stage of cirrhosis, brought on by the drinking habits in which the patient had so long iudulged, although this is improbable; or the secreting power of the liver might have been more or less impaired, as that of the kidney is often known to be under the like conditions, by the prolonged and severe pressure to which the secreting element had so long been subjected; or, lastly, some amount of obstacle might still have existed to the free flow of bile into the intestine.

Finally, it would be an omission to take leave of this case without remarking what a strong motive it furnishes, not less in the unexpected deliverance from so desperate a state by the common resources of nature, than in the probably fatal risk averted by abstaining from surgical interference, for extreme reserve, as well as caution, in attempts to relieve fluctuating tumours conected with the liver, by simple puncture with the knife or trocar. Altogether to proscribe such attempts would be, no doubt, to go too far.

OF THE LIVER.

BY P. M. DUNCAN, M.B., LONDIN., F.G.S.,

PHYSICIAN TO THE ESSEX AND COLCHESTER HOSPITAL.

PART II.*

THE last communication referred to the development, generation, and decadence of acephalocyst hydatids; in the present their distribution, symptoms, and treatment will be considered.

Although hydatids are most frequently found in the obnoxious to their attacks; and there is hardly a tissue liver, yet the spleen, kidneys, lungs, and brain are in the body which has not, at some time or other, been the seat of these pernicious parasites. The superficies cellular tissue supporting the true skin, is, especially of the body, consisting of a greater or less amount of after severe contusions, liable to be affected by acephacellular tissue beneath the basement membrane of the locyst hydatids. The nidus of the parasite is in the

true skin.

A

In the 27th volume of the Medico-Chirurgical Transactions a case is recorded by Mr. Barlow, in which the operation of tapping a gall-bladder, distended by retention of bile, was not only followed by no ill result, but was, most probably, the means of saving backwards whilst carrying a heavy weight, and struck Case.-A man, aged 46, of intemperate habits, fell life. Many circumstances, and among them some connected with its own history, concur to show, how-siderable pain beneath the angle of the right scapula, his back against a log of wood. He experienced conever, that it would not be safe to make the course where there were evidences of a considerable bruise for followed in that particular case a rule of practice. For several days. After the lapse of a week, the tenderness this one case of success many could be related in which and pain having subsided, he noticed that the swelling the operation was the actual cause of death, and where was not decreasing so rapidly as it had done. After a the introduction of the trocar sealed the fate of the while a decided tumour appeared at the above spot, patient. It is a matter of experience, in fact, that in grew rapidly, gave him no pain, and produced no conthe majority of such cases the gall-bladder is nonstitutional disturbance. He was admitted into the adherent; and thus it happens, that (by the common Colchester Hospital, under the care of my colleague, mode of proceeding) the immediate effect of the punc- Mr. Waylen, some months after the accident. ture is to cause the pent-up bile to escape into the tumour as large as an infant's head was found below peritoneum, and thus to hasten on that very catastrophe the right scapula; its form was rather irregular; it which it is the great object of art to avert. But, not-presented the sense of fluctuation very indistinctly; withstanding all these difficulties and objections, it must the skin was moveable over it, and manipulation prostill be confessed, that this mode of relief will occur to duced no pain. An incision let out pus and many the mind as a possible means of saving life where death and containing secondary cysts. acephalocyst hydatids, some collapsed, others globular might otherwise be inevitable; and thus, in spite of be discharged for a fortnight; no constitutional disCysts continued to former mishaps, on the one hand, and unexpected turbance followed, and the man was discharged cured. recoveries on the other, it will still remain to be a source of perplexity in all desperate cases. In solving this perplexity, the occasional presence, or the contrary, of bile in the ejecta, is an element of far too great importance to be lost sight of. Where it was at length determined, after due deliberation, to risk the operation, it might be worth considering whether the chief * peril attaching to its performance might not be averted by proceeding in the mode now practised in the first steps of the operation for the extirpation of ovarian cysts,-namely, by securing the sac to the walls of the belly before making the necessary opening for the discharge of its contents.

Park Street, Bristol.

It would appear that the parasite found a proper nidus in a bloodvessel implicated in the contusion; that it grew gradually; and at last, owing most probably to those intrinsic changes described in my last paper, suppurated.

Usually considerable constitutional disturbance follows the opening of superficial hydatid sacs, on account of the sloughing of the external fibrous tunic. It is to be remembered that the older the hydatid the thicker is the fibrous coat; and that the vascularity of this last tissue decreases with its thickness. Open, then, all tumours made out to be hydatid, occurring in the superficial cellular tissue, as soon as possible.

• Concluded from page 654, No xxiv., of last volume.