that of a gentleman, Mr. MacC., aged thirty-two, a professional photographer, who happened to be visiting Chapelton in October, 1865, at the time when I and the other gentlemen of Upper Clarendon were keeping watch, night and day, at the Court-house, as volunteers, for the protection of our homes, and of the honour of our wives and children, during that terrible ordeal through which Jamaica passed. Mr. MacC. had ridden down to the river to bathe, without having taken the usual precaution of putting on his truss-for he had an inguinal hernia previouslywhen, on making use of exertion, a large mass of intestine came down into the scrotum, and soon became strangulated.

I was quickly with him, for he lodged very near the Courthouse, on the floor of which I had to sleep for many a night during the rebellion; and I tried the taxis, but in vain. He vomited incessantly; and the scrotum swelled out to such an extent, the wind gurgling through its contents, at each sickly gulp of the weak man, to such an extent that I thought the inflated intestine would have burst.

Again and again I tried the taxis, and failed. A stout drillsergeant placed him with his heels over his (the sergeant's) shoulders, at my suggestion, in the hope that the intestine might, in this way, be drawn back into the abdominal cavity-but in vain.

I now made Mr. MacC. lie with his hips against one of the bottom posts of the bed, both his legs being supported against this post, between it and the wall. His legs were thus at right angles with his body; and he was placed in the most favourable position for the taxis, or for the gradual return of the contents of the hernial tumour. I left him for a little, and, having given him an opiate, he had some rest; but, in the meantime, the stricture had become relaxed; and a portion of the protruded intestine had returned, by means of its own weight, into the abdomen. The remainder was soon easily returned by the taxis.

The fourth case bears no point of interest, except that the plan of placing the patient in the position described in the preceding remarks, in this instance with one leg only, on the affected side, placed against the bedpost, enabled me to return an inguinal hernia as large and as hard as a cricket-ball, into the abdomen.

I never saw a hernial tumour so hard and unyielding as in this case; and yet the plan adopted, without any help from chloroform, tartar emetic, tobacco, the warm bath, or any other auxiliaries,

enabled me to overcome all difficulties, and to reduce this hard and exquisitely painful tumour, in a few minutes, by the taxis alone. Thus, a most unpromising case became, by this simple expedient, one very easily managed indeed.

ART. XI.—On the Diagnosis of Renal from Ovarian Cysts and Tumours. By T. SPENCER WELLS, F.R.C.S.; Surgeon in Ordinary to Her Majesty's Household; Surgeon to the Samaritan Hospital; &c.

DURING the few years which have passed since the revival of Ovariotomy in England, great attention has been paid to the diagnosis of abdominal tumours; and a knowledge of their distinctive characters is becoming so general, that mistakes which were formerly not uncommon are now comparatively rare. The diagnosis of ovarian tumours from pregnancy-from fibroid or fibro-cystic tumours of the uterus ascites-tubercular or cancerous affections of the peritoneum-other forms of intra-abdominal cancer-hydatid cysts in the liver-iliac or pelvic abscess-is made repeatedly, in hospital and private practice, with a readiness and certainty which render a mistake quite an exception in a long series of accurate opinions. But exceptions still occur; and men of great experience must occasionally admit that an exact diagnosis is impossible. In other cases, it is only after an explanatory or incomplete operation, or after the death of the patient, that a mistake is discovered, and the means of avoiding it for the future are learned. Such a case has recently occurred in my own practice-a cyst, believed to be ovarian, proving to be a cystic degeneration of the kidney; and I avail myself of the earliest opportunity of bringing this case before the profession, with a few remarks on other cases in which I have known renal to be taken for ovarian disease.

The first case of the kind which came under my care was one of

SOFT CANCER OF THE RIGHT KIDNEY

in a girl only four years old. She was sent up from the country to me, in 1862, supposed to be suffering from ovarian disease. Her appearance is very well shown in the annexed woodcut, copied from a photograph, taken by Dr. Wright, while she was in the Samaritan Hospital.

The diagnosis in this case was made without much difficulty, although the urine was quite normal. The growth was extremely rapid; hardly six months from its commencement to its fatal termination when the diseased mass weighed between sixteen and seventeen pounds. The tumour occupied the whole of the right side of the abdomen, bulging backwards in the right loin. It was uniformly elastic, but not fluctuant. The intestines were pushed downwards, and to the left side. The rapid growth, and the absence of fluctuation, were, of course, strongly against the opinion that the tumour was ovarian; while the rarity of ovarian disease in young children, and the comparative frequency of renal encephaloid, led to a diagnosis which was confirmed by a puncture with a fine exploring needle. A few drops of reddish serum were obtained, containing nucleated cells of most varied size and shape. I sent the child home, with a note, to Dr. Williamson of Nantwich, expressing my opinion that the tumour was a mass of soft cancer, and that the right kidney was the most probable seat of the disease. This proved to be correct. Dr. Williamson sent me the specimen, and I exhibited it at the Pathological Society, in December, 1862. The whole kidney was infiltrated with encephaloid. Although so enormously enlarged, the shape of a normal kidney was distinctly VOL. XLIII., No. 85, N. s.

K

preserved. Its surface was soft and elastic, in some spots giving sense of deep-seated fluctuation; but no cyst was found, nor were there any marks of suppuration or hemorrhage. Coils of small intestine adhered to its inner and under surface. The ureter was completely occluded by the pressure of the tumour. The left kidney was quite healthy. Thus the normal condition of the urine was explained. The diseased kidney added nothing to the contents of the bladder, and the healthy kidney supplied only normal urine. The following remarks on this point by Dr. Roberts, of Manchester (Urinary and Renal Diseases, p. 444), are well worthy of serious consideration. He says:-"The presence of cancer cells in the urine is a sign which usually figures prominently in the catalogue of symptoms of renal cancer, but its value is very doubtful. In all the later cases, especially when there was hematuria, the urine was carefully examined for cancer cells, but without success. Rosenstein mentions a case in which a cancerous villus was actually found projecting into the ureter, yet no cancer cells could be detected in the urine during life. It is by no means an easy matter to identify cancer cells in the urine, in consequence of their similarity to the transitional epithelium of the pelvis and ureter. In two examples of renal cancer, with hematuria, which I have had an opportunity of observing, repeated and careful examination of the urine failed to discover the presence of cancer cells. Mr. Moore (Med. Chir. Trans., xxxv., 466) believes that he succeeded in identifying cancer cells in the urine drawn after death from the bladder of a man in whose kidneys cancerous nodules were found; but his description rather accords with the appearance of the epithelial cells which are always freely detached from the vesical mucous membrane after death."

Whether renal cancer be observed in children or in adultswhether it be or be not accompanied by hematuria, or by the presence in the urine of albumen, or of epithelial cells from the ureter and pelvis of the kidney-whether the progress of the disease be slow or rapid-whether there may be much, little, or no pain, or emaciation, or gastric symptoms-or great or little effect upon the general health—the abdominal tumour is the most prominent characteristic of the disease. As Bright observed (Abdominal Tumours-Sydenham Society's Edit., p. 199):-"The enlargement shows itself much more towards the anterior part of the abdomen than towards the loins." It is, however, more or

less confined to one side of the abdomen and to the corresponding lumbar region, whence, as a rule it is immovable-and equally, as a rule, some portion of the intestines are fixed in front of it. But in one extraordinary case, an exception was found to both these rules. In the Lancet of March 18, 1865, a case is recorded in which an operation was commenced for the removal of a supposed tumour of the left ovary. The patient was in one of our general hospitals, and it was believed by the eminent physicianaccoucheur who carefully examined her, and by the skilful surgeon who performed the operation, that "the tumour was ovarian, and that from its great mobility, and the absence of adhesions, its removal would be easy." Yet the uterus and ovaries were found to be healthy, and the tumour to be the enlarged left kidney, which, instead of being fixed, was movable-its peritoneal covering being elongated into a sort of mesentery, admitting of free movementsand instead of pushing the intestines before it, the descending colon and sigmoid flexure were behind it.

The absence of fluctuation is the leading sign by which cancerous or other solid tumours of the kidneys are distinguished from ovarian tumours; for it is extremely rare to find a large ovarian tumour in some part of which fluctuation cannot be detected. But in some forms of kidney disease fluctuation is as evident as in ovarian cysts. It was perceptible in the second of the three cases on which this paper is founded-one of

PYONEPHROSIS OF THE RIGHT KIDNEY, WITH IMPACTION OF TWO CALCULI IN THE URETER.

On the 16th of May, 1865, I was hurriedly called to see the mother of a patient upon whom I had performed ovariatomy successfully, the daughter telling me that her mother had a tumour like that which I had removed from herself. I found the patient, about fifty years of age, in excessive pain all over the abdomen, but greater on the right side and in the right loin; and I felt a hard tumour between the right false ribs and the right ilium, reaching forward to within an inch of the umbilicus, as shown in the annexed. diagram. The patient was so ill that I could not get any sort of history from her. I prescribed a full opiate, and directed it to be repeated in smaller doses at intervals of an hour until the pain abated-hot poultices being also applied. On the next day she was much easier, and I gathered the following history:-