RETROSPECTIVE ADDRESS. Cancer of the Cacum.-On the 2nd of September, 1846, Mr. Harrinson read a case of cancer of the cæcum, accompanied with obstruction of the bowels, in which the small intestines were found distended with flatus, the colon empty, and much contracted. The cæcum was found to be enveloped in a mass of cancerous matter, larger than a man's fist, with an adherent nodule the size of a walnut, and connected at its upper part with the lower edge of the liver. Small masses of similar deposit were also observed scattered through the mesentery, omentum, on the surface of the liver, and in the cavity of the pelvis. One of a larger size half surrounded the sigmoid flexure of the colon. The internal structure of the liver, kidneys, stomach, &c., was apparently healthy. On examining the cæcum the termination of the ileum was greatly dilated, and distended with fæces. The ileo-colic valve was perfect, but much hypertrophied and elongated, extending into the cæcal cavity, like an elongated cervix uteri. On laying open the cæcum, it presented a large irregular ulcerated cavity, with the walls from a quarter of an inch to one inch in thickness, and containing masses in a state of separation or mortification, and of extreme fœtor. Two questions arose in this case as to the cause of the obstruction,-1st., as to whether it was fæcal or mechanical; 2nd., as to the seat of the obstruction. The farther the obstruction is from the pylorus, the less is the pain and the vomiting. As these were not very great, the inference was, that it was low down. The great distension also proved this. Another circumstance which indicates the seat of the obstruction, is the effect on the urine; when it is seated high up, the urine is more or less suppressed; when low down, it is not affected. Speedy or tardy collapse also follows the same rule. In the conversation which ensued upon this case, Mr. May mentioned that in cases of obstruction he had found the best treatment to consist of enemata; if, after their exhibition, there was no improvement, he had recourse to opium, with leeches and poultices. He considered the virtue of the opium consisted in restraining the peristaltic action of the intestine, and quieting the system, and he believed we were generally in error as to the necessity of emptying the bowels, for that the retention of fæcal matter for a longer time than usual, was of no great detriment. Secondary Cancer of the Liver.-On the 30th of September, 1846, Mr. May presented a portion of the liver which he had taken from a lady who died two days previously. He gave the following history of her case :-She had not borne a child for ten years, when she became pregnant about two years ago. At the beginning of her pregnancy she came to him for an affection of the mamina, which he found to be scirrhus. It was treated with palliatives. She went through ber pregnancy well, got through her labour easily, and continued to enjoy tolerable health for some time. She then began to complain of pain in the back, and was unable to ride on horseback, and take her usual exercise. She became emaciated, sub-jaundiced, and the subject of ascites. 369 Upon examination after death the liver was found to be very much enlarged, and having a lobulated appearance. Upon cutting into the lobules, they were found to contain nodules of scirrhous deposit. The internal structure of the liver was also hardened, and put on the character of cirrhosis. Mr. May remarked that, Dr. Walshe does not exactly describe this form of the disease, and says that cirrhosis and cancer do not usually accompany each other. But he (Mr. May,) did not see why they might not co-exist. There were about three gallons of sero-purulent fluid in the abdomen. The kidneys and uterus were healthy; the mamma was scirrhous, confirming the curious fact that where cancer is found in the breast, it does not affect the uterus, and vice versa. There was some fluid in the chest, and the apices of both lungs were occupied with cancerous infiltration to a small extent. Some of the deposit taken from the liver, shewed under the microscope several nucleated cells, floating around large globules of fat. Enlarged Spleen.—On the 2nd of December, 1846, Mr. Harrinson presented part of the lungs, liver, and an enormous spleen, removed from a gentleman, aged 67, a native of Lincolnshire, where he had ague. He had left that county, however, at 18 years of age. He was of active habits, and his general health had been remarkably good; it had, however, been failing for the last twelve months. His great complaint was pain across the stomach, and constipation. He never had sickness, vomiting, or spasms. While much as usual he was seized with a violent rigor, and quickly afterwards became partially insensible. Next day he was found to be jaundiced, alternating between a state of coma and muttering delirium, with a dry skin, feeble pulse, and troublesome cough. The abdomen on examination, was found much distended, liver enlarged, and in the left hypochondrium a tumour, part of which from its prominence could be laid hold of by the hand. He continued in much the same state, with intervals of partial coherence, for six days, when he died. Post-mortem.-Lungs much loaded with melanotic deposit; slight adhesions, with a small deposit of doubtful adventitious tissue, at the base of each lung; liver large, with two or three slight portions, offering a mother-of-pearl appearance; stomach adherent above to left lobe of the liver, and behind extensively to a large mass of scirrhous deposit, lying on the spine and around the aorta; spleen enormously enlarged, and proving to have formed the tumour which had been observed in the left hypochondrium during life. REPORT OF A CASE OF OVARIAN DROPSY SUCCESSFULLY TREATED, WITH REMARKS. By THOMAS HUNT, M.R.C.S.E., Herne Bay. Encysted dropsy is a disease for which no sensible man would prescribe an uniform method of treatment in every case. The circumstances under which it occurs are so various, that the modern controversy concerning extirpation, and other modes of arresting its course, might be reduced to a much smaller compass than it now occupies, if every writer would confine his observations to certain marked peculiarities of any individual case, instead of presuming to contend for any general method of treatment, as adapted to all, or even to a large proportion of the cases met with in practice. The treatment recently advocated (though not originated,) by Mr. J. B. Brown, of Paddington, consisting of pressure, mercurials, diuretics, and tapping, appeared in the first instance remarkably successful; but it has notoriously failed in one or two instances, and has been attended with extreme danger in others. His cases are, however, full of practical interest and instruction. The treatment of the following case was detailed in the Lancet, January 24th, 1846, and its sequel up to the present time is satisfactory. The leading particulars are as follows: The patient, Mrs. F., aged 30, a healthy subject, was delivered of her fourth child in the month of January, 1841, and on this occasion the nature of the tumour was first demonstrated. She was then residing at Ingatestone, and Mr. Cornelius Butler, who attended her, gave her subsequently the following memorandum in writing: "In Mrs. F's last confinement, the progress of the head of the child was much impeded by a tumour in the recto-vaginal septum. After some difficulty I delivered her with the forceps. I merely write this to sanction the puncture of the tumour, if it be necessary, at any future time, as it has increased considerably, by the testimony of the gentleman who attended her previously, and with whom I am acquainted. "Ingatestone, Jan. 1, 1841." "C. H. BUTLER. Her previous labours had been difficult, and the tumour had probably existed for several years. He subsequently observed an enlargement on the left side of the abdomen. In the autumn of 1843, proving again pregnant, she consulted Dr. Blundell, who is said to have advised her then medical attendant to have recourse to premature delivery. This was accomplished in the sixth month of utero-gestation. From this time the abdominal tumour increased more rapidly. In the autumn of 1845 she placed herself under my care. October 15, 1845. The abdomen measures thirtyfour inches; parietes very thin; umbilicus prominent; fluctuation very distinct; health moderately good; menstruation regular. The os uteri is slightly tumid, and has rather more sensibility than usual, but presents no indication of disease. She has the appearance of a woman in the seventh month of pregnancy. 22nd. The abdomen was tightly bound with a flannel bandage, which was renewed night and morning. One drachm of the strong mercurial ointment was directed to be rubbed into the abdomen every night, a diuretic mixture ordered to be taken twice a day, and three grains of blue pill night and morning. 24th. The diuretic having produced vomiting, the medicine was administered in the effervescing form. She had great uneasiness in the chest from the tightness of the bandage. 28th. She complains of vomiting, and pain in the jaws. The gums and throat are very sore, and a copious salivation has set in. The quantity of urine passed for the last three days exceeds that of the fluid swallowed; the abdomen is decreased in size about two inches. Discontinue the mercury. 30th. The mouth continues excessively sore; the soft palate is extensively, but superficially, ulcerated; the tongue can searcely be protruded, and the salivation is unabated; flow of urine still copious; the stomach rejects all medicine, except an occasional dose of aperient pills; the menses have appeared at the end of a fortnight from the last period; the abdomen measures less by three inches than at the beginning of the treatment. Milk diet ordered. November 4th. The soreness of the mouth is beginaning to amend slowly. Urine smaller in quantity since the diuretics have been rejected, which has happened in every form of their administration. 11th. Improving in health; is able to take more nourishment; secretion of the kidneys diminished; bowels costive; the abdomen, having previously measured less by three inches and a half, is now somewhat increased in size. The bandage has been constantly applied, but cannot be borne very tight. Ordered a dose of aperient pills. 12th. The cyst was tapped by Mr. Brown in my presence, and nearly nine pints of fluid were drawn off. It was almost as clear as water, and as colourless. When treated with nitric acid, at a high temperature, it exhibited a slight albuminous cloud, scarcely visible at the time, but distinctly precipitated on the following morning. She bore the operation without fainting, and was put to bed, tightly bound with a flannel bandage, a book, enveloped in napkins, being applied to the umbilical and pubic regions, as a compress. 13th. She has had a tolerable night, but complains of headach. She has passed five pints and four ounces of urine since the cyst was tapped, and has taken only a pint and a half of fluid. The bowels being costive, a dose of aperient pills was ordered, and some ginand-water. 14th. The pills excited vomiting, but have acted on the bowels. Complains of the corners of the book | hurting the ribs and hips. A large toilet pin-cushion was substituted, and the bandage re-applied. She has nearly lost her appetite, feels weak, and is distressed with flatulency. Ordered a glass or two of wine. 15th, 16th, and 17th. Has been constantly harrassed with flatus; when the bandage is withdrawn she eructates an immense quantity of gas. Urine about equal to the fluids taken. 18th. Appetite entirely gone; she has slept but CASE OF OVARIAN DROPSY. little; is much depressed in spirits; pulse 120; skin hot; abdomen somewhat tender; urine scanty; bowels costive. A cathartic pill was ordered, and an effer vescing draught every fourth hour. 19th. Better to-day; skin cool; pulse weak and slower; complains of noises in the head; has drunk about a quart of fluid, and passed less than that quantity of urine; the bowels have been freely relieved. An attempt was now made to resume the mercurials and diuretics, but it was found impossible to persevere. The stomach became excessively irritable. 24th. It is proper to mention that, about three weeks ago, one of her children returned from a visit to town with slight fever, (synocha;) since that time a second and third child have drooped with a similar febrile affection, and during the last week the mother has evidently been suffering from this cause. She has had a hot skin, rapid pulse, pain in the head at first, then noises and deafness. She has also been perpetually retching. An aperient pill was prescribed, the bowels being constipated, and effervescing medicines at short intervals. 25th. She has been delirious in the night, sitting up and singing. She is vomiting green bile. Pulse 125, weak; eyes glassy; manner excited. Blister to the back of the neck. Opium and calomel, a grain of each, relieved the vomiting, and she was better in the evening. 26th. She has had a restless night, but no delirium; the vomiting continues. She is much dejected; says she has been doing nothing but vomit for a fortnight, and cannot bear it much longer, She complains of distressing thirst, and thumping noises in the head, but no pain. Pulse 120, weak; features sunken; skin moist, but hot. The vomiting was by degrees controlled by repeated doses of creasote. 27th. Somewhat better. Complains much of the heat of the flannel bandage. A linen towel tightly pinned round the pelvis was substituted. A cold lotion was applied to the head, and the hair taken off. December 1st. There has been some improvement for a day or two, but she is worse to-day. Has slept much, and is now (eleven a.m.) in a copious perspiration, but is again vomiting a dark green fluid. The creasote to be repeated every fourth hour. Evening: No vomiting, but nausea and eructations. Pulse 120,very feeble; countenance hippocratic. The morning perspiration having been excessively copious for about two hours, was succeeded by general coldness. She is now hot and dry. The tongue has presented an appearance throughout remarkably normal. The creasote to be continued, and a little brandy-and-water occasionally.. 2nd. She has slept a little; has had no return of the vomiting or nausea, but feels “dying weak." The creasote to be continued. Take Evening She has again perspired most profusely; feels somewhat better; pulse fluttering; speech affected; great exhaustion; no nausea nor eructations. of sesquicarbonate of ammonia, one scruple; aromatic confection, half a drachm; camphor mixture, six ounces. A fourth part every five hours. She longs for some home-brewed ale. Let her have it. . 371. 3rd. Decidedly better; has slept well. A fortnight has now elapsed since the first accession of fever, and it seems to have arrived at a crisis. 9th. She has continued fluctuating, but gaining ground. The perspirations have frequently returned, and likewise the eructations and vomiting, which nothing would permanently relieve but the removal of the bandage. It has accordingly been abandoned, and her stomach has become very comfortable. She takes nourishment in small quantities. Pulse 90; urine scanty; skin soft but no disposition to profuse perspiration. There is no perceptible tumour in the abdomen, the muscles of which are so relaxed and attenuated that the presence of a tumour, if it existed, could scarcely escape observation. January 7, 1846. She has now a good appetite, and is gradually regaining her strength, but still totters as she walks, and complains of confused noises in her head. The secretion of urine is normal, and there is a slight oedema of the feet towards evening, but not more than frequently occurs upon first sitting up after a long illness. She has recovered her hearing and is in good spirits. The abdomen is flat and no vestiges of any tumour are discoverable. April 28, 1847. The patient has continued in good health during the last fifteen months, and sbe was delivered of a full-grown male child on the 4th of this month, after a natural and easy labour, having never previously had an easy labour at the full period. A few days after her delivery, a careful examination of the abdomen discovered no tumour, except the contracted uterus in its proper position. In all probability, therefore, the disease is cured. It is now sufficiently established that many cases of unilocular dropsy will yield to these four remedies conjointly, not however, as it would appear from this case and others published by Mr. Brown, without some degree of inconvenience and danger. The next question for experimental enquiry is,-can this practice be so modified as to avoid the objections attending it. These objections are chiefly,—the dangers attending the use of mercurials conjointly with the operation of tapping, and the inconveniences of severe pressure around the abdominal parietes. Mr. Brown himself has now been led by his experience to repudiate the former, and Dr. Locock has given his testimony to the use of bandaging without mercurials. It appears to me that after the operation of tapping, diuretics are useful as tending to divert the blood supplying the cyst, and to expend it on the kidneys; and to avoid the evils of pressure upon the bowels generally, perhaps a sort of spring tourniquet or truss might be so applied over the ovary as not to distress the other viscera. I throw out the hiat for the use of those who are much in the habit of treating these diseases. Herne Bay, May 14, 1847. CASE OF ABSCESS OF THE NECK, FOLLOWED | neighbourhood of the abscess was the source of the BY FATAL HÆMORRHAGE. By WILLIAM JACKSON, Esq., F.R.C.S., Sheffield. (Read at the Annual Meeting of the Yorkshire Branch of hæmorrhage. Was it practicable to secure it by a ligature? This was a most interesting surgical questión. We had a disease seated beyond or just at the the Provincial Medical and Surgical Association, held at confines of surgical practice. It is true, in one Sheffield, June 10th, 1847.) instance at least, the arteria innominata had been sucJuly 16, 1830, I was first requested to visit J. W., cessfully taken up. But here two difficulties presented aged 19, a young man following the trade of a cabinet-themselves :-First, if it were taken for granted that the maker, whose general appearance presented to the mind the characteristic features of scrofula. I learnt from his friends that he had suffered for several months from an extensive swelling of the right side of the neck, and had been under the care of a female practitioner, notorious for the treatment of sores, in a neighbouring town. It was stated, that by the applications made use of she had brought the swelling to a head, and at length there was a copious discharge of pus, finding its exit by two or three openings. His health had suffered considerably by the discharge, which had been established more than a month. I was summoned by an urgent message in the night of the 16th, and found the young man in a state of syncope from loss of blood, from two or three apertures on the side of the neck. The hæmorrhage had ceased, the opening being occupied by coagula of blood. The largest aperture was seated about two inches above the clavicle, and somewhat nearer the sternum than the scapular extremity of that bone. The other apertures were seated more outwardly. The attendants represented the bleeding to have been very sudden and copious, the almost immediate effect of which was complete syncope, and a cessation of the flow of blood. I remained till the patient recovered his | consciousness, expecting of course, a renewal of the hæmorrhage; but as he still remained in a languid state, with an almost imperceptible pulse, no immediate measures were adopted for his relief, From the appearance presented by the blood, as stated by the persons present, and from the rapidity of the stream, there could be no doubt but a vessel of considerable magnitude had given rise to the bleeding. The situation of the disease was carefully explored, and there was just reason to infer that the abscess originated from some deep-seated part, most probably from the bodies of the cervical vertebræ. The question presented itself, from what vessel did the bleeding arise. It might be from the subclavian or the vertebral artery, or the internal jugular vein; for a vessel of inferior magnitude would not pour out blood so rapidly as to sink the powers in so short a time as occurred in this individual. The pulse became gradually restored and consciousness returned. The application of cold, rest, and cooling drinks were enjoined. On the 17th, the circulation had become moderately re-established, and there had been no return of the hæmorrhage. On the 20th there was a sudden return of the hæmorrhage, which, as before, had quite subsided on my arrival; I found the poor young man deluged with blood, and in a state of insensibility. My friend Sir A. Knight, Mr. Gregory, and the late Mr. W. Staniforth, visited the patient with me to day. The case was one evidently of unusual occurrence, for all concurred that one of the great vessels in the subclavian was the vessel giving out the blood, the breach most probably was very near its origin. A ligature applied at this point would have been a practice in violation of a very important surgical principle,— viz., to avoid such operation upon an artery very near the situation of a large branch or division of a main trunk. Secondary hæmorrhage would almost inevi tably be the result. Nothing but the necessity of the case could justify such a proceeding. The second point for our consideration was the great probability of the existence of diseased bone being the cause of the abscess, and consequently connected with the bleeding vessel. Of course a ligature upon an artery under the circumstances of this case would be likely to be less favourable in its results than had aneurism existed in the subclavian, as there would be no probability of enlargement of those branches of the collateral circulation upon which the surgeon would hope for the support of the superior extremity. It was generally considered by the gentlemen engaged in consultation that the hæmorrhage proceeded from a part inaccessible to surgery, and that in all probability extensive disease existed, besides the ulcerated artery giving out the blood. Under these circumstances, therefore, nooperative means were advised. After the recurrence of hæmorrhage on the 22nd and 24th, our patient sank. Post-mortem. The blood-vessels were injected, and it was found that ulceration had occurred in the subclavian artery, as it lies upon the first rib. The rib was in a carious state, as well as the bodies of the contiguous vertebræ. The situation of the ulcerated opening in the artery was towards the bone, and occupied about one-fourth of the calibre of the vessel; the opening was of a somewhat oval shape, and well defined. There was no enlargement of the capacity of the vessel at the part. Mr. Liston's case at the North London Hospital, reported some years ago in the Journal, about which there was much criticism at the time, if it were really not a case of aneurism, may be considered to bear some resemblance to the one now presented to the Society. Hospital Reports. QUEEN'S HOSPITAL, BIRMINGHAM. CLINICAL REPORTS OF SURGICAL CASES By PETER HINCKES BIRD, one of the Resident (Continued from page 296.) CASE XXX.-OVARIAN DROPSY. Sarah Fretwell, aged 65, housewife, admitted into the Queen's Hospital on June 26th, 1846; married, QUEEN'S HOSPITAL, BIRMINGHAM. has nine children. She states that about twenty years ago she first perceived a swelling of the belly; she took medicines and she says it disappeared; a short time after the swelling re-appeared, and gradually increased notwithstanding medicinal treatment, until Feb. 10th, 1845, when she was tapped, and a large quantity of fluid evacuated ; since then she has been tapped eight times, and 69 gallons of fluid have been withdrawn. The swelling is stated to have come in the front, and not on one side; urine reported as sometimes thick and scanty, sometimes clear and plentiful; has never been jaundiced; has never had rheumatic fever; menstruation always regular up to her change of life; there is no evidence of any disease of the heart, liver, or kidneys; has always been hearty. She states that some time ago she passed considerable quantities of water per rectum. Was tapped three weeks ago. Present State. The belly is of an enormous size, and projects considerably in front, it measures 54 inches round; the skin is smooth and shining, and is covered by tortuous dilated veins; there is a distinct sense of fluctuation to the finger; there is no uneven feel; both sides are equally swollen; there appear to be adhesions under the parts where she has been previously tapped; she complains of a nasty taste in the mouth; health very good; breath short on walking; tongue rather furred; bowels rather costive; legs not swollen." July 2nd. Slightly increased, measures 57 inches. She was tapped this morning by Mr. Cox, and eight gallons of a thick glairy fluid were drawn off; she bore the operation very well, but felt rather faint towards the conclusion. The fluid, which was at first very thick, and flowed through the canula but slowly, became, however, rather thinner, and flowed in a full stream until the cyst was emptied; the consistency of the fluid varied at times, and masses of a whitish tenacious substance were frequently passed. When examined under the microscope it presented the appearance of a large mass of granules, which became slightly clearer on the addition of acetic acid, presenting an indistinct nucleus; the clear fluid contained many granules and epithelial scales; the fluid was neutral and albuminous, being very coagulable by heat and nitric acid. 373 puncture, but is in good spirits; pulse rather feeble, quick; tongue rather coated. 27th. Feels comfortable; in no pain; sleeps well, 29th. Health good; returned home relieved for a time. OBSERVATIONS ON OVARIAN DROPSY, AND ON THE It is now generally admitted that encysted diseases of the ovary, without reference to those of a malignant character, almost invariably lead to a fatal result. The disease in its progress is often attended with much pain, and with much distress, both mental and bodily; medicine also has little or no control over its progress ; it is therefore surprising that so long a period should have elapsed, and that so little has been done until the last few years for the removal of these affections by a surgical operation. Two measures only at the present day are applied to the surgical treatment of this disease,-paracentesis, and total extirpation. The first of these operations (paracentesis,) is professedly adopted merely as a palliative measure for the present relief of the patient, not for the cure of the disease. In some very few instances the tumour appears to become bound down by adhesions after tapping, and no re-accumulation takes place; but these instances are so very rare that in practising the operation we scarcely ever venture to reckon on the possibility of this occurrence. (The tumour may not be fluid, but if it be so and it is tapped, the cyst becomes refilled, it may be slowly, but it usually happens, as in the preceding case in a few weeks, and thus repeated tapping is necessary, the intervals between the operations diminishing until the patient dies, worn out; the average duration of life from the first tapping not exceeding four years. Paracentesis, however, when adopted, though s palliative measure only, is by no means so free from danger as some practitioners think, and some writers seem to allege. Mr. Southam has tabulated the results of twenty cases of the operation. Four of the twenty patients, or one in five, died of the effects of the first tapping. Four patients died of inflammation within a few days after the operation; three more died in one 3rd. Pretty comfortable; complains of pain in the month; fourteen in all died within nine months after iliac regions; is much troubled with flatus. the first tapping. Of the remaining six, two died in 5th. About the same; is filling again rapidly; sleeps eighteen months, and four lived from periods varying well at night. 7th. Complains of great pain across the abdomen, increased on pressure; tongue coated; pulse quick, small; countenance anxious. To have twelve leeches applied immediately. 9th. Pain quite relieved; tongue clean; pulse natural; walked this morning in the hospital garden; is rapidly filling. from four to nine years. Of eight cases which have come under my own notice, one died a few days after the operation from peritonitis, seven died at various periods within three years, and one is still living, having survived the operation more than three years. Thus, paracentesis, whilst only a means of palliation, is a proceeding in which no inconsiderable amount of danger appears to be incurred. Ovariotomy, on the 25th. Health good; is now quite as full as before. other hand, is an operation which, if successful, is She was again tapped by Mr. Cox, and more than two assuredly a means for the perfect and radical cure of buckets full were drawn off. The fluid presented the the disease, but it is undoubtedly a most serious and thethe same characters as the last; the patient bore the opera- dangerous operation, though not a painful one. tion well, and was not so faint as on the former occasion. The first operation for the removal of an ovarian tumour on record, was performed by Dr. M'Dowal, of 26th. Complains of pain round the seat of the Dansville, Kentucky, in 1809. The operation was |