and only extemporary anodynes and diuretic carminatives were given, along with strengthening broths, and a little gin daily. By these dietetic and negative medicinal measures, the patient struggled on till the 19th, when it was thought expedient to attempt to give her a little relief by paracentesis, which was performed by Dr. Francis, and sixteen pints of clear amber-coloured serum, without any flakes, were taken away, leaving a considerable quantity still unevacuated in the abdomen. Nothing but very temporary relief was the result of this measure, and our poor sufferer departed very quietly on the 21st of the month. Post-mortem on the 23rd. The trunk, neck, and upper extremities of the corpse emaciated; abdomen not conspicuously enlarged, but discoloured; and the thighs and legs were much distended with serous infiltration. The large anastomosing veins on the anterior aspect of the body had nearly disappeared. The lungs were healthy, without pus or tubercles; the right lung adhered a little to the costa, by an old band of adventitious membrane, while the left was posteriorly condensed, seemingly from moribund congestion. The heart was natural, only the right ventricle was less than the left; the valves were normal; the inner surface of the right auricle, and the corresponding ostium, with that of the base of the pulmonary arteries were much stained on the depending half by supposed imbibition; there were about four ounces of coloured red fluid in the cardiac sac. The liver was somewhat enlarged, obtuse at its margins, and slightly uneven over its peritoneal covering; on section it was very buffy, with the light-coloured element of the organ, or of the acini much hypertrophied, while the interlobular tissue was hyperemiated. An encysted depôt of thick creamy pus, about two inches in diameter, was found in the posterior and upper part of the viscus, nearly on a line over the track of the inferior vena cava, and close to the hepatic vein; the sac seemed a little dense in its walls, and its interior was villous and soft. The kidneys were normal, but hyperæmiated, and a urinary cyst was in the lower end of the left one, and its dark sanguineous condition might have arisen from postmortem gravitation, or from retrograde congestion from obstruction in the cava inferior. The stomach and intestines were much distended with gas, and had a dark grumous magma thoughout the whole tube to the caput coli. The interior coat was thin not villous; in some places of the ileum it was uneven, but no ulcers nor cicatrices were observed. There were about four pints of yellowish limpid serum in the peritoneal cavity, but the lining membrane was natural, with the exception of some suffused and arborescent patches of capillary blood. The bladder was empty, and the uterus was natural, with the ovaria dense and enlarged. The vena cava inferior, from the opening in the diaphragm to its junction, within a short space, with the iliac veins, was filled with irregular lymphous coagula and shreds, which adhered firmly to the inner coat of the vessel, and were connected with similar deposits in the azygos, renal and lumbar veins, but not to the same extent. Pus was found lodged in several of the upper parts of the vena cava inferior, but especially where it passed under the liver and just through the diaphragm. The right ovarian vein was much enlarged and somewhat tinged with blood; so was the left renal vein. The whole condition of the caval vein thus disclosed, very plainly showed that the returning amount of blood through the vessel must have been for some time previous to death much interfered with, if not totally obstructed. In making my remarks upon this very interesting case, we may first consider the history of the patient before death, and I am sorry I have not kept a more detailed account of her consecutive complaints. We have next to exercise our pathological reasoning after inspection, as to the morbid sequences, and to see if we can trace anything like cause and effect to have existed among the several lesions. Little or nothing definite was ascertained concerning our patient before admission, except that she had been leading a rather irregular life, and had been discarded by her near relatives, and from her own account she had for some time been complaining of the same ailment for which she was admitted-namely, rheu matism. When first prescribed for, this disease had a sub-acute form, from which in about thirteen days she was wholly relieved, with her gums very slightly affected. Diarrhoea then set in in a very persistent form, and from the tormina and discharges there was some fear of ulceration, the remains of which, if it had existed, were not, however, observed on inspection. In a fortnight afterwards she was also relieved from this complaint, when the swelling, pain, and tension of the abdomen made their sudden and unexpected appear. There was a probability that the diarrhoea was occasioned by an impression of cold while she was going about in the ward with her system not free from mercurial influence; but how this third and novel phase in her disease was occasioned was not so easily ance. accounted for. The first explosion of the entirely new symptoms suggested to us that we had to do with a case of sudden and diffuse peritonitis in a cachectic subject, attended with early effusion. In this view we thought ourselves supported by the pain and great tenderness on touching the abdomen, accompanied as they were with increased heat of skin, thirst, and a more frequent yet small and thready pulse. It was also assumed that the attack might have been accelerated, if not occasioned, in a constitution of so much mobility, by the cessation of the diarrhea, a fuller diet with wine, and also having suffered a fresh accession of cold. At this time she had long ceased to complain particularly of any pain in her right hypochondrium, for which a blister had been applied on the 20th of August. In the view then, of our patient being now affected with diffuse peritonitis, but occurring in a very asthenic subject, she was treated accordingly, but with no other result than a mitigation of pain and tenderness, while PHLEBITIS OF THE VENA CAVA INFERIOR. the abdomen and lower extremities continued to swell, with increasing exhaustion of the whole system. On observing the growing anastomoses and enlargement of the abdominal and mammary veins, our views of peritonitis became modified, for it was evident there was some obstruction in the abdomen to the due return of blood to the heart. This diversion of blood to the periphery of the trunk was at first attributed to the counter-pressure of the abdominal effusion, so rapidly generated under great resistance from the enclosing parietes, on the inferior cava and renal veins, and beyond this we had no farther data for speculation, as the patient had no ulcers nor varices in her legs, nor had she been for some time previously parturient. Our | diagnosis at length became more doubtful, and I may say subverted, when on paracentesis the effused fluid was found limpid, without any shreds, flakes, or albuminous granules, while it was observed, subsequently to the operation, that the enlarged anastomosing vessels in the outward integuments did not in any marked degree subside. The case was thus left for an opportunity of nature revealing her own secrets and operations. It will be seen from the record of the inspection, that the principal lesions worth notice were found in the purulent cyst of the liver, and in the vena cava, for the length of about six inches below the diaphragm, consisting of adherent shreds and plugs of lymph, along with coagula, extending into the renal and lumbar veins, and scattered depôts of pus, but especially where the caval vein just entered within the tendinous pillars of the diaphragm, and was joined by the hepatic veins. It was now evident that there were sufficient appearances in the state and contents of the vena cava to occasion most serious, if not total obstruction to the returning current of the blood, and that such obstruction was the cause of death. The important question, however, arises,—What occasioned this mortal affection of the vein? Was the lesion independent in its origin, uninfluenced by any previous affection of the bowels? or was it caused by sympathic phlogosis with, or on actual absorption of pus from, the cyst of pus in the liver? Considering how seldom veins do inflame or suppurate in the absence of injury to themselves or their branches, or of any focus of pus within reach of their circulation, and also considering the near allocation of the hepatic eyst to the portion of the vein that was most affected, which exhibited pus very similar to that in the cyst, it must be inferred that there was an intimate morbid connection; and the question is,-Which was the primary lesion that stood in the relation of cause to an effect? The density of the walls of the purulent cyst, and its appearance of some chronicity, compared with the filamentous and shreddy condition of the lymph, mixed with interrupted cysts, in the vein, and its purulent exudations of interspersed pus, which, at 65 the upper part of the cava was to the extent of two to three teaspoonfuls, led to the inference, that the lesion of the vein was posterior to the formation of the purulent cyst in the liver, and that the phlebitis of the cava, was, moreover, either caused by pus being transmitted from the cyst by the hepatic veins, or by mere proximity of morbid action, as the two lesions were in very close collocation of parts. It may be worth speculation to inquire, how was the purulent cyst occasioned? To fathom its initial steps, the inner surface of the ileum and colon was examined; but beyond what I have noted, no adequate causation could there be placed, whatever abrasion or mucous ulceration might once have existed. In referring to the history of the case, we find that the patient had been complaining of a pain in the right hypochondrium, for which a blister was applied, on the 20th of August, being about nine weeks before her death. Though this pain was in a short time relieved, and was not specially complained of afterwards, there is every probability, from what was observed in the liver on inspection, that at that period the local phlogosis had commenced in this viscus, that eventually terminated in the purulent cyst. A remote consideration then arises, whether this topical affection of the liver was purely indigenous and original, or was owing to purulent metastasis from some of the other chylopoietic viscera. In the absence of any derangement of the stomach or bowels for the first six days she was in the hospital, beyond those of a simple character, (rheumatism being her chief complaint,) and failing of any exact knowledge of her state of health before admission, we are led to infer that the local phlogosis of the liver was idiopathic, and independent of any metastasis of purulent inflammation, or of absorption of pus from the intestines or other organs, through the medium of the vena portæ. Taking then, this view of the primary state of the case, and that the purulent cyst in the liver had been slowly forming or of some standing, we have next to consider how the vena cava came to be affected; for the lesion of this vessel and its contents had every appearance of being acute and comparatively recent. The cyst being situate very closely to one of the large hepatic veins, though no ulcerous nor other communication was discovered between these cavities, and from the cyst also being in that part of the liver close to the notch for the vena cava, there seems little difficulty in attributing the lesion of the cava to either a venous absorption of pus from the cyst, or to a radiant irritation and inflammation from it. I should be inclined to assign the lesion of the great vein to the agency of purulent transmission and contamination. We know what disturbance and adynamic phenomema are occasioned by pus getting into the veins, either from purulent ulcers or wounds in the extremities, or from the iliac and hypogastric veins in cases of puerperal phlebitis, and therefore I need not enlarge upon them,-suffice it to say, as far as our case is concerned, that that part of the vena cava opposite the hepatic veins seemed to have advanced most in the consequential lesions. It was at this spot and immediately below the diaphragm that the most perfect depôt of pus was found, while lower down the pus shaded off intermingled with lymphous shreds and clots, and thence coagula of blood intermixed with fibrinous shreds closely adhering to the inner coat, and irregularly filling the veins, terminated the lesion at the inferior part, to within a short space of the bifurcation. How far death was specially occasioned by the toxic effect of the small quantity of pus that would thus likely find its way into the general circulation, or from the effects of the great abdominal effusion and oedema of the limbs on the vital and nutrient organs, it may not be easily absolutely to state. That the one lesion materially assisted the other in bringing on so rapidly the mortal event is very probable, as they were severally of a very grave nature. I should however, be inclined to attribute the acceleration of death more to the interruption of the vital and organic functions from the fluid pressure, conjoined with the very probable contamination of the systemic blood by even a small quantity of pus, than to the mere obstruction of the returning blood in the vena cava ; for the vicarious and collateral circulation by the integumental vessels seemed to have been well established, and there are several instances on record, where this collateral circulation had been observed to go on for a much longer period, and where death was obviously ascertained to be caused by the direct effects of other diseases, as in the kidneys, though almost complete organic or chronic obstruction had been detected in the vena cava inferior after death. Whichever of these several lesions had the greater share in anticipating the fatal issue, the case is very interesting, and as far as my researches have extended is a peculiar one. Instances of obstructed circulation in the cava inferior are recorded by Baillie, Reynaud, Wilson, and Cline; and also by Rayer, Bright, Cruveilhier, and Dr. Barlow,† in all of which the obstruction was found to have been occasioned by either organic and impervious contraction of the coats of the vessel, fibrinous or bloody coagula, tumours of different kinds pressing on the cava, or from fungoid or medullary deposits in the vessel. I have not been able to meet with any case where purulent phlebitis was detected, nor any deposits of pus, either independent or metastatic. In looking over the details of these cases, it is curious to see that the blood in its return to the heart did not always work out for itself the same circuitous route, depending no doubt on the extent Edin. Med. and Surg. Journ., Vol. 43. Medico-Chir. Trans., 2nd Series, Vol. 10. downwards of the more or less perfect occlusion of the inferior cava. In Dr. Baillie's case the returning blood found its way to the heart by the lumbar and azygos veins. In Mr. Wilson's case, as the obstruction had extended down to both sets of the iliacs, the recurrent blood had worked out a path through the vena pudica into the inferior mesenteric veins, and thence into the vena portæ, through the liver to the heart, a small portion of the cava inferior remaining pervious. Mr. Wilson refers to two similar cases in women dying after delivery. In M. Reynaud's and Mr. Cline's cases, the vicarious circulation was effected by the abdominal and thoracic veins, as in the case now submitted to the profession. Dr. Peacock relates a very interesting case in the last volume of the "Medico-Chirurgical Transactions," wherein the abdomen and limbs were much swelled for a month before death, and the patient died of hæmatemesis and hæmorrhage from the bowels. On inspection the liver was found free from disease, but it weighed only twenty-four ounces, though the subject, a female, was 47 years of age. The kidneys were in an advanced stage of degeneration. Coagula filled the cava, from the iliac veins to within an inch and a half from the diaphragm, and at this part the vein was contracted to an impervious ligamentous cord. The spermatic veins were large and firm, and the vena azygos, major and minor, were unusually large. The veins of the integuments of the abdomen were not enlarged, and Dr. Peacock saw no reason to suppose that the epigastric, thoracic, or mammary veins contributed to form collateral channels to the returning blood. No pus was anywhere discovered. He considered the disease inflammatory, but it was not easy to assign its period. He supposed death to have been occasioned by the renal disease. In Hasse's "Pathological Anatomy," translated by Dr. Swaine, (Sydenham Society,) there is a very full exposition of phlebitis in general, as well as its affecting the vena cava; but nowhere is mention made of a case similar to the one above described, or as connected with purulent cysts in the liver. So far as rheumatism has any pathological agency or relation to the disease, there is notice quoted of a case where it seemed to give rise to phlebitis and obstruction in the hypogastric veins of a male. Hasse, however, observes, that "phlebitis from rheumatic affections is less prone to purulent formations than to plastic exudations," though in another part he says, "that in a great majority of instances phlebitls inevitably leads to suppuration." I may here mention, though I have not noticed any analogous obstructions occurring in the vena cava superior, a very remarkable case of a patient that was presented by Dr. Carson, at the Medical Meeting at Newton, last summer,* after the patient being, with Provincial Medical and Surgical Journal, August 5th, 1846. 1846, he was able to resume his duties and preached frequently with no inconvenience. much probability, cured of the pathognomonic symptoms, arising from obstruction in the upper cava. The disease seemed to have been well diagnosed, and at the On the 30th of June he came to tell me that while period of exhibition, being twelve months after the stooping in his garden some days previously, a mouthsudden and painful attack, the man appeared in robustful of blood had come up, and his cough had retur health. His complexion was, however, of a dark hue, and the veins of the forehead, neck, and upper extremities, and of the anterior trunk, were dilated, while veins as large as a swan-quill proceeded over the anterior part of the chest, to a tortuous cluster of vessels in the epigastrium. From this cluster also ran large veins to the groin, and the course of the blood in all these vessels was, from above downwards, the very reverse to what obtained in our fatal case. I am afraid that I have enlarged too much upon this single case, but from its variety, if not from its being nearly unique in its special origin, it is presumed it may be somewhat interesting, as shewing the powerful yet ineffectual struggles of nature to overcome one of the most serious spontaneous lesions that can occur in the body. It is also one of those cases that shews us, that the difficulty of a special diagnosis is equalled by the inefficacy of our means of cure or much relief, even provided such lesions were as palpable as they are obscure. CASE OF HEPATIC ABSCESS COMMUNICA TING WITH THE LUNGS. July 10th. He now expectorated muco-purulent matter of little or no fator; the pulse was more rapid and emaciation proceeded rapidly. 15th. He had slightly improved under the tonic treatment again. August 10th. I saw him with another practitioner, who had occasionally visited him. We could discover nothing amiss in the lungs, and he coincided with my diagnosis. 24th. Still very ill; still nothing to be detected in the lungs. much of pain in the lower part of the right side, on September 3rd. Since last visit he had complained which he could not lie; decubitus on the back; the cough was very troublesome; the expectoration purulent and fetid. The lower part of the right side of the chest was now decidedly dull on percussion; the expiratory murmur very rough, loud, interrupted by occasional large moist sounds. The voice anteriorly at that part was tubular and snuffling; pulse 90; respirations 36; skin cool; emaciation great; appetite good. 7th. I put him under a course of the iodide of iron. 16th. A little better, I could detect no moist sounds in the lung. October 6th. Very much improved; getting round, he hoped quite, as he had done last year. He still By JOHN BARCLAY, M.D., Member of the Royal coughed and the expectoration became fetid after College of Physicians, Leicester. standing some time. A.B., aged 41, Dissenting Minister at a village in this county, first applied to me on the 18th October, 1845. His complexion was dark, his form spare, and his look cachectic. His general health had been good, and he then complained of slight abdominal pain, which was relieved by gentle stimulant tonics. On the 15th of November, he was brought to me much worse. He had had severe rigors and had afterwards spit up half a pint of matter. Nov. 21st. I saw him at home with the surgeon who had attended him. The auscultatory signs were quite natural; there was no dulness, no resonance of voice, no moist sounds anywhere to be heard, and both lungs expanded properly. He continued to expectorate a very large quantity of most offensive pus, which came up in mouthfuls. From all the symptoms, I formed a diagnosis of an abscess in the liver, communicating with the lungs through the diaphragm. I put him on a tonic plan of treatment, and bid him hope, as it was not "consumption." December 11th, I saw him again at home. The emaciation was now extreme; the expectoration continued in large quantity, and most offensive. Though his friends had all given him up, I continued firm in a favourable prognosis, as by another carefully-conducted examination I could detect no lesion of the lung; and from this day he began to improve. He rapidly gained flesh and strength, so that in April and May, 31st. He came to ask my permission to resume his duties, as he felt quite well. I withheld it however, and he continued to improve throughout November and the first weeks of December. On the 4th, and again on the 6th of January, he had severe rigors, and on the 8th I found him much worse, in bed, with acute pain at the superior part of the abdomen; the cough very troublesome; much exhaustion and debility; pulse irritable, small and weak. 12th. I found him jaundiced all over; urine dark; stools scanty; cough very bad, and expectoration muco-purulent; much dulness and large moist sounds at lower part of right side. 16th. Peritoneal inflammation had evidently now arisen, and the pain was most intense on the left side. 17th. Blistering had relieved the pain considerably, but he was evidently sinking, and unable to expecto rate from weakness. He died on the 18th. Post-mortem examination thirty hours after death. Body jaundiced deeply, and considerably emaciated; the pleure of the left side were slightly adherent, but the lung was healthy; the heart was pushed over considerably to the right side; the upper lobe of the right lung was healthy, but the pleura were adherent in their whole extent; the middle and lower lobes were very much condensed and contracted, adhering to the ribs by very old strong fibrous connections, and quite incorporated with the diaphragm. When cut into at the lower part it appeared a homogeneous mass of condensed cellular tissue, in which the bronchi were seen filled with a sanious purulent matter. In contact with thuscular tissue of the diaphragm were several Irregular ulcerated cavities filled with the same sanious pus. The upper surface of the liver was adherent in its whole extent to the diaphragm; in some places the adhesions seemed recent, but particularly at the spot corresponding to the abscesses in the lung, they were very firm, and evidently of long standing. When cut into the substance of the viscus was seen to be quite infiltrated with numerous small and some large abscesses, filled with unhealthy fetid pus; it was considerably | enlarged and very convex. The peritoneal inflammation had extended to the spleen, nearly the whole surface of which was covered with recently-exuded lymph. The other viscera were healthy. Hospital Reports. QUEEN'S HOSPITAL, BIRMINGHAM. CLINICAL REPORTS OF SURGICAL CASES UNDER THE TREATMENT OF WILLIAM SANDS COX, ESQ. By PETER HINCKES BIRD, one of the Resident Medical Officers. (Continued from page 42.) CASE XX. CARCINOMA OF THE MAMMA. Mary Ann Mason, aged 49, admitted into the Queens' Hospital, May 29th, 1846, under the care of Mr. Sands Cox, to have the operation for the removal of the breast performed. She is unmarried, and of spare habit. She states that last November she first perceived a small tumour on the left breast, accompanied with a sharp darting pain; the tumour was at first moveable, but afterwards became fixed, and the nipple gradually became retracted; it was lanced about three months ago, since which time it has rapidly increased in size; it has been much inflamed lately, and poultices have been applied; the discharge from it has never been fetid; has bled much at times. She states that she has got much thinner lately, but has no cough; her parents are both alive and enjoy good health; she is not aware that she ever received a blow on the part; is very anxious to have the breast removed. Present State.-On examination, the breast presents a large open wound with fungous granulations, and an inflamed irregular margin; it discharges a thin, but not offensive, matter, which does not excoriate the neighbouring parts; the parts surrounding the wound feel hard; the nipple is slightly retracted, and the integument puckered; complains of occasional, not severe, lancinating pains, as if "strings were pulling;" no enlargement of the axillary glands can be discovered; has no cough; sleeps pretty well, occasionally disturbed by the pain; appetite good; bowels open; tongue clean; pulse pretty strong, 86. June 1st. The breast was removed this morning by Mr. Cox in the following manner :-The patient being placed on a well-cushioned chair, and the pectoral muscle being rendered tense by an assistant keeping the arm back, two semicircular incisions were made, meeting at their extremities, including the whole of the diseased mass, and the suspicious integument, the direction of the wound being made obliquely downwards and inwards; the entire mass was dissected out, and every suspicious atom carefully removed; three vessels required ligatures; the lower part of the pectoralis major muscle, to which part of the diseased mass was attached, was completely exposed to view during the dissection. The patient bore the operation with stoic firmness; the wound was after a little time lightly dressed, and the patient put to bed. Examination of the Breast.—On being cut into, the diseased mass afforded considerable resistance to the knife, and gave the squeak peculiar to scirrhus; septa were seen diverging from the centre to the surrounding parts; in various parts of the breast were also several cysts, containing a yellowish serous fluid; these cysts occupied the place of the true glandular structure. A small portion of the scirrhous mass under the microscope presented the cells peculiar to it, embedded in their stroma. June 3rd. Sleeps well at night; complains of slight pain in the wound, which looks healthy. 10th. Doing well; granulations healthy; no lancinating pain in the wound; no swelling of the axillary glands; appetite good; getting stronger. 20th. The wound is granulating over, and presents a healthy appearance; health improved. July 3rd. Doing well; cicatrization is rapidly proceeding. 23rd. Nearly healed over; complains of no pain in the wound; no swelling of the axillary glands. 28th. Quite healed; health much improved; looks better, and is decidedly fatter; no cough. Discharged cured. Of the organic affections to which the female breast is liable, cancer is incomparably the most common and the most important; the scirrhous species is by far the most frequent; the encephaloid but rarely occurs; while colloid, especially as constituting the mass of a tumour, is excessively uncommon. It is said to be of more frequent occurrence in women who have not borne children, whether married or single, than in inothers. Sir Astley Cooper thinks it very probable that the natural change which the breast undergoes in the secretion of milk, has some power in preventing this disease; he knew one individual, however, with this disease, who had been pregnant seventeen times. Its evolution seems connected with the disappearance of the catamenia, for it most frequently appears in women who have had their change of life, its occurrence before the age of 30 being extremely uncommon. This patient was in her 49th year. According to Sir Charles Bell, scirrhus of the breast belongs to that period of life when the uterine functions cease; menstruation becomes irregular, both in respect to time and quantity; long intervals occur, |