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