BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF iienrg KJ. Sage 189X A.H^^MA.'^ ^/'7 I Cornell University Library RD 667.B85 Clinical memoirs on abdominal tumors and 3 1924 012 164 731 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012164731 THE NEW SYDENHAM SOCIETY. INSTITUTED MDCCCLVIII. VOLUME VI. CLINICAL MEMOIRS ABDOMINAL TUMOUES AND INTUMESCENCE. BY THE LATE DR. BRIGHT. Beprintecl from the ' Guy's Ho.tpital Eeports.' EDITED BY a. HILAEO BARLOW, M.D., M.A. CiTfTAu, PHTSICIAW TO gut's HOSPITAL. THE NEW SYDENHAM SOCIETY, LONDON. MBCCCI.X. EDITOR'S PREFACE. Theke has been no English physician — perhaps it may be said none of any country — since the time of Harvey, who has effected not only so great an advance in the knowledge of particular dis- easeSj but also so great a revolution in our habits of thought, and methods of investigating morbid phenomena and tracing the etiology of disease, as has the late Dr. Richard Bright. To those who have received the knowledge of the connections of dropsy, albuminous urine, and disease of the kidney, among the first rudiments of medicine, the facts which establish that con- nection may appear so simple and so easily ascertained, that the amoimt of labour, the accuracy of the observation, and the rigid adlierence to the inductive method which characterised the whole of Bright's researches, may hardly have been suspected, stiU less adequately appreciated. Por some time after the commencement of the present century, dropsy was regarded as in itself a primary disease, dependent upon a deficient action of the absorbents, though it was by no means proved that they were mainly, if at all, concerned in the removal of fluid from the serous membrane and cells of the areolar tissue ; the cause, then, which was commonly assigned for dropsical effusion was in the first place not a vera causa; since, as the function ascribed to the absorbents could not be proved, thus, a defect of function must also be a gratuitous assumption. The favorite notion, also, of referring every disease to the Hver was not without influence, and since, when morbid anatomy began to be VI PREFACE. more carefully prosecuted, the Hver was fouad structurally changed, the internal lesion upon which dropsy depended was supposed to have hence been satisfactorily demonstrated. But, though disease of the liver was so far a vera causa as that its existence was apparent in many instances, yet it was not one which could be shown to be capable of producing the effects ascribed to it, neither could it really be said to be a vera causa, since in many instances of dropsy it was wanting. A great advance towards the true pathology of di'opsy was made by Blackall, who pointed out that in a great number of cases the urine coagulated upon the application of "heat or nitrous acid;" and those wliich were for the most part cases of general dropsy, he called inflammatory dropsies. It is, however, remarkable that Blackall, although he availed liimself of all opportunities of inspection after death, never Succeeded in connecting the coinci- dence of these two remarkable phenomena, dropsy and albuminous urine, with disease of any internal organ. Dr. Wells, too, — a name scarcely less illustrious than Bright or Blackall, — investigated the subject in a most plulosophic spirit, but missed, though narrowly, the discovery of the disease of the kidney. Such was the state of knowledge upon this subject when the inquiry was taken up by Dr. Bright. And here we may pause, to observe the character of mind which was then brought to bear upon one of the most important investi- gations within the whole range of medical sciejice. Dr. Bright was, indeed, a man of naturally clear judgment; and, as far as such a virtue can be said to have been a natural gift, of great industry. But the strongest powers of intellect languish and become feeble, if not matured by exercise, and industry which is not consistently exercised upon some definite object degenerates into a fitful restlessness. Now it is to be remembered, that Dr. Bright brought not only these gifts to the study of his profession, but that his clear and vigorous intellect had been rendered more discriminating by the strict discipHne of a sound and extended education, by which, too, PREFACE. vn lie had leaxned to exercise his industry upon objects worthy of his energetic pursuit. He had also what might be considered as a natural giftj and by no means a common one — a singular power of observatiouj which had, perhaps, by constant exercise, become so habitual that the most trifling circumstance rarely escaped him; and he was in the habit of recording facts and observations in disease or morbid anatomy apparently the most trifling; saying, that if he did not at the time perceive their importance, they might be available to himself or others at some future period. It is not a little remarkable that this faculty of observation dis- played itself before Dr. Bright devoted himself, as he subsequently did, to his acquiring distinction in liis profession, by the honorable course of, at the same time, advancing that profession. This faculty of observation made the opportunities of travelling which he enjoyed a real advantage to Bright, and he produced a work upon Hungary which was at the time considered a most valuable acquisition to the knowledge of the natural historj'', the statistics, and the social condition of that country. There was one other quality by wliich Bright was eminently distinguished, and that was his philosopliic truthfulness. He was, indeed, in all the relations of life, a man without guile, and as he would have scorned an untruth, so would he not endure that the slightest bias should be given to any observation, in order to favour any particular views or opinions. This rigid and self- denying honesty in scientific investigation is no ordinary virtue; but in Bright it reaped its reward, for there have been few, if anj', who have observed and recorded so much, and have reasoned so extensively upon those observations, who have subsequently been required to correct or retract so little. The first volume of the ' Select Medical Reports' was published in 1824, ^^^ ill this work, which includes observations on the morbid anatomy of continued fever, and of phthisis, wliich for their carefulness and accuracy would alone have established his reputa- tion as a morbid anatomist and pathologist. Dr. Bright investigates vm PREFACE. tlie pathology of dropsj^; we say advisedly joa^^ofo^y, for Dr. Bright valued anatomy only in so far as he could connect structural changes with symptoms during life, and was not satisfied unless he could establish the connection by a rational etiology. Observations upon diseased liver in dropsy are also detailed; and these, whilst they point out the connection of ascites with obstructed portal circulation, show also that the necessary connection with diseased liver is limited to that particular form of dropsy. The most important series of cases consists of fatal cases of it in which the urine was albuminous, and by these observations was the connexion of diseased kidney, albuminous urine, and dropsy established. It is but just to Dr. Bright, as well as to those who have followed him in the same path of discovery, to state that he described three, or, at the most, four forms of disease, with wliich the train of symptoms constituting what is now generally known as Bright's disease were associated ; and that, having done this, he has left the investigation of the minute structural changes to be worked out by others, whilst he devoted himself mainly to the completion of the clinical history. It was not enough that the urine was found to be albuminous; it was also examined as to its difference from the healthy secretion -in other respects. This led to the discovery that, not only was there a continual abstraction from the system of a most important constituent of the blood in the form of albumen, but also that there was a non-elimination from the system of the natural ingredients of the urine, particularly of urea; and this led to the examination of the blood by Drs. Bostock and Babington, and the discovery of the urea in the circulation of those patients from whose system it was not eliminated, owing to the disease in the kidney. It was this that perhaps constituted the most important part of the discovery, and which produced so great a change in the whole science of pathology. Por it was argued, and with reason, by Dr. Bright, and stiU more earnestly by his disciples, that this inquination of the blood was the cause of many of the morbid phenomena, such as cerebral disturbance, and inflammation of the l'KEFAG£. IX serous membranes ; and thus was introduced a modified and rational humoral pathology. The doctrines of the solidists, as they were termedj were, however, in the ascendant ; and it was not till after much opposition, that the whole theory of the effects of retained secretion and consequent toxsemic poisoning was generally adopted. The facts upon wliich it was established were, however, not to be shaken, and the doctrines of Bright are now universally received. They naturally, however, gave rise to inquiries as to the analogy of the disease of other excretory organs, and toxsemic poisoning, owing to inquination of the blood by impurities from other sources ; and thus, not only was the possibility of bile poisoning recognised, but also was opened a wide field of investigation — blood-disease. We must not here pursue this subject, but simply point out that although the investigations connected with what is called kot' elflxnv, " Bright's Disease," were going on through so large a proportion of his professional life, liis active mind was frequently directed to other points of pathology. Diseases of the brain, of the liver, and of the pancreas received fi'om him much attention and elucidation. Disease of the abdominal viscera was, perhaps, always a favorite object of research with Dr. Bright, and accordingly we find that his last contributions to the literature of his profession was the following series of monogTaphs upon Abdominal Tumours ; which, however, want of health and time did not allow him to finish. These papers require little or no comment ; they do not, indeed, suggest any new doctrine; but, besides abounding in important suggestions as to diagnosis and function, they are especially valuable as examples of care and accuracy in observing and in recording observations. It is but due to the memory of Bright to state, though without any design of imputing plagiarism to more recent con- tinental pathologists, that the description of acephalocyst hydatids, at page 1 8, ei seq., is altogether original, and certainly an anti^ cipation of similar observations wliich have since been published in Germany. The papers in question being essentially clinical, and consisting X PREFACE. chiefly of well-grouped examples of tlie diseases under consideration, it lias been considered better to reprint them almost exactly as they were originally published. The memoirs themselves had no preten- sion to constitute a complete monograph on the subjects wMch they illustrate. To have attempted to make them such by the addition of notes or interpolated material from other sources, would have been to wholly change the character of the work. It would have taken it beyond the scope of what was contemplated by the Council of the Society, and would also in some degree have deprived it of its greatest merit — ^that, namely, of being clinical portraits, fresh from the hand of a master. The task of editing has, therefore, as far as the body of the work is concerned, been restricted to the careful correction of verbal errors and obscurities of expression, and the rearrangement of the plates, so as to bring them into juxta- position with the cases to which they belong. In the original papers most of the illustrations were on stone, and were appended at the end of the volume ; in the present reprint they have been repro- duced in wood (by Mr. Tuffen West), and are incorporated with the text, so as to facilitate reference. The addition of the List of Cases, which is given at page xii, and of the Index at page 323, will doubtless be found useful. In a few subjects, such, for example, as the histology of the acepha- locyst hydatid, great advance in knowledge has been made since tlie publication of Dr. Bright's papers. It has been thought best, how- ever, even in these matters, to adhere to the rule stated above, of not making any additions to the original statements. 5, Union Steeex ; September lith, 1860. CONTENTS. CHAPTElt 1. O.N' TIfE Exi'LOIlATlON 01' TUE AuDOMEN . . .1 CHAPTER II. Os Tumours j)i.penuexi upm; Acephalocvst liii)ATius . . ii CHAPTEll HI. OVAEIAN TUJIUUKS . . . . ■ ol CHAPTER I v. Disease oj' the Si'leex . . 14S CHAPTEK V, ReSAI, DlShASK . . . 19^ CHAPTER VI. Diseased Lj\eii ...... j-y xn CONTENTS. LIST OP CxVSES. HYDATID^ TUMOUES. Case I. Hydatids k the abdomen, of many years' standing, showiug the acepbalooysts in almost every stage of their existence Case 2. Hydatids extensively occupying the abdomen. Autopsy Case 3. Hydatids developed in the abdomen. Death from peritonitis Case 4. Tumour of the abdomen supposed to depend on the presence of hydatids ..... Case g. Hydatid cyst connected with the liver. Death from suppuration of the sac and its consequences , , Case 6. Hydatid cysts in the liver ossified Case 7. Tumour in the pubic region from an hydatid cyst situated behind the bladder .... Case 8. Tumour in the pubic region from an hydatid cyst situated behind the bladder .... Case 9. Hydatid cyst connected with the liver, emptied by paracentesis Case 10. Hydatid connected with liver emptied by paracentesis Case II. Hydatids in the spleen bursting into the abdomen, and causing death very speedily .... Case 12. Hydatid of the liver suppurating and bursting into the abdomen, causing death .... Case 13. Supposed hydatid of the liver bursting into the cavity of the abdomen ..... Case 14. Hydatids in the liver, supposed to have passed off by the in- testines ..... Case 15. Hydatid cyst in the liver, discharging itself externally ; and death from haemorrhage OTAEIAN TTIMOUES. PAGE 13 30 36 37 38 39 40 41 42 44 45 47 49 5° Case I. Small simple cyst hanging from the uterine appendages, dis- covered after death . . . 1 .70 Case 2. Small simple cyst in the ovary . . . .70 Case 3. Incipient ovarian dropsy, probably of a malignant character . 71 Case 4. Diseased ovary with cysts in a case of extensive malignant disease of other organs . . . -75 CONTENTS. XIU PAGE Case 5. Ovarian dropsy of eleven years' slanding. Death probably from inflammatory changes going on in tlie interior of the cyst . 76 Case 6. Ovarian dropsy, anasarca, and ascites. Death from peritonitis, after the fluid was partially drawn from the cyst . .81 Case 7. Ovarian dropsy of many years' duration, showing several cysts in different conditions ; with the analysis of the fluids they con- tained . , , . . '85 Case 8. Malignant tumour in abdomen, probably ovarian ; discharging constantly from the wound made by paracentesis . . 95 Case 9. Compound ovarian cyst. Death from exhaustion . . ()6 Case 10. Compound ovarian cyst ; the fluid never removed. Slow ex- haustion and death ; adhesions of the tumour to the parietes discerned during life . . . .98 Case II. Compound ovarian cyst; the fluid never removed. Death from irritation and exhaustion .... loi Case 12. Ovarian dropsy, fatal from peritonitis after the partial ab- straction of the fluid . . . .103 Case 13. Cyst, probably a diseased Graafian vesicle, communicating by ulceration with the colon. Death from irritation of the mucous membrane of the large intestines . . . 104 Case 14. Ovarian cyst, probably a diseased Graafian vesicle ; fluid partially removed; inflammation of cyst and peritoneum . . 106 Case ig. Ovarian dropsy; paracentesis. Death from peritoneal inflamma- tion ... ... 170 Case 16. Cyst in the broad ligament of the uterus. Death sudden . 109 Case 17. Ovarian tumour, partly fluid, partly fungoid ; paracentesis rendered necessary from the great pain experienced. Death after several operations, from peritoneal inflammation . no Case 18. Ovarian dropsy, possibly enlarged Graafian vesicle, rupture of the cyst internally. Death from inflammation of the cyst and neighbouring parts ; the cyst tympanitic . .115 Case 19. Malignant ovarian cyst ruptured internally ; subsidence of the tumour. Death in about two years, from increase of the disease . . . . . .118 Case 20. Ovarian cyst ruptured internally. Death after three years, with emaciation ..... 121 Case 21. Compound ovarian cyst, ruptured internally ; followed by death from peritonitis ..... 121 Case 22. Malignant disease of the ovary ; fibrous tubera in the uterus ; paracentesis, subcutaneous tubera in tlie abdominal wall. Death from extensive scirrhous disease . . . 124 Case 23. Ovaries affected with a modifloation of the malignant disease ; the peritoneum extensively invohed in a similar affection . 129 Case 24. Ovarian tumour, with extensive growth of pendulous malignant tumours from the peritoneum .... 130 Case 23. Malignant ovarian tumour, with ascites, communicating disease by contiguity to the sigmoid flexure and rectum . . 131 XIV CONTENTS. PAGE Case 26. Ovarian dropsy, cerebriform disease, commuiiicatiug to con- tiguous organs . . . . • i33 Case 27. Hysterical distension of tlie bowels, mistaken for ovarian tumour; operation to attempt its removal . • I37 Case 28, Ascites complicated with ovarian cyst . . • I4° Case 29. Ovarian tumour. Diagnosis complicated by pregnancy » 141 TTJMOrBS OE THE SPLEEX. Case I. Simple enlargement of the spleen connected with intermittent fever ..... Case 2. Enlarged spleen cured by tonics and purgatives Case 3. Enlarged spleen in a child Case 4. Eemarkable distension of the spleen without disorganization Death from the effects of diseased liver . Case 5, Enlarged spleen, occurring in a case of fatal diarrhoea Case 6. Enlarged and fleshy spleen, with chronic disease of the liver Case 7. Enlarged and fleshy spleen, with chronic disease in the abdomeU; mottled kidneys, and albuminous urine . Case 8. Abscess in the spleen opening into the colon Case 9. Sloughing abscess of the spleen Case 10. Jaundice from general enlargement of the liver. Spleen greatly enlarged, and studded with small, hard, opaque bodies. The glandular and absorbent system much diseased Case II. Spleen reduced nearly to a fluid state, connected with extensive disease of the absorbent system Case 12. Tuberculated spleen, in a case where the tubercular diathesis greatly affected the glands Case 13. Tubercles in the spleen in a case of phthisis where the glands were greatly affected Case 14. Tubercles in the spleen in a case of phthisis where the glands were greatly affected Case 15. Tubercle in the spleen, lungs, and liver . Case 16. Suppurating tubercles in the spleen, in a case of fever, with ulceration of the mucous membrane of the intestines Case 17. Tuberculated spleen in a case of fever Case 18. Spleen pervaded by malignant matter. The absorbent gland; very extensively affected Case 19. Spleen pervaded by malignant matter. The absorbent glands very extensively affected Case 20. Malignant disease of a scirrhous character affecting the spleen, together with many other organs of the body Case 2 1 . Malignant disease of a cerebriform characteraffecting the spleen, in common with otlier organs ... Case 22. Bony deposit in the spleen and mesenteric glands . Case 23. Cysts in the cellular membrane of the spleen Case 24. Peculiar appearance of the peritoneal coat of the spleen 159 162 165 165 169 171 172 173 176 177 179 180 180 182 183 184 186 188 189 189 191 CONTENTS. XV PAGE Case ag. Tubercular deposit on the peritoneum of the spleen . . 193 Case 26. Spleen with the peritoneal covering studded with flat scirrhous growths . . . . . . 192 Case 27. Laceration of the spleen .... 194 Case 28. Abscess in the fibrine left after the extravasation of blood in the spleen ...... 195 EEXAL TUMOrES. Case I. Tumour of the kidney from numerous cysts formed in its substance ..... 208 Case 2. Suppuration of the kidney from stricture of the urethra at- tended with perceptible tumour . . . 310 Case 3. Tumour formed by the kidney, the pelvis being distended with pus . . . . . .212 Case 4. Tumour from puriform collection in the kidney, first perceived after parturition, but apparently depending on the presence of a calculus ..... 317 Case 5. Large tumour formed by the left kidney, supposed to be uterine, the pelvis being distended with grumous matter, and the substance of the organ suffering, together with the liver, from inaligui.nt disease .... 220 Case C. Tumour formed by the kidney dilated with puriform fluid . 223 Case 7. Tumour of the kidney with copious puriform discharge through the urethra, and probably through the bowels . . 224 Case 8. Tumour formed by the left kidney, discharging pus copiously both by the urethra and the rectum, depending on a large renal calculus ..... 227 Case 9. Cerebriform tumour of the right kidney, supposed to be a tumour arising from the concave surface of the liver . 229 Case 10. Tumour of the kidney from fungoid disease mistaken for the spleen. Death by rupture into the peritoneal cavity . 232 Case II. Fungoid tumour of the kidney, affording the appearance of two tumours ...... 233 Case 12. Fungous tumour of the mesentery, resembhng enlarged kidney 235 TUMOUES OP THE LITEE, &C. Case I . Accumulation of faeces in the sigmoid flexure of the colon, imita- ting organic tumour .... 242 Case 2. Esecal accumulation in the colon, imitating hepatic enlarge- ment ...... 243 Case 3. Tsecal accumulation in the colon, imitating fungoid tumour . 244 Case 4. Fsecal accumulation in the colon, imitating malignant disease of the liver ..... 246 Case 5. Malignant disease of the peritoneum resembling hepatic tumour ...... 251 XVI CONTENTS. PAGE Case 6. The liver pushed down by fluid in the right side of the thorax ...... 235 Case 7* Apparent tumour of the liver, owing to that organ being pushed down by pleuritic effusion . . • 236 Case 8. Abscess situated between the diaphragm and the liver, producing apparent enlargement of the liver . . . 257 Case 9. Small intestines situated anteriorly to the liver . . 259 Case 10. Malignant tumour confined entirely to the left lobe of the liver, and ascending towards the thorax . . . 260 Case II. Liver enlarged and altered in its structure from frequent congestion ..... 264 Case 12. Tumefaction of the liver from retention of bile . . 271 Case 13. Tumefaction of the liver from retention of bile. The gall-bladder distended with its own secretion . . . 277 Case 14. Gall-bladder forming a tumour. The liver not gorged with ■ bile . . . . . -279 Case 15. Liver and gall-bladder distended with bile . . 280 Case 16. Hepatic tumour from chronic hypertrophy of the organ . 281 Case 17. Hepatic tumour from chronic change in the liver . . 283 Case 18. Fatty liver descending below umbilicus . . . 285 Case 19. Fatty change in the substance of the liver . . 286 Case 20. Liver large from the fatty change in its substance . . 289 Case 21. Malignant disease producing a regular, smooth enlargement of the liver . . . . . .291 Case 22. Chronie abscess presenting great diflicnlties in its detection . 294 Case 23. Deep cicatrices in the liver from former abscesses . . 296 Case 24. Tumour in the abdomen from oerebriform tubera in the liver . 299 Case 25. Tumour in the abdomen from cerebriform growth in the liver . 301 Case 26. Tumours in the abdomen from cerebriform growths in the liver 303 Case 27. Tumour in the abdomen from scirrhous tubera in the liver. Peritoneum and other organs affected . . . 303 Case 28. The small, hard, scirrhous tumour of the liver nearly confined to the left lobe. Peritoneum affected . . . 307 Case 29. Liver converted into a scirrhous mass, so contracted as to form no external tumour. Uterus scirrhous . . 310 Case 30. Scirrhous tubera of the liver. Mamma and ovaria diseased . 313 Case 31. Large irregular tumour from melanosis of the liver . . 313 Case 32. Melanosis occupying the liver very extensively. Very slight jaundice before death . . . • 315 Case 33. Extensive malignant disease very rapidly implicating the organs both of the chest and abdomen . , , 318 xvu LIST or WOODCUTS. I. 2. 3- 4- 5- 6. 12 14- 15- 1 6. 17- i8. ig. 20. 21. 22. 23- 24. 26. 27. 28. 29. 30- 31- 32- 33- 34. .35- 36. 37- 38. 39- 40. 41 42 Outline of abdomeiij showing division into regions (male) „ . „ „ (female) „ „ position of malignant tumours „ „ „ hydatid tumours The abdomen of Ann W — (Case i), hydatid tumours The same, after the removal of the integuments 8, 9, 10, and 11. Microscopic appearance of hydatids . and 13. Interior of hydatid cysts A cluster of hydatid cysts Hydatid tumours in abdomen (Case 3) The same, eight years after the previous one The same, laid open at the post-mortem examination . Ovary and Fallopian tube, showing pendulous, cystiform bodies Cyst in the broad ligament jj 3» • • . Compound ovarian cyst Stencilled outline of an abdomen, in a case of ovarian tumour Diagram showing gradual enlargement of an ovarian cyst Incipient stage of a malignant ovarian tumour The same, a vertical section Malignant disease of the ovary Malignant intra-cystic growth Litra-cystic growths . Secondary cysts in a larger one Internal surface of a malignant ovarian cyst Portrait from a case (Case 7) of large ovarian cyst The same, laid bare at the post-mortem The same — the abdomen after the removal of the cyst Sketch of a large ovarian cyst taken at the post-mortem examination Internal view of an ovarian cyst Post-mortem appearances in a case (Case 21) of rupture of an ovarian cyst .... Section of an ovarian tumour Ovaries containing solid tumours Section of spleen, showing deposits of bone „ „ cysts in the cellular membrane Stencilled outline showing enlarged spleen . and 43. The same, showing gradual diminution of tlie enlarged organ ..!.•• 4 a 8 9 16 18—21 28 — 29 2(5 30 32 33 58 .?8 59 61 65 66 72 73 73 79 80 83 84 87 89 90 90 log 122 141 147 1.53 164 160 161, i6z XVIU LIST OF WOODCUTS. riG. ■ PAGE 44 and 45. Enlarged spleen, in successive stages of the complaint, in the same patient ..... 168, 169 46. Abdominal tumour produced by enlarged spleen . . 170 47. Section of a spleen affected witli tubercle . . . 182 48. Section of an enlarged spleen from a case of fever . 184 49. Section of spleen, witli malignant growths . . . 186 go. „ „ . . . 187 51. Section of spleen which Lad probably been lacerated . . 194 52- „ ~ „ „ ■ ■ 194 53. Outline of abdomen, from a case of cystic disease of kidneys . 209 54. ^, „ suppuration of kidneys . 211 55. Appearance of abdomen in a case of purulent distension of the kidney ...... 212 56. Diagram showing the situation of the tumour in the same case as fig- 55 • • • ■ • • 213 57. Post-mortem appearances from the same case . . 215 58. The same, after further dissection (on a larger scale) . . 216 59. External appearance of the abdomen in a case of purulent disten- sion of the kidney . . . . .218 60. Diagram stowing the situation of an enlarged kidney . . 219 61. Tlie same, from another case .... 222 62. Diagram showing the position of a large kidney in relation to the colon ...... 228 6^. Diagram of a fungoid tumour of the kidney . . . 231 64. Diagram of a tumour of the kidney crossed by the colon . 234 6.5. Appearance at a post-mortem of a case of enlarged kidney . 235 66. Diagram showing tumour caused by accumulation of faeces . 247 67, 68, and 6(). Diagram showing varieties in the position and natural extent of the colon .... 248, 249, 250 70. Post-mortem appearance in a case of malignant disease of the peritoneum . . . . .251 71. Diagram showing the position of a malignant tumour in the right lobe of the liver ..... 261 72. Sketch showing the relative positions of the heart and liver in a case of congested liver from diseased heart . . . 267 73. Sketch showing enlargement of the liver from biliary congestion . 271 74. Diagram showing position of tumour depending on distended gall-bladder ..... 278 75. Sketch showing the liver enormously enlarged by malignant deposit . ..... 292 76. Diagram showing the situation of a tumour depending on chronic abscess of the liver . . . . ' , 293 77. Sketch showing malignant disease in the liver . . 303 78. Diagram showing a portion of a tumour in a case of malignant disease of the liver .... 308 79. Sketch showing melanotic tumours in the liver . . 315 CLINICAL MEMOIRS ON ABDOMINAL TUMOURS AND INTUMESCENCE. CHAPTEE I. ON THE EXPLORATION OF THE ABDOMEN. As it is my intention to devote the following pages to the consideration of Abdominal Tumours and Intumescence, it will be well, in the first place, to give a general outline of the subjects which may probably be included in such a survey; although it is not proposed to adhere closely to the line marked out^ but rather to take up the various points, as circumstances may render most convenient, or the hospital afford me the requisite means of illustration. The topics which naturally present themselves admit of being arranged under the following heads : — i. The inte- guments. 3. The peritoneum. 3. The stomach. 4. The intestines. 5. The Hver. 6. The spleen. 7. The pancreas. 8. The mesen- teric glands. 9. The kidneys. 10. The bladder. 11. The uterus. 13. The ovaries. 13. Extra-uterine bodies. 14. Aneurism. I. The integuments; including various cutaneous changes, polysarcia — anasarca — malignant deposits — abscesses — protrusions. 3. The peritoneum — the various results of inflammatory action ; as, efl'usion, including ascites — adhesions, and various depositions of adhesive matter — tubercular deposits — malignant diseases — hydatids. 3. The stomach; including flatulent distension — chronic diseases — malignant changes. 1 2 ON ABDOMINAL TUMOURS. 4. The intestines ; including flatulent distensions— retained faeces, and other matters — mechanical obstruction — mahgnant strictures. 5. The Hver; enlarged from congestion — forced down by the lungs or by effusion— distended with bile— enlarged by various changes of the structure generally — enlarged by malignant or other adventitious growth. 6. The spleen ; enlarged by congestion — changed in structure. 7. The pancreas; enlarged or hardened. 8. The mesenteric glands ; simple enlargement — scrofulous, malig- nant, and osseous changes. 9. The kidneys; enlarged by vesicles — by abscess — ^by mahg- nant disease — distended ureter. 10. The bladder ; distended — thickened — forced forward. 11. Uterus enlarged from pregnancy; chronic increase— scir- rhous disease, and other changes. 13. Ovaries ; enlarged by simple cysts — by malignant growths. 13. Extra-uterine fcetation. 14. Aneurismal tumours ; ccehac — aortal — ^Uiae. The sources to which we turn for evidence respecting the existence and nature of abdominal tumours, are, the form and appearance presented to the eye ; the form still further discovered by the touch ; the resistance ascertained by pressure ; the sounds ehcited by percussion; and, in a few instances, the sounds perceptible to the ear, either alone or by the aid of the stethoscope : and besides these local and physical signs, we look to the general condition of the system, and of the various excretions, as rendering us most important assistance, and being frequently indispensable towards the formation of a tolerably correct diagnosis. In studying the local indications of disease, the first object is, of course, to learn, and fix in our minds, the exact normal position of each viscus, and the modifications of form, appearance, and resis- tance which the muscles of the parietes are capable of impressing upon the different parts of the abdomen. There is, however, one circumstance connected with the abdominal viscera, which must always throw a certain degree of doubt upon all physical diagnosis, as directed to this part of the body ; and this is the diversity which sometimes takes place in the organs themselves, and that more par- ticularly with regard to the colon ; the. arch and the sigmoid flexure of which not unfrequently form extensive convolutions, which EXPLORATION OF THE ABDOMEN. 3 render any inferences derivable from its natural position somewhat doubtful. The liver, Kkewise, occasionally deviates from its ordinary situation and form ; and, in rare instances, an anomalous position of the kidney, or other organs, may be a source of fallacy : stiU, how- ever, these deviations are not suificient to interfere materially with our probable conjectures, though they must, of course, place a bar to that perfect certainty which it would be desirable, to obtain, and which, at aU events, it would be very satisfactory to look forward to, in such an important research. To facihtate our investigation, and to render our reference more exact, it has been found necessary to divide the abdomen into regions, by drawing imaginary lines, or passing imaginary planes, through the body. The divisions which have been proposed vary a little, on account of the irregular form of the abdominal cavity, and the difference of the fixed points assumed by various observers ; but the following, which I venture to lay down with the assistance of my friend Mr. Edward Cock, wiU perhaps approach as nearly as any to a useful, though still an artificial and somewhat variable sub- division of this part of the body : and to render the subject stiU more obvious, I have drawn an outline of the male and female figure, with the divisions marked upon them. (Kgs. i and a.) The first general division will be into three regions — the upper, the middle, and the lower ; or, the epigastric, the umbilical, and the hypogastric. The epigastric region is bounded above by the diaphragm ; below, by a horizontal plane passing through the anterior extremities of the tenth rib of either side. In a well-formed chest, the cartilage of the tenth rib ofl'ers a projection on its convex or lower edge, just as it is leaving the bone, and rising towards the sternum ; and this may generally be felt, without difficulty, on the Uviag subject. It must, however, be observed, that the situation of the two points, which have thus been chosen to mark the lower boundary of the epigastric region, vary somewhat in different subjects, according to the size and shape of the chest ; and in the female, more especially, are often found to have undergone considerable alteration from their original position, owing to the constriction produced by the long-continued use of tight stays. A horizontal plane, carried backwards, through these points, wiU pass between the bodies of the first and second limibar vertebrae ; and emerge posteriorly, just at the lower edge of the spinous process of the former. * ON ABDOMINAL TUMOURS. The upper boundary of the epigastric region, being formed by the diaphragm, varies in its position, at each effort of respiration. Anteriorly, it corresponds with the junction of the ensiform cartilage with the sternum ; but from this point it will be found to descend from before, backwards towards the spine, and on either side towards the ribs, until it reaches the lower boundary of this region. The epigastric region is subdivided into the right and left hypo- chondria, or the spaces enclosed by the false ribs ; and the scrobi- culus cordis in the middle, covered in merely by the abdominal Fis. I. Tigs. I and 2 present a general outline of the human abdomen, as seen in a front view, divided by dotted lines into its several regions : The scrobiculus cordis, and the two hypochondriac regions. Tlie umbilical and the two lumbar regions. The pubic and the two iliac regions. Fig. I is intended to represent the outline of the male, and Fig. 2 of the female, form. EXPLOKATION 01' THE ABDOMEN. 5 muscles. This latter is much broader below than above ; as may be seen by referring to the skeleton. Tin;. 2. The umbilical region is bounded above by the lower epigastric plane ; and below, by a horizontal plane passing through the anterior and superior spinous processes of the ilia. This plane, if produced backwards, will cut through the centre of the second portion of the sacrum, on the anterior or concave surface of that bone ; and emerge posteriorly, between the second and third sacral spines. This region is likewise subdivided by imaginary planes, as wiU be shown hereafter. The hypogastric region is bounded above by the lower umbilical plane, and below by the upper margin of the pubes in the centre, and Poupart's ligament on either side; the latter forming two divergent lines, extending from the spinous processes of the pubes, upwards and outwards, to the spinous processes of the Uia. This t) ON ABDOMINAL TUMOURS. region may be said to be extended into the hollow of the trae pelvisj ocenpying its whole cavity, and continued to its lower outlet. A horizontal line passed backwards from the upper edge of the symphysis pubis nearly corresponds with the extremity of the coccyx. The umbilical and hypogastric regions are each divided into three, by two ascending planes passing directly backwards, and drawn through the spinous processes of the pubes and the points on the tenth ribs, already alluded to as marking the lower epigastric plane. These planes diverge from each other ; and if continued over the chest, will pass rather to the outside of the nipple in the male, until they reach the clavicle, not far from its scapular extremity. The umbilical subdivisions thus produced, consist of a central region, which retains the name of "umbilical," and two lateral regions. These last may be again divided into the iliac fossa below, corresponding with the venter of the ilium ; and the lumbar region above and behind, comprising the space between the lower epigastric plane and the level of the crista of the ilium. The deep fossse on either side of the bodies of the lumbar vertebrae have more particu- larly received the name of lumbar regions. The hypogastric subdivisions consist of the middle or pubic, which descends into the cavity of- the true pelvis ; and the lateral or inguinal regions. These latter comprise but a small extent of surface ; and are likewise exceedingly shallow, in consequence of the approximation which here takes place between the anterior and posterior abdominal walls, previously to their union at Poupart's ligament. Indeed, the serous cavity of the abdomen may be truly said to terminate at a line a little above Poupart's ligament, where the peritoneum becomes reflected, from the fascia transversalis before, on to the fascia iliaca behind; thus rendering the inguinal region of the belly smaller, from above to below, than its external boundaries would appear to indicate. Assuming these, then, as the regions into which the abdomen may be divided, it is evident that they will not correspond exactly with the extent and form of the different viscera; but that one division will often contain portions of several viscera, and one viscus will occupy portions of several divisions. Generally speak- ing, however, the position of the different organs will be as follows:— The epigastric region will contain, in its whole length, the liver with the gall-bladder, the stomach, the contents of Ghsson's capsule, the EXPLORATION OF THE ABDOMEN. 7 two angles and part of the arch of the colon, the duodenum, the spleen, the pancreas, the renal capsules, and a portion of each kidney ; together with the aorta, the cava, the coihac ajcis, and the commencement of the superior mesenteric artery. The middle portion of the upper region, which is called the scrobiculus cordis, contains the whole of the left lobe of the hver, and a part of the right ; together with part of the gall-bladder, the ducts and Glisson's capsule, the pyloric end of the stomach with the commencement of the duodenum, a portion of the colon, the pancreas, the aorta, and the coeliac artery with the cava and supe- rior mesenteric artery. The right hypochondrium contains nearly the whole of the right lobe of the Uver, the angle of the ascending colon, the greater part of the duodeniun, the renal capsule, and the upper portion of the kidney. The left hypochondrium contains the rounded cardiac portion of the stomach at aU times, but a very large part of that organ when distended, the left angle of the colon, the spleen, and a small portion of the left kidney, with the renal capsule. The central subdivision of the umbilical region, which may be called the " umbilical region proper," is chiefly occupied by a portion of the arch of the colon, the omentum, and the smaU intestines; and contains, likewise, the mesentery and its glands, the aorta, and the vena cava. The right lumbar region, again subdivided into the "lumbar region proper" andtheihac fossa, contains the csecum, chiefly lodged in the iliac fossa, the ascending colon, the lower and middle portion of the kidney, a portion of the ureter ; and, as it is bounded pos- teriorly by the lumbar and psoas muscles, these parts may be con- sidered as entering into its composition. The left lumbar region, also subdivided as the right, is occupied by the descending colon, and, chiefly in the iliac fossa, by the sigmoid flexure, the left kidney, and the ureter. The small intestines likewise occupy the lumbar regions on either side, and cover the ascending and descending portions of the colon. The lower or hypogastric division is the smallest of the three. The central subdivision, termed the pubic region, contains the urinary bladder, with portions of the ureters, the rectum, and sometimes a projecting convolution of the sigmoid flexure of the colon ; together with some portions of the small intestines, more 8 ON ABDOMINAL TUMOURS. particularly the lower convolution of the ileum, and, in the female, the uterus and its appendages. The two lateral subdivisions of the hypogastric region, termed the inguinal regions, are very limited : the right sometimes contains the lowest part, or cul de sac, of the caput coli, and the vermiform process and the iliac vessels. The left inguinal region contains a part of the sigmoid flexure, and the iliac vessels of that side. Pig. 3- Such, then, is the distribution of the different parts and viscera, in their healthy and quiescent state : but they are subject, as I have said, to some variations, from anomalous formations ; and besides this, many of the viscera, particularly those which are hoUow, un- dergo considerable changes, as to form and extent, according to the state and progress of the operations in which they are destined to assist : and we must, of course, be prepared to appreciate and make allowance for such changes, when investigating the condition of the abdomen, or speaking of the natural contents of its different arti- ficial subdivisions. EXPLORATION OF THE ABDOMEN. Fig. 4. Figs. 3 and 4 present two outline figures of the male abdomen, as obtained by a brass plate properly prepared for stencilling ; by means of which, such an outline may be transferred to the blank page of a note-book in a few seconds. The plate from which this outline was obtained, as likewise one of the female figure, was made, under my instructions, by Mr. Bentley, of High Holborn ; and may be had, by any one, at an expense of two or three shillings. Fig. 3 has had the marks drawn upon it, signifying the situation of abdominal tumours which occurred in a case of cerebriform malignant disease. Fig. 4 is intended to mark the situation of several abdominal tumours in a case of hydatids. With a view of assisting in registering facts, it appears very desirable that every one who is really anxious to make the most of the experience which comes within his reach — a duty wliich, unfor- tunately, from the time it occupies, we are aU too apt to neglect — should provide himself with some ready mode of transferring to the corner or the blank page of his note-book an outhne of the abdo- men ; upon which he may mark, as nearly as possible, the exact position of any tumour which he is caUed upon to treat : and, for this purpose, I have employed one or two different little contrivances. 10 ON ABDOMINAL TUMOURS. which it may not be amiss to mention. In the first place, having drawn on a thick sheet of paper the outhne desired, we may, with a pin, make holes in a few prominent points ; and pricking the note- book through these holes, the least-experienced draftsman wiU be enabled to make an intelligible sketch in a very short time. I have likewise had the figure cut in a brass plate, to use it in the mode of stencilling ; and have thus procured, in a few seconds, upon any part of the page, such an outhne as is represented in Kgs. 3 and 4. Again, it would be a matter of a very few shillings' expense, to have a woodcut or type formed, which might be used like a seal, even with common ink. It is obvious that no one single sketch can serve for every case ; because the relative proportions of the different parts of the abdomen are somewhat altered, as it be- comes distended, and consequently thrown out of its natural form ; but still, the convenience of some such mechanical contrivance is very great, and there is no difficulty in being provided with more than one form of outhne ; and perhaps a second, representing the moderately distended abdomen, would be quite sufficient for every purpose. It will be at once perceived, by a reference to the figures, how the situation and extent of tumours, whether visible to the eye or ascertained by the touch, may be traced on the outline ; and thus remain a fixed record, by which to judge of the progress of the individual case, or afford a means of comparison with others. CHAPTER II. ON TUMOURS DEPENDENT UPON ACEPHALOCYST HYDATIDS. It is intended to confine the present communication to the illus- tration of abdominal tumours derived from a single disease ; which, though not strictly an affection of the peritoneum, yet, as most extensively occupying the peritoneal sac, or the parts immediately covered by that membrane, may be arranged, for convenience, amongst its diseases. Of the origia of hydatids we are so completely ignorant, that it would be vain to hazard a conjecture on the subject. They are beUeved to be independent animals, existing without any vascular connexion with the body ia which they are developed ; but whence the ova are derived, or how introduced into the body, is altogether unknown. They are confined to no particular organ ; having been found in the abdomen, the chest, and the pelvis, and various other parts : occupying, indiscrimiaately, the glandular, the muscular, and the cellular structure ; but, undoubtedly, the most common situa- tion is somewhere in the abdominal region : while, of the individual organs, the Kver is most frequently affected by them ; and, in many cases, it is probable, that when they have ultimately occupied a larger space, and spread more extensively through the abdomen, they have originally been situated in the Kver only. Almost the only indication of their existence, at the commencement, is the occurrence of swelling, corresponding with the part in which they are situated; and the gradual increase of this is, for a time, the chief mark of the progress which the disease is making. Occasion- ally, when a rounded projecting elastic tumour has been observed and felt for a time, a sudden subsidence takes place, accompanied by more or less constitutional and local excitement ; and then the tumour may never arise again ; or, instead of one definite tumour which had before been observed, several may appear to develop themselves within a limited period : at other times, the sudden dis- 12 ON ABDOMINAL TUMOURS. appearance of such a tumour may be followed by symptoms indica- ting peritoneal inflammation^ so severe, as quickly to lead to dissolu- tion. In a few instances, the subsidence of such a tumour is attended by the evacuation of hydatids, through the lungs, or the intestines, or in some other way, attended by various results. The tumour which presents itself externally is most commonly, at first, distinctly referable to the hver ; and either occupies the right hypochondrium, or, protruding from beneath the ribs and their cartilages, encroaches upon the middle subdivision of the epigastric region, or descends into the right lumbar region, or approaches the umbUicus : its form is rounded, and its feel elastic ; sometimes varying a little in the resistance it presents, being occasionally hard and even bony in some parts, and often indistiactly fluctuating on percussion. When situated in the right hypochondrium, it is some- times accompanied by jaundice. When situated in other parts, the derangement of the functions of the particular organs upon which pressure is made will afford collateral indications not to be neglected. This form of disease is not confined to any age, or either sex ; and the length of its continuance is not ascertained, though it is certain that it may exist for a great number of years without destroying Kfe, as will be shown by some of the cases I am about to state. Neither the situation, nor the sensation yielded to the touch, will be found to afford a complete means of diagnosis, in cases of hyda- tids : for, as I have said, they may occupy any part of the abdomen, and may arise from, or encroach upon, any organ : and this source of difficulty will be well illustrated by Mgs. 3 and 4; in which Pig. 3 represents the sketch I took in a case of cerebriform disease of the abdomen; while Kg. 4 is a similar sketch from a case of hydatids. In these cases, the liver was, in both, the seat of elastic tumours ; and so likewise was the space corresponding to certain convolutions of the intestines. There was, it is true, an appreciable difference in the feel : in the case of the hydatids, the elasticity was greater ; but as the tumours in the other case were full of soft cerebriform matter, they were by no means devoid of a degree either of elasticity or of imperfect fluctuation. It is therefore quite necessary, in aU cases, to call to our aid the concomitant circum- stances. Thus, in the present instance, the greater constitutional affection, the general irritabihty of the system, the saUow and un- healthy complexion of mahgnant disease, and, on the other hand, the slowness with which hydatid tumours develop themselves when ACEPHALOCTST HYDATIDS. 13 compared with cerebriform disease, would be amongst the most decisive marks, modifying or confirming the conclusions to which situation and feel had led. Case i. — Hydatids in the abdomen, of many years' standing ; showing the acephalocysts in almost every stage of their existence. — Aim W — , set. 54, was admitted into Gu/s Hospital, under my care, August 15th, 1837, with a peculiar swelling of the abdomen; her health at that time suffering so far, as to make her feel all exertion irksome. It appeared, from her account, that she had given birth to her first child, which was stiU living, about fourteen years before; — that, about two years after, she bore a second healthy cloild, which was her last. She never thought that she returned completely to her natural size, after her first confinement ; but it was not until nine or ten years ago that she suspected any unnatural condition of the abdomen ; and the enlargement was so gradual, that she was unable to say whether it began in one part more than another ; nor was it tiU. about three years ago, that the swelling, gradually assuming its present appearance, very decidedly attracted her attention. At the time of her admission, the whole abdomen was greatly enlarged ; the upper two thirds occupied by an irregular tumour, indistinctly fluctuating, and, in various parts, some- what tender on pressure : the lower part of the abdomen was also occupied by a fluctuating tumour, apparently a large cyst arising from the pelvis. The iatervening space was soft; and was the only part which gave a clear or tympanitic sound on percussion. She complained chiefly of constipated bowels and loss of flesh, although her appetite continued good. During the first months that she was ia the hospital, she remained chiefly ia bed, sitting up but little ; not so much from any feeling of positive iUness, as from the uneasiness produced by the weight of the tumour. She lay down without suffering any inconvenience, or any additional dyspnoea. Her urine was clear, and not in the least coagulable ; and there was no anasarcous swelling at any time. In October, she complained, on several occasions, of increased pain and tenderness in various parts of the abdomen, which were always much reheved by the applica- tion of ten or twelve leeches : she at the same time took gentle bitter and tonic medicines, and occasional purgatives ; amongst wliich I found none more ef&cacious than five graias of the Hydrarg. c. Greta, followed, in four hours, by castor-oil. On the 29th of October, she 14 ON ABDOMINAL TUMOURS. complained much of imeasy sensations in the abdomen^ which she spoke of as throbbing, starting, and jumping, and was apprehensive that suppuration was taking place ; and at two or tliree separate periods, in November and December, she was affected with faintness and cold perspiration, continuing for haK an hour, and followed by a sense of lowness, and a feebleness of pulse, which lasted for a day or two. The breathing all this time was strong and clear, and the bowels regular. December 31st, a dull aching pain came on, in the lower part of the abdomen, with slight tenderness on pressure. This was followed by a diarrhcea ; which continued, in some degree, for ten days, with occasional attacks of sickness and vomiting. She again returned to a more comfortable state ; but in the middle of ]Pebruary, suffered some pain in the abdomen, which she sometimes compared to the formation of an abscess, and, at other times, to something suddenly running through her. In the latter part of this month, the urine became high coloured and very scanty, with pain in the loins : and on the 27th, haematuria took place, the urine throwing down a brown ilaky coagulum on exposure to heat. The counte- nance was now beginning to lose the healthy appearance it had hitherto maintained, becoming sallow. The hsematuria continued for several days. Throughout the months of March, April, and May, she suffered occasionally from rigors, which continued for two or three hours ; and her stomach became so irritable, that she often rejected her food almost as soon as it was swallowed, or experienced pain if it was retained. Diarrhoea returned in the beginning of June; and on the loth of that month she expired. I have not thought it necessary to detail the various remedies which were administered during this protracted illness : they were • throughout directed rather with a view to reheve symptoms, than with any expectation of curing the disease, which, from the first day of her admission, I plainly perceived to be beyond the reach of medicine. The tumour of the abdomen had abeady existed for several years ; and from its peculiar and irregular forms, and its obscure fluctuation, I concluded that it consisted either of hydatids extensively distributed, or was an ovarian tumour ; and if the latter, — which, from its very singular form, and more particularly from the existence of the upper portion so separated from the lower, I could scarcely believe, — I supposed that it must be one of those ACEPHALOCYST HYDATIDS. 15 complex and malignant forms of disease which could afford very little prospect of permanent relief from paracentesis. This remedyj howeverj I proposed to the patient, who was a remarkably sensible and well-educated woman, shortly after her admission, and again when the irritability of the stomach became urgent, probably from the pressure of the tumoui ; but I was obhged fairly to confess, that I considered it an experiment of doubtful issue, and only likely to give temporary relief. The day subsequent to her decease, the body was examined, in pursuance of her own particular request, made to me during Hfe, and likewise left in writing on her death. Sectio cadaveris. — The body was extremely emaciated. The abdo- men presented two large tumours, the one occupying the lower, the other the upper part, projecting greatly, and divided by a soft, yielding portion. (Kg. 5.) When the integuments were turned rig. 5- Pigs. 5 aud 6 represent the abdomen of Ann W — (Case i, p. 13). Kg. 5. A view of the abdomen during life, seen on the left side. Fig. 6. A view of the abdomen, seen on the right side, after the integuments had been removed; showing the two large hydatid cysts. The upper one is seen incorporated with the liver, from which it arose; and which it has forced upwards, encroaching on the thorax. The lower is obliquely traversed by one of the Pallopian tubes, attached to the angle of the uterus. Part of the small intes- tines are seen occupying the right lumbar and iliac regions ; while the contracted arch of the colon is stretched across the abdomen, between the two large hydatid cysts. 16 ON ABDOMINAL TUMOURS. back, two large cysts came into viewj between wliich, the arch of the colon was seen, in a very contracted state, passing across the abdomen ; while the small intestines, likewise greatly contracted, chiefly occupied a triangular space in the right lumbar region. .(¥ig. 6.) rig. 6. The lower cyst was nearly spherical ; and on its anterior surface, to the right of the centre, was seen a flat triangular body, from which a long Hne extended upwards towards the left ; and besides this, several nerves and vessels were stretched on its surface. On further examination, this triangular body proved to be the uterus, compressed to half its natural thickness, and proportionably extended in surface ; and the line from it was one of the Tallopian tubes, closely united to the cyst. On making a small incision into the tumour, nearly a gallon of perfectly limpid fluid escaped ; and then several hydatids, each of the size of a hen's egg, presented them- selves at the opening. It now appeared that the whole of tliis enormous cyst was closely Hned by one hydatid, the thickness of which was as great as tolerably thick wash-leather. It was trans- parent, and easily torn, and fitted, in aU. parts, closely to the sac in which it was contained ; but was so slightly attached, that it might have been torn away perfect, by the application of very slight force. The sac itself had its inner surface of a bright pink colour, and appeared very vascular. Behind, and to the left of this large cyst, a smaller one was dis- covered, of the size of a very large hen's egg, which was attached ACEPHALOCYST HYDATIDS. 17 to the left ovaryj and proved to be of tlie same natiire as the large cyst; but in this, the hydatids, instead of being entire and spherical, were all burst ; and that which appeared to have served at one time as a lining to the sac, was found, when taken out and examined, to be at least four times as large as the whole superficies of the present cavity. The superior tumour of the abdomen was attached to the Uver, in the substance of which it was partly imbedded. The upper part, where it had come in contact with the integuments, was completely cartilaginous ; and a very singular appearance was discovered by raising the body of the tumour. There were a great number of en- larged absorbents, filled with a puriform fluid : they were quite varicose, of the size of the iliac artery after its division. One of these was seen of the length of two or three inches ; while others were convoluted, and assumed a cellular appearance. Owiag to the weakness of their coats, they were mostly flattened, collapsing Hke veins. "When an incision was made into this tumour, the fluid which escaped was turbid, and of a yellowish-white colour; and it was chiefly filled with hydatids, in all their different states and stages ; but by far the greater number were compressed and broken, the shreds and empty cysts being compacted together; while several, even of the size of an egg, were unbroken ; and from this cyst, again, nearly a gallon of fluid and of hydatids was collected. To the left of the gall-bladder, which was itseK seen in a tolerably natural condition, was another cyst, about a third part as large as the one we had just opened : and in this case, the bile had commu- nicated with the cyst, and the fluid it contained was green and tur- bid; while the hydatid cysts floating in it, and chiefly broken down, were deeply tinged of the same colour ; and the iaternal surface of the general cavity, to which probably an hydatid had formerly been attached, was now scabrous to the feel, and covered with yellow and dark oHve-coloured particles, apparently inspissated bile. "With regard to the viscera, the stomach was greatly compressed by the tumoui appended to the liver ; and the contracted condition of the intestines bespoke the scanty supply of nutriment which had passed into them during the last weeks of life. The kidneys had suffered most materially from the pressure made upon the ureters, and were almost reduced to the state of membranous sacs.' The right was the larger of the two, and was distended with grumous, bloody urine. The inner surface of the pelvis approached, in one 18 ON ABDOMINAL TUMOURS. or two parts, to a condition of ulceration, or spliacelns. Tlie liver was granulated, of a light coloiu^ and soft textnre. The lungs were healthy, with the exception of some osdematous effusion. The heart was flabby, and of a Hght coloui'. As to the hydatids themselves, they seem to have varied from the size of the large cyst in the lower part of the abdomen to the minutest object capable of Ijeing seen by the eye : many of them were of the size of a hen's or a tluusli's egg ; and these were often studded internally with httle rounded bodies of an opacpic wliite t'i-s =. 9, 9 '■('. pllllllll B Hj H w ^^ 9| I^^^mhuSh^^^HB l^^B^ m^X ^^M It * J f\M '^^^^M HhkhH^B^H RPIsra S^gt: ^s^ Iw ■ifw ^l^^^u HHHHj ^m m^ J^ A • ^ul ^^HBh^HB^BS^^^ \f ^^^ ^■^ ^H ^ ^^^m. ""^W IBB^^IBP^ W^^ ^wr hr^ ^ ^^^H i i > a Bh^^BHH^^H ^^fe^ ^hB 'M mba ^mI^^H IBBBIIIIIil hh IH IS H ^HH Pigs. 7 to II represent diifercut appearances of minute hydatids, from Case I, as seen through Amici's microscope. Figs. 12 and 13 are representations of the natural size, from Case 2. rio-. 7. A very small portion of an unbroken hydatid, as seen through Amici's microscope (p. 19). Fig. 8. Internal surface of a portion of hydatid, as seen through the microscope (p. 21). Fig. 9. A cluster of very minute hydatids, as seen through the micro- scope (p. 19). Fig. 9 «. The natural size of tiie cluster of hydatids. Fig. 10. A cluster of small hydatids, seen through the microscope (P- 20). Fig. II. A collection of minute hydatids, as seen through the micro- scope (p. 20). Fig. II «. The natural size of Fig. ii. Fig. 12. Appearance presented on the internal surface of some hydatids ; natural size (p. 29). Fig. 13. Another peculiar appearance occasionally seen on the inner surface of an hydatid ; natural size (p. 29). ACKPHALOCYST HYDATIDS. 19 colour, Avliicli, -nlieii separated from the surface, floatecl for a little M'liile iu the fluid, and theu gravitated to the bottom. It was observable, that the coats of the hydatids were elastic, and admitted of au almost indefinite division into smooth and even lameUic. As, in this case, the hydatids were exceedingly numerous, and presented themselves in various forms, I availed niyseK of my friend Dr. Eoget''s kindness, and submitted many specunens to o])servation under the microscope he had lately obtained from Aniici ; and I procured, at the same time, the assistance of ]\lr. Say, of whose talents as au artist I need say nothiug, iu dehncating some of the appearances they presented. An hydatid, of aJjout the size of a pigeon's egg, taken from the lo'wer cvst, lia^dug been carefidly ruptured, was found to contain almost innumerable small hydatids, scarcely visible to the eye : and a little group of them, not exceeding in size, altogether, a few grains of sand, being examined by the third power of Amici's microscope (Eigs. 9, 9 (/), was found to consist of simple hydatids, and of such as, having generated others within themselves, might be con- sidered as pregnant or prohfic. The single minute hydatids gene- rally inclined to an oval form ; and all of them appeared to be studded within bv innmnerable points or inequalities, giving them a spotted appearance ; the specks being light or dark, according to the direction in which the light fell upon them. These single hydatids seldom completely touched, and never compressed each other as they lav. Tlie pregnant minute hydatids contained from two to twenty, or more, witlun them : they were exceedingly thin and transpareutj so as but little to obscure the appearance of the contained hydatids, by the projection of which they frequently seemed to be changed from their regular ovoid or spherical shape. Another hydatid, of the size of a tlmish's egg, but exceechngly 20 ON ABDOMINAL TUMOURS. transparent^ was examined, -without being broken, tlirougli Amici's third glass. (Fig 7.) It appeared as if it were covered internally with innumerable small projections, hardly larger than those seen within the small single hydatids I have just described; wliile, at the same time, a few vesicular bodies were seen within ; but whether iloating in the fluid, or adhering to the sides, could not be determined. A portion of an hydatid, about the size of a pigeon's egg, being taken so that a part of the internal surface was seen at the edge^ as the membrane coiled upon itself (Mg. 10), groups of single Fif;. 10. smaU vesicles were seen attached, almost like clusters of grapes closely set upon a branch ; an appearance which I had several times an opportunity of seeing and drawing. (I'igs. 11, 11 a.) figs. II, 11 tf. A similar portion of another hydatid being examined, it wf ACKniALOCYST IIYDATIDS. 21 observed, that Q^'e.r a considerable part of its surface a botryoidal ppearance prevailed (Fig. 8), from the elevation of oval bodies a like compressed single hydatids, transparent and spotted as the other minute single hydatids had been ; and some of these hemi- spheres projected more than the rest, either forming little clusters, or apparently attached to the surface by a footstalk formed of a portion of lining meudjrane drawn out from the parent hydatid: and on examining some portions of the internal surface, an appear- ance of a number of very minute rents and oval depressions was seen, not improbably left by the esca[)c of hydatids from their nidus. There is every reason to believe that the disease in this case had existed ten, or probably twelve years, before it proved fatal ; for to that period coidd the patieirt trace the gradual enlargement of her abdomen. The progress of the symptoms corresponded well with the appearances discovered after death : and from the condition of the various cvsts, I tliink we are authorised in concluding that the hydatids had fu'st developed themselves in the liver. The disease, perfectly local in its nature, had given rise to no lu'gent symptoms, till the tirmour pressed upon the m-eters, and thus mechaiucally pro- duced irritation and absorption of the kidneys ; and afterwards, by its pressure on the stomach, as well as by the sympathy of the stomach with the kidneys, it interrupted the frrnction of that organ likewise. It is difhcult to say what was the cause of those faint- 22 ON ABDOMINAL TUMOURS. ings, peculiar sensations, and rigors, which were frequently expe- rienced from the month of October. They might possibly have been connected with changes taking place within the cysts ; and I was, at the time, inclined to consider them in that light, thinking it not improbable that something analogous to the constitutional im- pressions which have appeared to take place when the cysts of ovarian tiimours successively burst might be thus produced : but I believe that the operations and changes of the hydatids themselves would have very little influence on the patient ; it is rather those diseased actions, and that absorption, which takes place from the cavity in which the hydatid is contained, that may be looked upon as the sources of the serious and distressing symptoms which attended the concluding periods of this, patient's bfe. There can scarcely be on record a more instructive post-mortem examination, as regards the history of the disease ; containing with- in itself, as has been seen, a most singular variety of the different states and conditions in which the hydatid presents itself. The four principal masses into which these were distributed each afforded its remarkable peculiarity. In the large inferior tumour, the whole economy of the hydatid was in its most flourishing and healthy state. The parent, or protecting cyst, accurately lined the cavity in which it was contained ; and the numerous progeny might be sup- posed to exult in the uninterrupted prosperity of their prolific com- munity, and the peUucid medium by which they were surrounded. In all the other masses, or communities, some of the accidents to which the hydatid existence is subjected, were illustrated and proved. In the small inferior cyst, placed behind the cyst of which I have just spoken, we found the parent hydatid separated from the cavity, that cavity contracted, and the hydatids crushed by the diminution of the cavity, and exposed to the influence of the ab- sorbents of the body. In the large superior cyst, the hydatids had apparently multi- plied till they had perished for want of space : the parent cyst had died, the cavity suppurated, and the few hydatids which remained entire were floating in a mixture of pus and the decomposing debris of other hydatids; and here, likewise, the absorbents seemed to have been distended by the fluid of the cyst, and probably impeded in their action. In the fourth cavity, the secretion of the Hver had insinuated ACEPHALOCYST HYDATIDS. 33 itseK behind the parent cyst, destroyed its vitality, forced it from its situation, and, mingling with its contents, proved a source of death and destruction to the greater part of the hydatids it con- tained. Thus, as I have said, does this single case illustrate many of the most important epochs and accidents which mark the progress of the hydatid. The following case I find already detailed, somewhat at length, in the excellent volume of lectures lately published by my friend Dr. Hodgkin, who has selected it as a very illustrative example to which this affection occasionally goes; but as I had this patient frequently under my care, and was of course greatly interested in the post-mortem appearances, which afforded several varieties and modifications, I shall not hesitate to give a pretty full abstract of the notes I took at the time, though they may appear more minute than absolutely necessary for the elucidation of the subject. Case 2. — Hydatids extensively occupying tJie abdomen. — ^Edward C — , set. %6, a dyer by trade, admitted Pebruary a ad, 1826. Has a large, iirm, elastic tumour of the abdomen, which projects abruptly from the hypochondria, and soon attains its largest circumference, which, at present, measures forty-three inches, afterwards tapering downwards to about forty inches. It is not tender on pressure, and, when grasped, presents an irregular knotted surface, both above and below a margin which crosses the umbilicus, and seems to be that of the liver. The integuments of the abdomen exhibit a number of enlarged veins, running upwards, but are otherwise healthy. With this tumour he has considerable dyspnoea and cough. An attempt to lie on the back or on the left side is attended with a sense of suffocation, in consequence of which, he either sits during the night or reclines on the right side. He sleeps ill, is somewhat emaciated, complains of much weakness, and, towards evening, has a little oedema of the legs. Pulse 20, quick, and rather irregular ; respiration 28, chiefly thoracic, and attended with some effort and wheezing. On percussion, the chest every- where sounds well, except on the right side, throughout the lower haK of which the sound is dull. Examined by the sthetho- scope, the respiration in the same region is inaudible, as likewise in the lower part of the left side, but in other parts of the chest natural. The complexion is pale ; conjunctiva sHghtly tinged, and 34 ON ABDOMINAL TUMOURS. injected; tongue wMte and clammy, -with reddisTi edges; some tHrst, and little appetite, much flatulence. Small quantities of Hght animal food, with bread, agree best ; but vegetables, liquids, or a large quantity of anything taken at a time, inflates and oppresses the stomach. The bowels are iachned to costiveness, which increases the dyspncea. Urine reported to be scanty, high- coloured, and occasionally turbid. He can assign no other cause for his complaint than pressure of the abdomen on the edges of the vats used in dying, which, at an earlier period, apparently induced hernia in each groin. The abdominal tumour commenced, nearly three years ago, in the right hypochondiium, and has gradually grown to its present size, with the addition of the symptoms above described. He has been repeatedly a patient in Guy's, and was last week dismissed, after a year's residence in Luke's Ward ; since which, the dyspnoea, cough, and flatulence have increased, and he is therefore again admitted into the hospital. The daily observations, which were carefully made tiU the i6th of March, when he died, confirmed what has been already stated. The respiration was frequently embarrassed, more at one time than another, but was performed about a8 times in the minute. The pulse not unfrequently intermitted very much, and was irregular ; sometimes varying, in the course of a few minutes, from 58 to lao; at other times small, weak, and indistinct, having the second beat sometimes nearly lost. The urine was scanty, high-coloured, and very turbid, and, on one occasion, of a deep mahogany colour, with a pinkish sediment, as if tinged by the purpurates. The bowels required to be frequently assisted in their action by purgatives, but the evacuations were often natural, and only on one or two occasions, and for a short time, deficient in bile. His legs, which had occasionally before been oedematous, became very much so a few days after his admission, and continued in that state as long as he survived. Seotio cadaveris, March 17th, i8a6. — ^Face purple; veins of neck distended; abdomen covered with marks of a network of veins, but not so much enlarged as in many cases of pressure on the cava; a great many parts of the body and thighs quite purple or lilac, as in one who has died a violent death ; abdomen much distended, with the same knotty feel as during life. On opening the abdomen, the liver was seen descending much lower than natural, having afforded that evident margin which was ACEPHALOCTfST HYDATIDS. 25 perceptible during life. Almost the wtole lower part of the abdo- men was full of rounded bodies, of the size of moderate potatoes, partially covered or intermixed with omentum, the vessels of which ramified over their surface. The small intestines were seen in the left iliac region, occupying a very smaU space of the whole. A large dark-coloured body was seen above them, in the left side, which looked at first like diseased spleen. On further examination, it appeared that the whole of this morbid mass was a collection of hydatids, situated in the omentum, to which they were attached, and seemed as if entangled amongst the meshes of a net. (Fig. 14.) The dark body on the left side was another of these hydatids, as large as the largest orange, casually coloured, apparently by blood, of a darker or blacker tint. The liver, though to appearance so much enlarged, was, in fact, not at all larger than usual, but was filled with hydatid cysts, some of which held at least a pint of the most limpid fluid imaginable, as pure as distilled water ; and the substance of the hver was, in some parts, attenuated Kke a mem- brane. One very large hydatid occupied the right hypochondrium, and entered the substance of the hver, and one, situated just above the gall-bladder, and capable of containing at least half a pint, seemed to have opened into a biliary duct, so that it was fuU of a turbid yeUow fluid, bearing so much the character of bile, that at first it was supposed to be the distended gall-bladder ; how- ever, on further observation, it appeared that this had been filled by one large hydatid, completely discoloured by the bde, and that the surface, from which this cyst had been detached, was scabrous and uneven, and of a dark-green colour, with black and yellow in- termixed. The gall-bladder itself was found quite healthy, and not communicatiag with any preternatural cavity, but rather compressed by the surrounding hydatids. The semi-transparent or opalescent hydatid cysts which lined the cavities formed in the Hver were very easily detached, and left a yellow semi-membranous pouch in the Uver itseK, quite incapable of beiag separated from the sub- stance of the organ. The cysts were most of them filled with other hydatids, almost aU fully distended, floating in more or less water. In some of the cysts there were no hydatids of any size larger than millet-seeds, which either floated, almost like dust, in the water, or were attached, as frost, to the large hydatid cyst. Some of the hydatids in the omentum were much thicker than others, and, in general. 26 ON ABDOMINAL TUMOURS. tlie thickest appeared to contain the greater number of hydatids Fig. 14. Pig. 14 represents a small portion constituting, perhaps, a twentieth part, of the large mass of hydatids which came into view when the abdomen of Edward C — (Case 2) was laid open. The appearance of the hydatids in the omentum was that of sacs, not larger than moderate-sized potatoes ; but, frequently, two, three, or four of them were found to communicate together, with a very imperfect septum between them, or only a depression in their surface ; over which, in general, a vessel of the omentum was observed to pass, as if it had been in part the means of pro- ACEPHALOCYST HYDATIDS. 27 duoing the form. On opening the sacs, they were found to be of a semi- cartilaginous consistence, so firm that, when completely emptied, they main- tained tlieir spherical form ; and when all the hydatids had been removed, the sacs were lined with a somewliat scabrous, yellow structure, formed by an irregular coating of coagulable lymph. They were generally filled with a great number of pellucid hydatids, full of the most transparent fluid. The hydatids were of all sizes, from a pigeon's egg to a mustard-seed, spherical in shape ; some of them were imbedded in the rough lining of the cartilaginous sac; and thus it appeared little pouches were sometimes formed, probably swelling afterwards into other subordinate sacs. Many, both large and small, appeared to have been burst by the pressure of the rest, so that they were squeezed quite flat ; but it was remarkable that, in most of these instances, there was no fluid effused in the sac, but that it was quite full of the turgid hydatids, or the skins. In a few instances, in which the hydatid to the right of the drawing was one, and which the space would not allow me to introduce in this figure, where a single hydatid had formed the lining of the cartilaginous sac, no others had developed themselves. In this instance, the single hydatid seemed to have been lately ruptured, and the sac was full of the water, in which the skin was seen curled up : the water contained thousands of little opaque white bodies, not much larger than sand, apparently of one shape and size, being all spherical ; they were rather heavier than the water, and soon subsided to the bottom. They were not examined in a microscope, but were, probably, small hydatids. ■within them; some were completely filled, and, when opened, poured forth one mass of globules, from the size of small shot to small marbles, only differing in degrees of transparency, scarcely at all in colour, except that some were quite transparent, some of an opaque white. These numerous large cysts had forced the liver, forming one, as it did, with the cysts, very high up towards the thorax, so that the lungs only extended half way between the third and fourth ribs on the right side. In attempting to remove the liver by cutting through the diaphragm, two or three large hydatid cavities were opened. It is almost impossible to describe how the different cysts were placed in the abdomen. The spleen was surrounded and occupied, like the Kver, with hydatid cysts, of the size of large oranges ; two or three others had pressed upon the kidneys, particu- larly on the right one, so as to have completely deformed it, and produced some absorption, but, on the whole, the kidneys were rather large, and were quite healthy in structure. There were several small yellow calculi in the right, and the ureter of the left was distended, from the pressure of hydatids. 28 ON ABDOMINAL TUMOURS. The pelvis was quite Med by two or three large hydatids, ap- pended externally to the bladder. The stomach was congested ; and an hydatid of the size of an eggj not far from the pylorus, seemed as if it would have . burst very shortly into the stomach. The small intestines were con- gested, but otherwise healthy. The colon was very much involved in the hydatids lying on every side in the omentum, but was itself quite healthy. The mesentery was altogether free from even any attached hydatids. The glands were slightly enlarged. The lungs perfectly natural, but diminished in size, a few dilated air-vessels on the thin margin, on both sides extremely restricted for room — on the right by the Uver, and on the left still more — by projections from the abdominal contents, and by the heart being much enlarged (probably nearly twice the natural size, but healthy in valves and structure) . The lungs on neither side diseased. The hydatids which lined the sacs in the liver and the spleen were rather opaque, as thick as wash-leather, and were very easily detached from the cavity in which they were contained, being entirely united, except by close apposition ; yet their external sur- face, on being pulled out, was slightly shredded with lymph-Hke, transparent membrane. They tore easily, and had a strong tendency to curl up, whenever torn through, so that it was dif- ficult to spread them out. Internally, they were slightly and Kg. 12. pretty evenly granulated, on every part ; and in a large one, taken from the liver, a space about the size of a sixpence was very curi- ously marked with raised rugse, forming semi-transparent waved ACEPHALOCYST HYDATIDS. 29 lines, while in others, both small and large, irregular, but some- what circular spots were, in two or three instances, seen, of the brightest white colour, studded with white tubercles, of the size of pins' heads (Fig. la); and in a parent hydatid, Hning a large cavity in the spleen, was a very singular mass of jelly-hke substance, attached to the internal surface, and looking as if it were composed of a multiplicity of irregular transparent bodies, of the size of mustard-seeds, or larger, stuck together, so as partially to conceal their individual forms. Of this I procured a drawing (Fig. 13), and I observe that Dr. Hodgkin, speaking of this Kg. 13. case, seems to consider these anomalous appearances in the light of diseases of the hydatids. In the foregoing case the disease had certainly existed for several years, having begun, in all probability, in the hver ; from which, at some unknown period, the hydatids had escaped into the cavity of the abdomen. The patient had distinctly observed the tumour in the right hypochondrium above three years before his death. The immediate cause of death in this case was probably connected with the very insufficient state of nourishment, which was the result of the pressure of the hydatids and their encroach- ment on the various organs of the abdomen, while the dilated condition of the heart favoui'ed the tendency to internal congestion, and hastened death. 30 ON ABDOMINAL TUMOURS. Case 3. — Hydatids developed in the abdomen. Death from peritonitis. — Thomas D — was admitted^ when at the age of 14, into Gu/s Hospital, in June 1838; a slight-made boy, marked with the smallpox, the eldest of five children of a very poor family in the Borough. The account he gave of himseK, as to the dura- tion of his complaint, was not very satisfactory ; for he stated, that he had observed nothing wrong about his abdomen till nine weeks previous to his admission, when he perceived a hard lump in the right side below the false ribs, and since that his abdomen had swollen to its present state. It was greatly enlarged ; and over the whole might be felt, from the scrobiculus cordis to the pubes, ar number of small round bodies, some of the size of walnuts, and others of large eggs, elastic to the feel, and scarcely leaving a doubt on our minds that they were of the hydatid character. In some instances, the projections occasioned by these bodies were sufficiently obvious to the eye ; and a sketch, which was taken for me by Mr. Canton, at the time, wiD. give a very fair idea of the appearance the abdomen presented, as the boy lay, inclining to the right side, on his bed. (See Kg. i_5.) His general aspect was not unhealthy, Kg. 15. Fig. IS represents the abdomen of Thomas D— (Case 3), as it presented itself in June, 1828, when the existence of hydatids was first discovered. except from a certain degree of emaciation ; his teeth were unusually white and regular, and his tongue clean. He experienced little or no uneasiness when pressure was made on any part of his abdomen. ACEPHALOCYST HYDATIDS. 31 He remained in the hospital several monthsj during which time he was generally able to go into the court-yard to walk, but suffered two or three febrile attacks, on which occasions his tongue became coated, his pulse accelerated, and the abdomen tender on pressure. On the whole, however, very little change took place, except in the gradual enlargement of the abdomen, and the general emaciation. He left the hospital after several months, and returned to liis family. Prom that time he continued to be subject to aU the hardships and irregularities to which his situation necessarily exposed him, and was chiefly employed in selling fish about the streets, in which occupation I frequently saw him, poor and miserable, but by no means so deficient in activity as might have been expected from his bulk. On October 5th, 1836, he applied to be again admitted into the hospital. His symptoms were, at that time, those of an acute but neglected attack of peritonitis, accompanied probably by effusion into the abdomen. The fluctuation, however, was very indistinct, and the tenderness such as to preclude a very minute examination. The general size of the abdomen was greatly increased, and the sur- face was marked by numerous superficial veins. The lobulated form of the abdomen corresponded with the idea previously formed, that the disease depended on hydatids ; but the rounded bodies were larger, and by no means so weL. defined or so elastic as they had been eight years previously. In two or three parts projections were obvious to the eye, and I had no doubt that one corresponded with a very prominent projection in the sketch taken on the former occasion, allowance being made for the greatly increased bulk, and consequent pushing upwards, of the whole mass. The enlargement of the abdomen had produced great dyspnoea, by the singular encroachment which had been gradually made upon the chest, as will be distinctly seen in the sketch made by Mr. Canton on this occasion. (See Mg. i6.) He survived in this state but a few days, and died on the 15th of October. Sectio-cadaveris. — The abdomen was enormously enlarged, en- croaching upon the thorax. In one part only, of small extent, was any clear or tympanitic sound eHcited on percussion, and this was in the umbihcal region, towards the left side, and in the left lumbar region. AU the rest of the abdomen felt solid and lobulated, only slightly elastic, and was perfectly dull on percussion. The parietes adhered closely to every part of the contents of the abdomen, so that 32 ON ABDOMINAL TUMOURS. it was difBcult to detach them, and one or two slight punctures of rig. 1 6. Mg. 1 6 represents the abdomen of Thomas D — as it presented itself in Octo- ber, 1836; more than eight years after the sketch which is seen in Fig. ig was taken. The projecting tumour, a little below the right mamma, which contained a solitary hydatid, was believed to correspond with the lower of the two project- ing tumours on the right side of the abdomen in Eig. 15. the colon could not be avoided. "When the integuments were at length careMly dissected off (Kg. 17), the whole, except the parts where the tympanitic sound had been elicited, proved to be one mass of cysts, covered with a firm dense membrane, which so closely bound them down that it looked like a large lobulated mass, rather than a collection of cysts. On opening the cysts, some of ACEPHALOCYST HYDATIDS. 33 them were found to contain a solitary hydatid, having no others within it, while the greater part were full of small hydatids, pre- senting all the forms and peculiarities which are ever observable, and which have already been minutely described in the foregoing cases. In general, it might be remarked, that the skin and debris of the Fig. 17. rig. 17 represents tlie abdomen seen in fig. 16 laid open, and the integu- ments dissected carefully from the hydatids, to which the whole parieties were closely and firmly glued by thick deposits of adyentitious structure. The dis- proportion between the abdomen and the thorax, encroached upon as it was by the disease, is very remarkable. hydatids, which by compressiom had lost their vitality, bore a large 3 34 ON ABDOMINAL TUMOTJES. proportion to those which were entire^ spherical, and transparent. One particular cyst, which had been distinctly felt on the outside and had been obvious to the eye (and which I considered the same that I had observed and figured in the sketch made eight years before), contained a perfectly isolated hydatid, which formed the lining membrane of the cyst, and was filled with the most peUucid fluid. A very large cyst occupied the upper portion of the liver, and was full of hydatids, of different sizes and in various states, and another very large one, apparently communicating with the gall- bladder, was filled with a congeries of hundreds of small hydatids and innumerable broken fragments, with a large quantity of soft, broken-down biliary concretions, the whole of the contents being deeply stained with bile. One cyst encroached upon and was insinuated into the substance of the spleen, while a few smaller hydatids had apparently found their way amongst the fibres of the diaphragm, and occupied the lower part of the mediastinum. The kidneys were healthy in structure ; but the right was in a great degree absorbed, owing to the excessively distended state of its pelvis caused by the obstruction of the ureter. The bladder contained about haK a pint of urine. The small intestines were found occupying the central part of the diseased mass ; they had evidently been the seat of recent peritonitis,- for wherever former chronic diseases had left them free, which was over a large part of their extent, they were now connected together by long bands of yellow friable lymph; there were also many flocculent tufts of fibrinous matter hanging about these portions of the peritoneum, the evident remains of former inflammation. The lungs were most exceedingly compressed, for the contents of the abdomen actually reached the second rib. In this case, then, we have a distinct history of the disease having existed in its most characteristic form for a period little short of ten years, during which time comparatively little general derangement had been experienced; indeed, under the most un- favorable circumstances, this young man had continued to perform the avoca,tions of life, with some interruptions, tiU within a few months of liis death. It seems probable, from all that can be gathered in this case, that the first development of the hydatids was in connexion with the liver j that for a period of considerable, though uncertain duration, ACEPHALOCTST HYDATIDS. 35 the disease had been quite unobserved ; and perhaps the attention was first called to its existence when some escape had taken place from the original seat^ and probably the inflammatory action thus set up had produced the illness for which he first sought admission into the hospital. The hydatids, escaping from their original seat, soon enlarged, so as to be plainly felt over the whole abdomen, as round, well-defined, elastic tumours, although he clearly stated that nine weeks previously he had discerned nothing but the enlarge- ment in the right hypochondrium. The hydatids thus poured out became fijced by inflammation in the various parts of the abdomen where they first lodged, and, according as they were single, or capable of multipKcation, they remained either like simple sacs — as in one case, on the right side of the abdomen, was very well marked — or they became the source of those congeries of hydatids which were found in several parts ; and the whole of them, owing to the repeated processes of inflammatory action to which they had given rise in the omentum and peritoneum, had changed their distinct elastic character for the more hard, lobulated, botryoidal substance discoverable by examination on his last admission. It was quite evident that the immediate cause of death was an extensive but accidental inflammation of the peritoneum, chiefly in those parts, amidst the convolutions of the small intestines, which had escaped the effects of chronic attacks and the gluing of adhesive inflamma- tion, but it is very greatly to be doubted whether the disease in this case had not advanced almost to its natural or necessary termination, seeing that it had already greatly encroached upon the thorax, and compressed the lungs to such a degree that certainly these organs were no longer able to admit one fourth of the air requisite for the healthful discharge of the function of respiration. There is one point deserving of remark in this and the two pre- ceding cases. In each of them, but particularly the two last, it would appear probable, as I have said, that the hydatids were at first confined to the Hver, but that, from some cause, they became diffused into the abdominal cavity; and yet it is observable that none of these bodies seem to have effected a lodgment, or to have been developed amongst the duplications of the mesentery and the convolutions of the intestines, and thus they have offered com- paratively little interference to the peristaltic motions and the general functions of the alimentary canal. It is probable that the 36 ON ABDOMINAL TUMOUKS. immediate cause of this immunity is the close apposition of the con- volutions, and the tendency which the intestinal motions may have to propel the little bodies forward, but in the pelvis, particiilarly behind the bladder, where a good opportunity of lodgment is afforded, we often meet with the hydatid cysts. Case 4. — Tumour of the abdomen supposed to depend on the presence of hydatids. — E — , set. 42, a weaver, was admitted into the hospital, April 4th, 183 a, on account of a great enlarge- ment of the abdomen, under the care of Dr. Back, who afforded me an opportunity of examining the tumour very carefully. It appeared that the swelling was of a very irregulai character, occupying the upper part of the abdomen, and that just below each hypochon- drium a round, soft, and elastic projection was discoverable. The projection on the right side was the larger, and proceeded from im- mediately below the margin of the ribs, and, though it could not be traced decidedly under them, might well be supposed to arise froto the liver. According to the statement of the patient, these two had been preceded ,by one or two nearer to the centre, and towards the umbilicus, which had appeared to disperse and move a little more to the right ; but statements of this kind are always so doubtful, that little confidence can be placed in them. There was an umbi- lical hernia, of the size of a small egg, and several enlarged sub- cutaneous veins were seen passing longitudinally up the abdomen. In a sketch I made, a liae, passing somewhat irregularly across the body, haK way between the umbilicus and the pubes, had the whole tumour above it. He stated that, occasionally, when he neglected his bowels, his ancles swelled, but otherwise they did not. The motions were rather pale, and the urine high coloured. His own statement of the progress of the disease was, that about six years before he had a severe illness, which he believed to be scarlatina, and at that time his abdomen was enlarged. After about three months of active treatment, he became better ; and though never quite well, he continued ia tolerable health till three years ago, when his abdomen swelled, and a year after he first perceived the unequal tumours of which the swelling is now composed. He has never been decidedly iH in his feelings, nor has he been jaundiced. His eyes are clear and bright, and he has no pain on pressure of the abdomen, but the enlargement is such as to prevent his getting into the loom, on wliich he has always depended for his livelihood. ACEPHALOCTST HYDATIDS. 37 The extent of this irregular and lobulated tumescence, its being almost confined to the upper part of the abdomen, and the absence of that obvious fluctuation which could not fail to be present were so large an increase of the size to depend on fluid, distinguished this case from ascites, and its slow progress, together with the sKghtness of the constitutional derangement, rendered it very improbable that it should be a malignant growth. The inference therefore is, that it is a case of hydatids, which has now been at least three years in its progress. Case 5. — Hydatid cyst connected with the liver. Death from suppuration of the sac and its consequences. — Sarah T — , set. 42, admitted into Guy's Hospital, March 35th, 1829, ra-ther a bulky woman, with a dark saUow complexion. She states that, during the last twelve years, she has been at least twelve times the subject of jaundice; that about six weeks ago she became again suddenly jaun- diced, and continued so for ten days, the stools being perfectly white, and the iirine bilious. Three weeks ago, when the jaundice had gone off, she suffered a severe rigor, of four hours' continuance, and has not since recovered. At present, her pulse is 84, and sharp; tongue moist, but covered with a brown fur. There is great appearance of prostration, the bowels are relaxed, and the stools of a very dark colour. There is a tumour at the pit of the stopiach, extending almost to the umbilicus, tender on pressure, elastic to the feel, and appearing to have a solid base. This tumour she says has been observed for three or four years, appearing larger or smaller, according to the degree of distension of the stomach. The symptoms went on increasing ; the sickness became more urgent ; the tongue more dry and red at the edges ; the abdomen more tender. On the 30th, she passed blood, by stool, two or three times, and falling into a state of insensibility, remained so about twenty-four hours, when she died. Sectio cadaveris. — The tumour was very evident, projecting at the scrobiculus cordis. There was a considerable accumulation of yellow adipose matter in the integuments. The parietes of the abdomen were attached very firmly by old adhesions to the tumour, which occupied chiefly the right lobe of the liver; the tumour was of a membranous appearance and vascular, and contained nearly a washhand-basin full of hydatids, of aU sizes, from that of a Trench walnut to a pea, but chiefly of about the size of a hazel-nut. The 38 ON ABDOMINAL TUMOURS. greater number were burst and opaquBj but many retained their globular form. The fluid in which they were closely impacted was puriform^ and the parietes of the large cavity were lined internally with a layer of thick pus-like matter, with slireds and cakes of a cheesy substance, adliering closely. The cyst itseK, owing to the sup- puration that was going on, had assumed a worm-eaten appearance. The liver seemed healthy, but was thrown out of its shape by the large cyst, which had likewise encroached upon the thorax.. The gaU-bladder contained about an ounce and a half of yellow fluid, almost entirely mucus, with a slight bilious tinge. The whole peritoneal surface of the abdomen showed marks of severe recent in- flammation, having on it shreds of yellow lymph and a considerable quantity of puriform serum. The intestines were highly vas- cular. With regard to the hydatids themselves, they differed in no respect from what have been abeady described ; many of them had a num- ber of small holes within them, and some of them presented that peculiar appearance of the inner surface which resembles a heap of transparent granulations arising from their inner surface, such as is represented in Kg. 13. In this case there can be no doubt that the irritation produced in the system by the unhealthy suppuration going on in the cyst, and afterwards the diffused inflammation of the peritoneum, were the immediate causes of death. The strong adhesions which subsisted between the cyst and the parietes suggest the probabiHty that, had this cavity been evacuated by an operation before the inflammation had been set up, the result might possibly have been favorable. But the time when such an operation could have been useful must have been long antecedent to her admission into the hospital, before her system had suffered from the slow suppuration of the sac, and still more, before this general peritoneal inflammation was set up, which, from the actively vascular appearance of the tumour, was, no doubt, a consequence of the local disease. Case 6. — Hydatid cysts in the liver ossified. — ^Lydia S — was admitted into Guy's Hospital, October 8th, 18 13, labouring under slight jaundice and mania. It appeared that constipation of the bowels, attended with sickness and pain, had occurred about ten days before, and that two or three days after jaundice came on, ACEPHALOCYST HYDATIDS. 39 with occasional derangement of the intellect^ which had been con- stant for the last two days. She frequently lay in a state of insensibility, approaching to coma; at other times she was raving in mania; her motions were very dark. She died on the 1 6th. The liver was found to contain hydatid cysts, of which one, about the size of an orange, was completely ossified tliroughout more than haK its extent ; and there were two or three smaller ones imbedded in the liver, which were not larger than a pea, but were also ossified, and aU of them were fiUed with the remnants of hydatids pressed together, and in some parts the convoluted laminae were capable of being separated and unroUed. The dura mater was in tliis case spotted over its whole internal surface with a great number of bloody points from ruptured vessels. In each of the two following cases the only hydatid cyst which was discovered had developed itself in the space between the bladder and the rectum. Case 7. — Tumour in the pubic region from, an liydatiA cyst sittia' ted hehind the bladder. — ^W. S — , set. 54, was admitted into Guy's Hospital, labouring under serous effusion, with dyspnoea, and coagu- lable urine. He died after remaining in the hospital some weeks ; and on examining the body a tumour was found, about the size of a very large orange, situated between the bladder and the rectum, so that it had pushed the bladder forwards, and, together with the bladder, presented a projection which was quite obvious before the abdomen was laid open. This proved to be a cyst, containing a number of hydatids about the size of marbles and smaller, with a large collection of the broken remnants of other hydatids. The cyst was in some parts nearly a quarter of an inch in thickness, and in- ternally many patches of bony matter had been deposited ; grasped in the hand it gave, when emptied, the elastic feel of an India- rubber bottle. The mucous membrane of the bladder was quite free from any inflammation. The rectum was a little irritated. The kidneys were rather small, their tunics adhered firmly, their ex- ternal surface was coarse and granulated, and they were not easily broken down by pressure. Another case had previously come to my knowledge of a very similar character; and as I was present at the post-mortem ex- 40 ON ABDOMINAL TUMOURS. amination/ and I believe the preparation is in the Museum at Guy's, I will state the facts nearly as I collected them. Case 8. — Tum.our in the pubic region from an hydatid cyst situated lehind the bladder. — The patient, who had been labouring under other disease, complained of the difficulty he had in retaining his water; and when an examination was made, it appeared that the urine was continually passing away, and that a tumour bearing all the characteristics of a distended bladder presented itseK at the pubic region. This at once suggested the idea that the patient was suffering from retention of urine produced by enlarged prostate or some such mechanical cause. A catheter was introduced by a skilful surgeon, and a few drachms of perfectly healthy urine drawn off, without producing any diminution in the bulk of the tumour. As it was still supposed that urine was retained, more than one medical man attempted to draw it off, and at length the catheter became obstructed by the passing of small hydatids. When this was dis- covered a sucking-pump was apphed to the catheter, and thus a considerable quantity of the debris of hydatids were removed ; how- ever, the symptoms of this disease remained, his other complaints increased, and ultimately the patient died. Sectio cadaveris. — The tumour which appeared on opening the body, filling the whole pubic region, proved to be a large hydatid cyst, attached to the posterior part and the fundus of the bladder, and pressing so much forwards as to prevent entirely the bladder from being filled with urine ; and this was the source at once of the tumour and of the constant escape of urine. The bladder itseK was quite healthy, nor had the catheter passed through it to reach hydatid cyst, but on the contrary, had passed by an opening from the urethra behind the bladder. The cyst which contained the hydatids was in some parts about one sixth of an inch in thickness, and irregularly converted into a cartilaginous substance, with a rough internal surface. It contained at least a quart of the shreds of burst hydatids, with a few of the size of small marbles, which were quite perfect and transparent, the whole contents being of the thickness and consistence of a paste. The tumour made pressure on the orifices of both the ureters, which were consequently very much distended with urine ; and the pressure which had been made upon the kidneys by the fulness of the pelves had produced a very extensive absorption of the substance of both. The fluid contained ACEPHALOCYST HYDATIDS. 41 in the meters was puriformj and there were some small clots of blood in the infundibula. In cases of so doubtful a kind we might derive diagnostic marks from the history of the tumour, if the patient had sufficient inteUi- geuce to assist us in the inquiry ; so likewise from the feel of it, which would probably be harder or less regular than the bladder, but on this no perfect reliance could be placed. The character of the urine which is drawn off would almost be sufficient to decide the question, for if the urine be retained any time in the bladder, it generally acquires a much darker hue, and all its sensible pro- perties at once bespeak that it has been long secreted and concen- trated or altered by retention. Case 9. — Hydatid cyst connected with the liver, emptied by para- centesis. — M. H — was admitted into Guy's Hospital with a large fluctuating tumour of the abdomen, occupying apparently almost the whole cavity. As she suffered much, both from constitutional irritation and from the pressure of this tumour. Dr. Chohnely, whose patient she was, thought it right to draw off the fluid by tapping, and a very large quantity of purulent fluid, mingled with shreds and portions of hydatids, came away. It was now discovered that she was pregnant, a circumstance which she had concealed. By perfect quiet she recovered somewhat after the operation, but, after two or three weeks, miscarried. Her bowels became obstinately costive, she had frequent vomiting, became deeply jaundiced, was unable to take any food, and died completely exhausted. Sectio cadaveris. — ^A large cyst was found arising from the Hver, descending quite to the pubes, adhering to the parietes of the abdomen on the whole of the right side and making pressure on the kidney. This cyst arose as high as the diaphragm, and had pushed all the intestines back into the left lumbar and iliac spaces, so that they did not occupy one third of the abdominal cavity ; the stomach had likewise been completely displaced by its pressure. This cyst still contained about three pints of greenish-yeUow pus, and a large quantity of the skins and remains of hydatids, but not one could be found in its entire or globular form. The cyst itself, which was of considerable thickness, was internally undergoing a process of suppurative softening, and was pulpy and irregular on its surface. The upper part of it near the diaphragm, where it 42 ON ABDOMIINAL TUMOUES. seemed to have originated in tlie substance of the liver, contained a curd-like matter, almost cheesy in its consistence, apparently a mass of fibrine, pus, and the shreds of hydatids. Exactly in the seat of a femoral hernia there was a small tumour, of the size of two large marbles, which proved to be a cyst, con- taining a number of hydatids. The liver was soft throughout, and the left lobe very large, extending far towards the left side. The gaU-bladder was much distended with bright green bile, and the obstruction to the passage down the ducts had probably been the cause of the deep jaundice which had occurred before death. The right kidney was to a great extent absorbed by the pressure of the tumour, and the pelvis much enlarged, containing some calculi. The left kidney was unusually large. The uterus was large, and imperfectly con- tracted ; the ovaries were unhealthy, with vesicles. In this case I am unable to say how long the disease had ex- isted, but there could be no doubt, from the great extent of the cyst, and what we know of the general progress of such cases, that many years had elapsed ; and as it had gradually encroached upon the right lobe of the liver and the liver and the right kidney, it was curious to observe the apparent compensation which had been established by the unusual increase of the left lobe of the liver and of the left kidney. In this case the inflammation and suppuration set up in the cyst seems to have been quite destructive of the organization and the validity of the hydatids, none of which were found in their globular arid unbroken state. Case io. — H'l/datid, connected, with the liver emptied, by paracen- tesis, with success. — A young woman was admitted into Guy's Hos- pital, in December, 1838, under the care of Mr. Key, with an elastic swelling occupying almost the whole scrobiculus cordis, and incUn- ing rather to the left side ; it was not the least discoloured, and gave an evident sense of fluctuation. The swelling was divided into two lobes, of which that to the left was the largest, and the fluid seemed to pass from one to the other. Her health did not suffer ; but of late the tumour had become rather painful, and, by its bulk, had interfered considerably with her comfort, having enlarged much more rapidly than when first perceived. She had been in the hos- pital two years before, when Mr. Key attempted without success to ACEPHALOCYST HYDATIDS. 43 make an opening gradually by a caustic issue ; he now tliouglit it right to employ a small trochar ; andj accordingly, on the a2d of December, four pints of a perfectly limpid fluid, with little or no smell, nor any appearance of lymph, shreds, or flocculent matter were drawn off. The operation afforded her great ease, and was followed by no symptoms of inflammation. Por a time the cyst appeared to fill gradually ; she lost her colour, and had frequent tendency to faint, and afterwards a little diarrhoea came on, which, however, was easily checked. February 5th. — The tumour, though it has not entirely disap- peared, is much less than before the operation, and presents no un- equal or lobulated swelling, as it formerly did, but gives a slight appearance of fulness to the scrobiculus cordis. Towards the end of the month she left the hospital : and I have heard from Mr. Key, within these few days, that she remains per- fectly well, has since married, and enjoys excellent health, without any rcaccumulation having taken place. I examined the fluid very carefully, by means of Dr. Roget^s microscope; but could detect nothing like minute hydatids, or other foreign matter. Mr. Key also allowed me to put a portion of it into the hands of Dr. Bostock, who was kind enough to undertake its analysis ; and I shall give the communication I received from him a few days ago; observing, that, in one point, his account differs from what I find stated in my notes ; the fluid having appa- rently lost a little of its pure and limpid character, when he under- took the investigation. " My dear Sir, — I have revised my note-book, which contains the account of the experiments that were performed on the fluid from the hydatid, in. December, 1838; and I have extracted what appear to be the most remarkable or characteristic circumstances respecting it. If you require any further explanation, on any of the points connected with the experiments, I shall be most happy to fuinish you with it, as far as lies in my power. "Most truly yours, J. Bostock. "Putney Heath; Aug. 28th, 1837. " The fluid was homogeneous, somewhat opaque, of a light-brown colour; it had a slight but peculiar acrid odour, and a specific gravity of 1008. It scarcely affected the most delicate test-papers; 44 ON ABDOMINAL TUMOURS. the uncombined alkali, if any, being in so minute a quantity, tbat one part of the acetic acid of the Pharmacopoeia, added to loo parts of the fluid, caused it to redden litmus. There was, however, a perceptible, although very shght, indication of alkalescence, when it was evaporated to one tenth of its bulk ; a portion of it, also, became sHghtly alkaline, after being exposed for about three weeks to the atmosphere ; at the same time, it had acquired a sharp, acrid odour, and was covered with a very thin, brown film ; the fluid was somewhat more opaque and coloured, but there was no sediment. It was not affected by the boiling temperature ; and the reagents for albumen indicated the presence of this substance in a minute quan- tity only. When evaporated by a heat not exceeding 150°, a resi- duum was obtained of i"a5 per cent., which evidently consisted, for the most part, of muriate of soda. Along with this there was a portion of an animal substance ; which was soluble both in water and in alcohol, and which I should characterise as nearly related to the substance which forms the specific ingredient in the serosity of the blood. There were also indications of the presence of sulphuric acid and potash, but each of them in very minate quantity. No Hme could be detected in it. It appears, therefore, that this fluid exhibited some decided peculiarities, when compared with other fluids which may be presumed to have a similar origin: i. The absence, or at least the very minute quantity, of uncombined alkali. 3. The small quantity of albumen, compared with the total amount of solid contents. 3. The presence of a considerable quan- tity of extractive matter; and, 4. The large proportion of the muriate of soda which it contained. Tlie composition of the fluid may be estimated as foUows, in 1000 parts : "Water ....... 987*3 Extractive, with a trace of albumen . . . 4- Muriate of soda, with, minute quantities of sulphuric acid and potash ...... 8'5 lOOO'O Case ii. — Eydatiis in the spleen bursting into the ahdomen, and causing death very speedily. — In the month of February, i8ai, a patient in Guy's Hospital, who had been under the care of Dr. Back, with obvious hepatic derangement, and a large tumour in the abdomen, became suddenly most alarmingly ill, and died within ACEPHALOCrST HYDATIDS. 45 half an hour. On a post-mortem examination, it appeared that the immediate cause of death was the bursting of a large hydatid in the spleen, by which at least a pint of limpid fluid had been effused into the abdomen. The appearance of this large hydatid was rather peculiar ; as it entered so much into the substance of the spleen, that over nearly half the cyst that viscus formed an external coat, gradually dying away into a tough leather-like substance, which formed the more protruding part of the membrane covering the hydatid, and which, in the present case, seemed to consist of a thickened portion of the peritoneum. Within this was situated the true hydatid cyst, like a lining of soft leather, having its external surface marked by numerous projections, which fitted into httle cavities in the spleen — an appearance which probably depended on the cellular structure of the viscus which the hydatid occupied. The internal surface was smooth, as if covered with a thin trans- parent membrane. In the Uver there was an hydatid, of the same size as that of the spleen; and there were smaller cysts in the kidneys. These hydatids were, as far as I remember — and the notes I made at the time do not contradict it — each formed of a single unproductive cyst. Case \%. — Hydatid of the liver, suppurating and bursting into the abdomen, causing immediate death. — In the year 1813, when I was attending the practice of the Bishop's-Coujt Dispensary, a very interesting case occurred, the hydatids taken from which I had a long time in my possession. Not being able to fimd the notes which I took on the occasion, I have applied to my excellent friend Dr. Laird, who during many years discharged the duties of physi- cian to the iastitution at which the case occurred, and those of physician to Guy's Hospital, with singular dihgence and success ; and I shall give the case in his own words. "Bognor, August 30th, 1837. "I perfectly remember the patient to whose case you refer; and the interest you took iu the examination, which you had the kind- ness to undertake at my request. But I think his death must have occurred in 1813 ; rather than in 18 14, as you suppose. " The patient was about five or six and twenty years of age, and was employed in the shop of Messrs. Laurie and Whittle, the map- seUers in Fleet Street, contiguous to whose premises he had fixed 46 ON ABDOMINAL TUM0T3RS. himself, on the west side of Fetter Lane. He siiffered under obvious inflammation of the liver, attended with jaundice, indicat- ing that the parenchymatous substance of the liver was affected. He was, at first, so much benefited by what was done for him, that I hoped a favorable issue in the case ; but a visit which he most imprudently made to some friends at Yauxhall was immediately fol- lowed by a sad aggravation of his complaint ; which then rapidly passed to its fatal termination in a few weeks, not more than two or three, to the best of my recollection. His death took place sud- denly, on his getting out of bed ; and I was the more anxious to know the immediate cause of death, because I had previously found, by a post-mortem examination, that the bursting of hepatic abscess had been followed by immediate failure of the vital energies. You wiU doubtless remember, in our Dispensary case, that you were obliged to remove much purulent effusion from between the folds of the intestines, I think to the amount of two or three pints, in order to follow your inquiry; and that a great number of small hydatids were found floating in the fluid. The source of this effu- sion you found in a ruptured cyst on the convex surface of the right lobe, the capacity of which must have been very great. In the left lobe there were several small independent abscesses ; but I do not remember any appearance of hydatid origin in them. There was no appearance of recent inflammation in the peritoneum, death having so quickly followed the rupture of the cyst; the other viscera of the abdomen were, I think, in a healthy condition, as were those of the thorax." In these two cases we find the sudden rupture of an hydatid cyst causing immediate death. There is every reason to believe, as I have before stated, that, under certain circumstances, the rupture of the cyst and the escape of the hydatid into the abdominal cavity is not followed by a fatal result ; but where it happens suddenly, and by a large opening, we cannot but apprehend either immediate death or the occurrence of peritoneal inflammation. It is, how- ever, no doubt, where suppuration has aheady gone on within the cyst, as in the last case, that we are to expect the more dangerous effects, both from the previous state of the constitution and from the condition of the part, as well as from the more irritating character of the fluid thrown into the abdominal cavity. In the following case ACEPHALOCYST HYDATIDS. 47 it is beKeved that a large cyst burst suddenly into the abdomen, without being followed by a fatal result. Case 13. — Supposed hydatid of the liver bursting into the cavity of the abdomen. — June 13th, 1836. , a boy, cet. 14 years, was admitted into Barnabas Ward, under Dr. Addison, with the chest quite deformed by the protrusion of the lower ribs of the right side ; but more particularly by the entire displacement of the false ribs, affording a sense of elasticity and almost of fluctuation in that part. At the same time the liver was pushed below its usual position, so that its margin was to be felt far down in the abdomen, below the umbilicus. It appeared most probable from the projecting form of the tumour — from the way in which the false ribs were raised, and the degree in which, at the same time, the liver was pushed down, while the respiration was quite natural on that side of the chest — that the disease was situated below the diaphragm. At the same time, the absence of many symptoms and the want of any decided tendency to jaundice led to a belief that it was not an abscess of the liver ; and it was therefore inferred as highly probable that the enlargement arose from an hydatid cyst situated in the convex surface of that organ. His condition scarcely underwent any change while he remained in the hospital ; and after staying about a couple of months he left it, and- returned to his friends, who were iii circumstances to main- tain him comfortably. In the latter part of August he suffered from heemorrhage, after having a tooth drawn ; and while recover- ing from this, in the beginning of October, he was attacked with severe paiu in the swelling of the right side, and was very ill for several days, but recovered from that attack ; and in the middle of the same month he applied as an out-patient at the hospital. Till the a5th of October the fluctuation remained the same, and the swelling increased a Kttle ; but on rising from his bed on that morning he had a feeling of faintness, with a sudden sinking and a peculiar motion, as he stated, in the tumour, which from that time greatly diminished in bulk, giving the conviction to those who had seen him most, that the contents of the supposed hydatid tumour had escaped into the abdomen, without, however, producing any unpleasant symptom, except, perhaps, a little sickness at the stomach. 48 ON ABDOMINAL TUMOUKS. October 2,6th.. — I saw him at his own house : the tumour had subsided; but there was evident fulness and fluctuation at the pubic region and below the umbilicus. He had taken two or three doses of calomel, followed by sulphate of magnesia; and had passed a tolerably healthy loose dejection. He had experienced a little pain that afternoon in the lower part of the abdomen, but very httle tenderness. His cliief pain was in the act of passing urine, as if from the contraction of the bladder. Pulse about 140, sharp ; tongue slightly furred ; countenance flushed. 27th. — No bad symptoms ; bowels freely opened by the calomel, of which he had taken two grains three times a day,_ since the 25th. Pulse 120; no sickness; no tension of the abdomen. aSth. — I examined the abdomen very carefully, and found the margin of the Uver much raised above its former position, descend- ing only half-way to the umbilicus, and not apparently adhering to the diaphragm. The fluctuation at the lower part of the abdomen was diminished; there was neither tenderness nor pain. Bowels well open ; he had scarcely moved from the same recumbent posi- tion, and had eaten nothing but a little gruel each day. Pulse 96. The ribs still bulged a little on the right side. Rep. Pil. Hydrarg., gr. iij. Ext. Conii, gr. iij, bis die. Mr. King, who observed this case very attentively from the first, has just now informed me that he soon began to manifest signs of amendment, to sit up, and to take food ; and not long after, it was evident that the fluid in the peritoneum was decreasing in quantity. At that time, the displacement of the ribs was still great, and there was a considerable lateral curvature of the spinal column. He continued for some months in a very emaciated state. His pre- sent condition (September 7th, 1837), Mr. King says, is decidedly good. He is by no means thin, has some natural colour ; the spine is straight ; the abdomen not full, and the thorax is almost sym- metrical. He works for a printer ; and has no complaint but that of a painful weakness in the left knee, which, as well as the right, seems to fall inwards, more than it has been wont to do, If, instead of discharging into the peritoneal sac, the hydatids fortunately escape from the body, the event is occasionally favor- able ; though, as the organs through which the hydatids pass are ACEPHALOCYST HYDATIDS. 49 liable to be inflamed and irritated, such a discharge may, at last, lead but to a more protracted fatal disease. In the first volume of this work a case is related, which occurred under my care in the clinical ward, where an hydatid cyst in the Hver opened into the lung ; and a considerable number of the hydatids, mingled with bile, were evacuated, in their collapsed state, by expectoration; the patient ultimately doing quite well, and leaving the hospital without any obvious remnant of the dis- ease. Another case, almost precisely similar, has been stated to me by Dr. Babington, as occurring many years ago, under his observation, in the practice of his father. In that case it likewise happened to a young woman, who, after suffering a considerable time from symptoms of very serious hepatic derangement, with cough, began to ex- pectorate hydatids, which she brought up to the number of several hundreds, and many of them unbroken ; they were yeUow, and deeply tinged with bile, leaving no doubt of their hepatic origin. After going on for some time, this expectoration ceased, and the young woman recovered completely. Case 14. — Hydatids in the liver, supposed to have passed off by the intestines. — In the spring of the year 1834, I was consulted by a shoemaker, about fifty years of age, whose abdomen was enlarged, almost Uke that of a man labouring under ascites, and the superficial veins were distended to a great size. On examining the abdomen more attentively with the hand, it appeared that a tumour, fixed in the right hypochondrium, occupied the whole of the right side of the abdomen, passing considerably beyond the hnea alba, so as to encroach upon the left side also. To all appearance, this tumour was connected with the liver ; it was elastic, and pretty smooth, though it varied in its hardness in different parts. He represented himseK as having never possessed a very strong con- stitution, but having lived so temperate a hfe, that he was never but once intoxicated ; he had always been able to work hard at his trade. About a year and a half ago, he had begun to feel out of health, with lassitude and drowsiness. About a year ago, while walking along, he was suddenly seized with a very acute pain in the right hypochondriac region ; which lasted, in spite of remedies, for a few days, and then subsided gradually, leaving a duU, aching 4 50 ON ABDOMINAL TUMOURS. pain; and at that time he first perceived the enlargement^ which had continued to increase to the present time, when his general health was beginning to suffer, and his respiration to be impeded. He was put upon a course of taraxacupi and soda, and the camphorated mercurial ointment rubbed upon the abdomen tiU the gums were affected. In the month of July, three or four months after his fiist application, he was seized with a fit of vomit- ing, in which he brought up haK a pint of what he called " matter ;" and shortly after, passed, by stool, a large quantity of what, from his description, could have been nothing but hydatids : some were only skins or cysts, but others were fuU and round. This evacuation was attended with an immediate subsidence of the tumour ; and when I saw him, on the 8th of August, the swelling had not increased again, and was very inconsiderable in comparison with what it was at first, though it was stUl to be paartially detected. It occasionally happens that hydatid cysts approach so near the surface, that, inflammation taking place, they discharge themselves externally ; the result of which may be favorable or not, according to circumstances. I remember, some years ago, being taken by Dr. Stroud to visit a female, in whom, judging from her own minute account, this had taken place several years previously ; but though one cyst had probably discharged in this way, her abdomen was still the seat of tumours, which had aU the characters of hydatid cysts. The following case, however, in which there can be no doubt of the fact, was communicated to me by Dr. Babingtonj and I shall state it in his own words. Case i^- — Hydatid cyst in the liver, discharging Itself exter- nally J and death from hcemorrhage. — " It was during an attend- ance, two and a half years ago, on some other patient, with my friend, Mr. May, of Bow Lane, that he requested me to see Mrs. E — , a poor woman, whom he represented as labouring under visceral disease of a remarkable character. I found her in bed, much weakened by sickness and dyspepsia. Her skin was of a deep-yeUow hue; and her secretions sufficiently demonstrated an obstruction to the natural course of the bile. This state of jaundice was described to have' existed for many months. On examining the abdomen, a hard tumour, irregular in figure, and rising into roundish masses, was felt on the right ride, issuing from beneath ACEPHALOCTST HYDATIDS. 51 the ribs, and extending to the pit of the stomach. Thus there seemed every reason for supposing an enlargement of the liver; but its precise boundaries could not easily be traced, in consequence of a further enlargement of the rest of the abdomen, dependent on an advanced state of pregnancy. In the tumour first mentioned there was no fluctuation. The whole presented a firm, solid growth, free from pain ; and the symptoms to which its presence gave rise, were such as might proceed from any cause of hepatic obstruction. From time to time I learned from Mr. May the state of his patient. She gave birth to a healthy child ; which she was able to suckle, notwithstanding her permanently jaundiced condition ; and I may remark, by the way, that neither the skin of the child nor the mother's mUk was in the slightest degree tinged with bile. Her general health must, indeed, have materially improved; for she again became pregnant, went her full time, and bore a living infant. After her first confinement, when I took an opportunity of examin- ing her, the tumour was more distinct and larger than before ; and I was subsequently informed that it continued to increase in size. In the beginning of December last, Mr. May again requested me to see Mrs. R — ; and informed me, that, a day or two before, the parietes of the abdomen had spontaneously given way, and an enormous discharge of fluid had issued from the aperture. On removing a poultice and bandage, which had been subsequently applied, I found an ulcerated opening, rather less than an inch in length, situated immediately below the umbiKcus. From this opening a portion of what, at first view, bore a general resemblance to intes- tine, protruded about half an inch. On closer examination, its col- lapsed and puckered form, its total insensibility, and its greater thickness, led to a belief that it was the empty cyst of an hydatid ; and, by gradual and gentle traction, I succeeded in bringing it away. The part which passed last was thinner, and more gelatinous in appearance, than the rest; and was torn in coming out. The whole was nearly as large as a bullock's bladder; and would pro- bably have contained, previously to its rupture, a gallon and a half of fluid. No pain was felt during its abstraction ; and the patient expressed herself as relieved by its removal. We saw her on the following day, and found that she had passed a good night. A second cyst now presented itself at the aperture ; but as it seemed, on gentle traction, to be adherent, no force was used to withdraw it. The bandage with which the abdomen had been bound was soaked 52 ON ABDOMINAL TUMOURS. by a constant drainage of serous fluid. On the day following my secondvisit, blood, instead of serum^begantomakeits appearance; and this was accompanied by such a degree of prostration, rigor, and faint- ness, as led to the apprehension that some serious internal haemor- rhage was taking place. This was verified, as the day advanced, by more alarming seizures of syncope ; and one of these proved fatal, in the course of the night. That hydatids had caused all the mis- chief in this case, was demonstrated during life ; and an examina- tion, after death, proved that one of these had formed in the interior of the liver, near its under surface ; forcing, as it grew, the substance of that organ upwards and forwards, and its posterior peritoneal coat backwards. A large cavity, lined with a false mem- brane, and filled with grumous blood, was found thus bounded. A second hydatid, the cyst of which remained, seemed to have occupied a portion of the same cavity ; and a third, about the size of a walnut, appeared on the convex surface of the right lobe. Mr. Eng, of Guy's Hospital, has, I understand, succeeded in find- ing the mouth pf an hepatic vein, whence the fatal haemorrhage had its source. Mrs. E — 's age was about thirty-five. The tumour which caused her death was first observed by Mr. May, in March, 1833 ; and she died on the 9th of December, 1836." I have thus brought together fifteen cases, occurring chiefly under my own observation ; in most of which the existence of hydatids, in immediate connexion with the cavity of the abdomen, has been placed beyond a doubt, either by their discharge during hfe, or by examination after death ; and they may be considered as forming a series, which includes a fair view, not only of the general history, progress, and result of such cases, but Kkewise of most of the par- ticular facts, occurrences, and accidents which may be expected to present themselves to the practitioner during their course. The liistory of this disease, when viewed attentively, is curious and interesting. The little hydatid first introduced, or generated in the structure of the human body, gradually increases in size ; pro- ducing by its pressure, displacement and absorption of the surround- ing parts ; and leading to the deposit of lymph, and the gradual formation of a cyst, in which it becomes, as it were, insulated, interfering only by its bulk with the processes of the system. In some instances, it would appear that the principle of reproduction is not possessed by the individual hydatid; but, more generally, an ACEPHALOCYST HYDATIDS. 53 indefinite multiplication takes place ; and the new progeny may be traced arising again from the internal surface of many of the secondary and successive hydatids, and gradually increasing in size tiU they burst the cysts in which they have been generated. It is, however, remarkable, that while some, which have arrived at a very considerable size, still only appear to be producing the smallest offsets, others, when they seem but just to have separated from the internal surface of the parent, are pregnant with a new progeny, bearing so large a proportion to the whole dimensions of this young parent cyst, that they are already prepared to dilate it, or to escape from it, and mingle with those which float in the fluid contained within the older hydatid. The first parent cyst, which now forms a hning to the cavity it has made for itself in the tissues of the body, continues to increase ; but in vain can that increase be expected to keep pace with the in- ternal multiplication of its offspring, which, pressing upon each other, are ruptured ; and the fluid which escapes seems to form a pabulum for those which stiU retain entire the small degree of vitahty with which they are endowed. It must likewise undoubtedly happen, that some are ruptured by the enlargement of those within them, when they attain a considerable size ; but it is not very common to find those which have arrived even at a medium growth ready to give way, from the increase of their internal cysts ; the multiphca- tion generally taking place so rapidly, as to burst them before they arrive at that size. "We do not know how long the original hydatid, which forms the Hning to the whole cavity, is capable of existing, but probably for many years ; and, as long as it does exist, it seems to serve as a complete protection to the whole of its contents, from the action of the absorbents of the organ in which it is developed : it often increases very much in thickness and firmness, and seems connected only by the juxta-position of its external surface with the interior of the cyst of coagulable lymph or thickened membrane, which belongs properly to the body, and not to the hydatid. As soon as, from circumstances, the protecting hydatid dies, it separates from the cavity, curls itseK up, and falls down amongst the other debris ; then, probably, the absorbents first begin to act upon the fluid; but whether they ever act on the more solid parts of the semi-membranous cyst of the hydatid itself, may be doubted ; at all events, their action is very slow, so that the renmant of an hydatid, retaining aU its usual character, was found in one of the cases 54 ON ABDOMINAL TUMOURS. related above, which must have belonged to a cyst three or four times larger than the cavity in which it was discovered; showing, that it must have remained unacted upon by the absorbents, while the cavity was contracting in that degree, and while the proportionate quantity of fluid was being absorbed. The absorbents do, however, gradually take away almost every drop of the fluid ; reducing the contents of the cavity to a state of dryness, in which the original forms of the membranous structures become lost; and pressed together, and deprived of moisture, the mass assumes a paste-like, and ahnost cretaceous, consistence. I am inclined to believe, that as soon as the protecting cyst is separated from the cavity, there is no longer any security for the rest; for as the cavity contracts, which it does in proportion as the fluid is absorbed, it becomes a constantly opposing agency ; and as quickly as, by its own contrac- tion, or by the distension of the hydatids themselves, fresh hydatids are ruptured, the absorbents of the cavity take up the fluid ; and nothing but the close application of another hydatid cyst to the whole absorbing surface, which is obviously almost impossible, can put a stop to the work of destruction. With regard to the cyst in which the hydatid is placed, that un^ dergoes such changes as an adventitious structure, formed from the vessels of the parts by the irritation of a foreign body, and itself often well supplied with vessels, may be expected to exhibit ; and that it is capable, during some periods of the disease, of very active processes, may be inferred from the great vascularity sometimes observed ; as was particularly marked by the diffused pink colour in one of the active and healthy parent cysts mentioned in the exami- nation of the first case in this communication. Its vascularity is also marked by the occasional effusion of blood between the cyst and the hydatid ; mentioned, in one case, as discovered after death, and itself bearing part in the fatal termination of another case. Sup- puration, also, is not unfrequently established in the cyst; as is proved, by many cases, related above, to have taken place, as a source of great irritation to the system, and occasionally the more immediate cause of the fatal result. Morbid appearances are like- wise impressed upon the containing cyst by the presence of bUe, which has either found its way at once from the liver, or has been poured into the cavity by communication with the gall-bladder. Another alteration, which is very often observable in the cyst, is, a more or less perfect conversion of it, generally oi- partially, into ACEPHALOCyST HYDATIDS. 55 cartilaginous or bony matter, which must interfere considerably with its power of distending; and how far this, or any of the other changes, take place antecedently to the separation of the hydatid lining its walls, may be matter of doubt ; but certain it is, that some, at least, of these changes must necessarily lead to the derangement, if not to the disintegration, of the hydatid. Of the treatment of this disease I have little to say. While con- fined to one cyst, whether formed by a solitary hydatid, or by one which is productive, and therefore contains within it a number of others, I believe that an opening, or a puncture, offers the best chance of cure ; and if the cyst be solitaiy, it is not unlikely the result will be satisfactory. If, on the contrary, the cyst contain a great num- ber, much risk wiU be incurred, lest some of the excessively minute bodies should find their way into the peritoneal cavity ; where, in aU probability, though they might not produce any intense inflamma- tory action, they would gradually develope themselves and multiply. On the other hand, there is great danger in the existence of such a cyst, lest it should burst suddenly into the abdomen ; and then the extent of mischief is incalculable ; so that, supposing our diagnosis quite certain, there would be the greatest justification in performing the operation. As, however, our diagnosis in a single cyst is infi- nitely more diificult than when the disease becomes diffused, it will be always right to employ an exploring needle, such as has been recommended by Dr. Davies in cases of empyema, before an opening is made. Should the operation be performed, the most careful treatment must afterwards be adopted, to prevent any portion of the fluid, which will almost certainly be left behind in the cyst, from passing into the abdomen. In what way the pianctuiing of an hydatid cyst might be ex- pected to prove useful, is a question worth inquiry. If the cyst contain numerous hydatids, it wiE be no easy matter to make such an opening as would allow the larger of these bodies to escape, without too great a risk to the patient's Hfe ; but perhaps this might not be necessary to the success of the operation. I imagine one of the best results which could arise from the operation, would be the destruction of the parent or protecting cyst. Whether a simple puncture would effect that purpose, J cannot say ; but probably it would; more especially as, when a considerable portion of the fluid contents of the cavity was withdrawn, the cyst would be likely to 36 ON ABDOMINAL TTIMOUKS. fall in, and separate from the parietes of the cavity, and thus subject the whole contents to the influence of absorption ; but this result would be more certainly obtained, if a more extensive rent or separa- tion could be inflicted on the hydatid. In the cases which have been detailed, there are three instances of the external discharge of the hydatid, besides those discharges which have taken place by the in- testines and the lungs. Of these cases, one was spontaneous, and was followed by haemorrhage from the cyst, after the separation of the hydatid. In another case, suppuration was far advanced in the cyst, before recourse was had to the operation. In the third, the operation was performed upon an hydatid which proved apparently to be soHtary and unproductive, and a cure was effected. Here, probably, the cyst was destroyed; and being separated from the walls of the cavity, which were healthy, the absorbents acted as far as was necessary, while the cavity contracted. The chief good which it appears likely that medicine can effect, is to excite the action of the absorbents when the parent hydatid is dead or separated; for tiH that prehmiuary step is obtained, the absorbents may act upon the system, but are not likely to act upon the hydatid, or the fluid contained within it ; and it would be a legiti- mate object, in the administration of medicines, to destroy the life of the parent hydatid ; but, as yet, we know httle upon this point of treatment. Whether repeated doses of turpentine, or other diffusible substances, might have any effect, or whether the more local agency of electricity might be applied directly to the part affected, is a sub- ject of fair speculation ; though so little is at present known of the agents which are able to destroy the hydatids, that such propositions must be classed as unsupported conjectures ; and, amongst them, it might perhaps, be permitted to mention the assiduous apphcation of ice to the tumour, as calculated to lower the animal temperature locally, and thus interfere with one of the conditions on which pro- bably hydatid life depends, without at the same time inflicting such violence upon the containing cyst as is likely to induce suppuration, from which we have seen, in many of the foregoing cases, that very dangerous or fatal consequences will probably ensue. CHAPTEE III. OVARIAN TUMOURS. There are, imquestionably, no form of abdominal tumour, with the exception of that which is occasioned by the uterus in a state of pregnancy — ^if that natural enlargement deserves to be spoken of as a tumour — so frequent as those which arise from the uterine ap- pendages ; and which, as they often involve, and most frequently originate in, one or both of the ovaria, have acquired the name of ovarian tumours ; and, when accompanied by the accumulation of fluid which often takes place within them, the denomination of ovarian dropsy. At the same time, it is right to bear in mind, that the analogy between these and other forms of disease, usually denominated dropsies, is very slight. There are, perhaps, four distinct diseases which form pelvic tumours with fluid contents, and which are therefore spoken of as ovarian dropsies. The first presents itself as a simple bag, con- taining serum; whose external surface appears to possess aU the attributes of the peritoneum, attached to the surface of the ovary or some neighbouring part, and supplied by blood-vessels from the point whence it arises ; sometimes, sessile ; more frequently attached by a longer or shorter neck; generally single; but occasionally presenting the appearance of being composed of more than one cyst. (Pig. 1 8.) This simple cyst, with a long footstalk, is not of unfrequent occurrence ; and is sometimes congenital, or at least exists within a very few months after birth. The tumour is generally of small dimensions, from a size less than a pea, to that of an orange; and, though I have no case to adduce, it is not impro- bable that it occasionally attains to a considerable bulk. The sessile variety of the simple cyst often developes itseK in the broad 58 ON ABDOMINAL TUMOURS. ligament; and appears still more deoidedly placed beneath the natural fold of the peritoneum than the last variety^ so as appa- Kg. i8. rig. 1 8. Ovary and Fallopian tube, from which are seen arising three cystiform bodies, possibly the incipient state of the simple ovarian cyst. rently to involve ■within it the Pallopian tube ; which, however, is found passing round it, and not materially altered from its natural state, or slightly dilated, but not communicating with the cyst. Of this we have a specimen in the museum of Guy's (Kg. 19); Kg. 19. Fig. 19. A simple cyst in the broad ligament ; which is evidently unconnected with the ovary, as that organ is perfect. the ovary of that side being, at the same time, quite sound' and OVARIAN TUMOURS. 59 healthy. In another specimen (Kg. ao)^ where a simple cyst of the size of an orange appears in a similar maimer developed in the rig. 20. Fig. 20. A simple cyst, developed in the broad ligament of the uterus : the Fallopian tube, which is attached to it, has been laid open : it is doubtful whether this cyst may not depend on disease of the ovary itself, as that organ is not found in the preparation. The cyst, as preserved in the museum, is about four inches in its longest diameter. broad ligament of the uterus, having the Fallopian tube on its outside; no ovary is discoverable, and therefore it is doubtful whether the cyst is not the product of a diseased condition of the ovary itself. The second source of tumour containing fluid, connected with the uterine appendages, is found in a distended state of the Fallopian tube, which is not unfrequently seen obstructed and filled with serous fluid, so as to be much dilated, forming a pouch of con- siderable size, and often both of the Fallopian tubes are similarly affected. Whether, however, the dilatation is ever of such dimen- sions as to present a very distinct elevation above the pubes I cannot say from my own observation ; I have much more frequently found these sacs capable of containing a few drachms, or at most an ounce or two, of fluid. One, which is preserved in the Museum of the College of Physicians, and of which a plate has been published in Dr. Seymour's excellent treatise on the diseases of the ovary, is five or six inches in length, and would probably contain half a pint of fluid. It may not be altogether out of place to mention here the dis- tended state of the Fallopian tube, which sometimes occurs from other causes, particularly from purulent and scrofolous deposits; this, however, is a disease which has neverj in my experience, 60 ON ABDOMINAL TUMOURS. arrived at sufficient size to form a decided abdominal tumour, and is usually so complicated with scrofulous or inflammatory affections of the peritoneum as to form an undistinguishable portion of the original disease. The third form of tumour, the existence of which, as a separate disease, distinct from others, appears to me very doubtful, consists of a simple vesicular body developed beneath the proper tunic of the ovary ; supposed to be produced by an accumulation of fluid in one of the Graafian vesicles. Tumours said to be of this kind differ greatly in size; they are frequently not larger than a hazel-nut, sometimes of the size of an egg, and occasionally are believed to attain to a great magnitude, so as nearly to fill the abdomen. Yet, from the description which has sometimes been given of the contents of such supposed cysts and their glutinous quahty, it is probable that they have often been no other than largely developed cysts of a malignant character. There is a state of the Graafian vesicle by no means uncommon, and of wliich we have several specimens in the Museum of Guy's, where a coagulum, more or less stained with blood, or of a somewhat glutinous character, is collected in the vesicle, distending it to the size of a hazel-nut, or sometimes larger j this, likewise, bears a doubtful relationship to the malignant forms of tumour ; but from the circumstances of some of the patients and their youthful age, I suspect that they are, at least occasionally, unconnected with such disease. (See Case a.) The fourth is by far the most frequent form of ovarian tumour, and is essentially a specific disease, assuming all the varieties of structure which result from the numerous modifications of that morbid action called malignant. When speaking on this subject in a paper in 'Guy's Hospital Reports,' vol. i, p. 638, I endeavoured to point out, that the mahgnant disease was probably to be traced as originating more peculiarly in the ceUular tissue of the body ; first displacing, and then gradually involving and implicating, the proper structure of the organ in which it is developed. I need not, on the present occasion, repeat what I have already said ; but having there mentioned ovarian tumours as affording some marked examples and very striking modifications of this fact, I shall refer to the cases and dissections I am about to state, as illustrating the extensive growth and propagation of malignant disease in the loose ceUular tissue of an organ, the more essential parts of which seem to present, in their OVARIAN TUMOURS. 61 natural structure, a prototype of that involved system of cellular arrangement observable in malignant growths. ' But here I must observe, that the development of the disease in the ovary, owing to the decidedly cellular character of its various parts, seems, even in its early stages, to lay hold on the most important portions of the organ, as well as on the common cellular tissue; and it is often quite impossible to say whether it be the meshes of the cellular tissue, or the vesicles of De Graaf, which are become the seats of the morbid deposits, or to what extent new structures have been gene- rated; for, looking at the innumerable cysts, vesicles, and cavities which display themselves in the various parts of these ovarian tumours, we may sometimes doubt whether they have all of them had a portion of the natural structure, complicated as it is, even as the commencing nidus of their growth ; but are inclined to grant, that new vesicular bodies may probably have been added in the progress of the development, such as Dr. Hodgkin seems to consider almost essential to malignant disease ; and yet, when we look to a portion of loose ceUular tissue which has been distended with air or filled with serum, we find no apparent want of ceUular cavities to bear out the possibility of the contrary supposition. Fiff. 21. Pig. 21. A greatly diminished sketch of a large compound ovarian cyst, laid open. This is drawn with the design of giving a general view of the structure very frequent in this disease, where the whole diseased mass appears divided by septa ; and in the compartments formed by them, when the mucilaginous secretion is removed, numberless small cysts display themselves. What part of this structure can be accounted for by the increase of natural cellular membrane, and what part is owing to peculiar growth, is no easy problem to solve. The preparation from which this sketch is taken is preserved in Guy's Museum, and is above a foot in diameter. 62 ON ABDOMINAL TUMOURS. It is evident that a disease consisting of a simple cyst filled with a bland, inoffensive serum, apparently originating in some excess or irregularity of a comparatively healthy action, or arising from some inflammatory deposit, ought not to be confounded with any form of malignant disease, from which it must so essentially differ. Unfor- tunately, it is no easy matter to distinguish, with certainty, these two diseases; nor, indeed, does the subject often admit of perfect elucidation, either daring life or after death. StiU, however, we must endeavour to take as our guides the best indication we can find, in the age of the patient, the progress of the enlargement, or the feel of the tumour. I do not profess to be conversant with the history of the simple cyst ; I believe that the only indication afforded is a tumour, more or less spherical, felt first in one of the inguinal regions of the abdomen, and very gradually, if at all, ascending. That this may take place very early in life — that its growth is slow — ^that the constitution suffers little or not at all — and that after the cyst has attained even a large size, it occasionally disappears, with- out any very evident cause, or under the action of remedies, or from being burst internally by some accidental occurrence — the fluid, in this last case, passing off by the Pallopian tubes^ or taken up by the absorbents, and hurried very rapidly through the kidneys ; and though this effusion of fluid may be accompanied by a certain de- gree of peritonitis, the symptoms are, in general, by no means so alarming as might be expected. I am not sure that I can recall to my memory a single dissection where the simple ovarian cyst has been the cause of death, or has even advanced to such a size as to be the subject of material inconvenience to the patient during hfe. In most of the cases — and they are pretty numerous — ^in which simple cysts have been discovered after death, they have been too small to have attracted notice during life, and have been casually detected. Their attachment has been even more frequently to the Fallopian tubes, or to their fimbriated extremity, than to the ovaries themselves ; and they have seldom exceeded the size of a small plum. The subjects in which they have occurred have varied, as to age from children in arms, to women in the decline of life ; and in these latter cases, though still small, they have often borne, in their structure, such evidence of having long existed, that I am inclined to believe their increase to be generally very slow ; and that they frequently become stationary at a very early period. OVAEIAN TUMOURS. 63 With regard to the accumulation of fluid in a Graafian vesiclcj leading to its gradual distension, this likewise cannot easily be de- tected ; and, if detected, must with great difficulty be distinguished from other forms of ovarian tumour. As soon as it has acquired a sufficient size it will, of course, be felt rising from the pelvis ; less spherical and less moveable than the simple cyst; less lobulated than the malignant disease ; which circumstance, together with its more moderate growth, and the httle inconvenience it produces, may afford a clue to our diagnosis, and guard us against an inordi- nate anxiety for the result. It is probable, however, that this form of tumour more frequently attains a larger size than the simple cyst ; and that it more frequently affords those instances of sudden dis- appearance by accidental rupture of the cyst, or of gradual decrease, assisted by medicine, than any other form of ovarian growth. When rupture takes place, there is very often a more or less acute inflammatory action induced; and, according to the various cir- cumstances arising from that inflammation, the succeeding history of the disease wiU be modified. Still it is a fact, that from a very early period of its history to the very end, we are not only unable to make any decided distinction between it and the malignant disease during life, but are seldom able to demonstrate, even after death, the pre- cise nature of the tissue in which the cyst has been first developed. With the history of the more ordinary form of ovarian tumour, we have, unfortunately, very frequent opportunities of becoming acquainted, and I wiU. endeavour shortly to state the prominent points which it presents. This form of disease seldom shows itself much before the twentieth year of life, and generally much later, and is not, hke the simple cyst, unexpectedly discovered during the examination of children or young persons who have died of other diseases. The first recognised symptom is usually a tumour, not altogether devoid of pain, in one of the inguinal regions; and which, on examination, evidently rises out of one side of the pelvis, and even at this early period is sometimes distinctly lobulated, or uneven in its form, and unequal in the resistance its different parts afford on pressure. The growth of this tumour is, on some occasions, so nnperceived, that though it may have originated on one side, it has abeady risen into the pubic, and even the umbilical region ; and when the medical man is first consulted, its lateral origin is with difficulty ascertained. At other times the enlargement is at first 64 ON ABDOMINAL TUMOURS. slow; andj after some indefinite period^ the increase takes place suddenly, so that in a few months the whole abdomen presents, to a common observer, the size and appearance of pregnancy far ad- vanced. From this time the patient often asserts that the abdomen does not increase, and she willingly deceives herseK by measuring at some particular part, when it often happens that, with a little unconscious adjusting of the measure, no increase is discovered; but, ia the mean time, there is no doubt in the mind of the medical attendant that the tumour becomes more and more tense — ^that the fluctuation bespeaks a further thinning of the parietes — that the functions of the abdominal viscera are interfered with — that the respiration is more embarrassed — and that increased pressure is made on the cava and other returning vessels, as evinced by the serum, which now begins to accumulate ia the cellular membrane of the lower extremities, and the distension and turgescence of the subcutaneous veins of the abdomen; the important question of paracentesis presents itself, and to this operation, however unwil- lingly, he finds himself at length necessarily reduced. When a physician is consulted, either at this or in any previous period of the disease, a careful examination of the state of the abdomen is necessary. In passing the flat hand cautiously and regularly over the abdomen, the extent of the tumour will often be- come at once manifest to the touch ; at other times no limits wiU then be discovered, for the tumour occupies the whole of that part of the abdomen which is not formed by the concavity of the diaphragm, the recesses of the loias, and the hollow of the pelvis. Casting the eye over the abdomen in the earlier part of the disease, the greater rotundity or projection of one part wiU often be most apparent ; and the tumour wiU. in this way immediately discover itseK, as occupying the iliac and lumbar region on one side, and extending over half at least of the umbilical region, or beyond the umbilicus, so as to encroach on the opposite side ; at other times its extent wiU be less ; while, in the more advanced cases, no inequality win strike the eye, but the rounded form of the abdomen, while the patient lies on her back, will contrast it with the more ordinary ovoid appearance. of ascites, as well as distinguish it in some degree from the form produced by the uterus distended in pregnancy. In many cases, moreover, the eye will be struck by a great enlargement OVARIAN TUMOURS. 63 of the subcutaneous veins, as I have just observed, and such as often takes place to a still greater degree in ascites. On making more firm, though not violent pressure on the various parts of the abdomen, we often find at once the general sense of fluctuation, and ascertain inequalities which neither the eye nor the hand, when passed but gently over the surface, will enable us to detect; and then it sometimes happens, particularly if the abdomen be not very tense, that we discover considerable masses of unyielding matter, partaking of the general rounded feel of the whole disease, but conveying the impression of more or less flattened spherical bodies, attached to the inside of the fluctuating tumour ; and these bodies are sometimes so large, and sometimes so variously placed, as to suggest to the inexperienced observer the idea that the liver, the spleen, or the kidneys are enlarged, and in some way involved in the disease. (Kg. 22.) Fin Pig. 22. Sketch, drawn upon a stencilled outline, to illustrate the indi- cations derived chiefly by the touch, in a case of comiiound ovarian cyst. 5 66 ON ABDOMINAL TUMOURS. Sometimes the seuse of fluctuation is very indistinct or very partial, and various parts of the tumour yield it in different degrees. At other times, the fluctuation is even more evident than in the most extreme cases of ascites ; and sometimes, as the patient lies on the back, a thin layer of fluid is discoverable, external to the great distending tumour, so that when the points of the fingers, placed on the surface, are moved forwards with a jerk, they are evidently resisted, after pressing aside a little fluid, by the surface of the tumour within. Sometimes this layer of fluid extends over a wide space, and the fluctuation it yields by percussion may be plainly Pig. 23. Pig. 23. Diagvam, sliowing the gradual enlargement of a tumour of the right ovary, till at length it Alls a large portion of' the abdominal cavity, forcino- the lutcstmes into the lumbar regions, where they maybe recognised by percus^sion OVARIAN TBMOURS. 67 felt, or even seen as a wave passing over a large portion of the abdomen. The use of percussion is likewise very important in these cases, not only as detecting the existence, precise situation, and extent of fluctuation, but as eliciting sounds, hollow or otherwise, in the various parts of the abdomen. These will, of course, vary as the disease advances, pushing before it the hollow viscera ; and in this consists one of the remarkable differences between ascites and ovarian disease. In ascites, as long as the peritoneum has under- gone no serious change, the hollow viscera float upon the surface of the fluid, and rise to the highest part, whatever position almost the body assumes ; but the ovarian disease displaces these viscera, and retains its relative position under all circumstances ; so that instead of discovering the clear sound yielded by percussion in the umbilical region, or at the scrobiculus cordis, or in the lumbar spaces, according as the patient lies upon her back, stands erect, or re- chnes to the right or to the left side, we find the chief sound of the hollow viscera always on the side opposite to the tumour, till by its encroachment it has driven the intestines entirely into the out- skirts of the abdominal cavity (Fig. 33) ; and to this the exceptions are very rare, unless it be in those cases where communications have taken place between the cyst and the intestines, and thus air has been admitted. Having ascertained the existence of a tumour or cyst, it will still further be right to examine carefully the state of the subcutaneous cellular membrane, to detect any traces of the existence of scirrhous or other tubercles deposited in it. And lastly, by applying the palm of the hand pretty firmly on the integuments covering the tumour, we should endeavour to ascertain whether, by its motion, we can discover any such crepitation or rubbing sensation as would lead us to infer the probability that adhesive effusion or adhesions existed between the tumour and the peritoneum lining the parietes of the abdominal cavity. When by all these indications and, if any doubt have arisen, by an examination per vaginam, the extent, the nature, and the cir- cumstances of the tumour, and the existence of a fluid have been ascertained, then, if the various functions have suffered so much interruption that prudence will allow of no further delay, the fluid is drawn off by the trochar; ten, twenty, or thirty pints of the contents of the cyst are discharged, varying in quality, but generally 68 ON ABDOMINAL TUMOURS. less clear in its colour and more mucous in its consistence than the serum of ascites. The operation is attended with very little pain, and followed by very little constitutional disturbance, but affords the most marked relief; and, for a few days, the comfort of being freed from such a burden is most gratifying to the patient. Still, however, she is not unfrequently disappointed that the size of the abdomen is not more completely reduced, and the large masses and nodules, which were but indistinctly felt or discovered by the dullness yielded locally by percussion, are now not only easily grasped by the hand, but present large and obvious elevations and irregularities in the contour of the flaccid abdomen (Fig. %%). Not many days elapse, before the regular and spontaneous tightening of the bandage with which the body has been swathed, and which percussion shows to depend on no accidental evolution of flatus, gives warning of the speed with which fresh accumulation is taking place, and there is too often reason to believe that the rapidity of the effusion is increased by the withdrawal of the fluid. The nodular masses again become indistinct; in the course of a few weeks the abdomen has arrived almost at its former size, and perhaps before two or three months have elapsed the operation must again be performed. It may be that the patient still retains a fair state of general health ; but if the accumulation be rapid, the system soon begins to suffer, the body to emaciate, the countenance to fade, and if pain be added, as is not unfrequently the case, when the disease assumes its more active or virulent forms, the suffering of the patient greatly reduces her strength. The interval between the operations become less, and at length, after the lapse of an uncertain number of months or years, she dies worn out. Or, on the other hand, if the suffering continues comparatively little, and operation after operation be borne without a visible decrease of bodily power or mental energy, yet, at length, some inflammatory process, apparently accidental, or some state of unexpected collapse for which no reason can be ascribed takes place, and the patient sinks. To assign any precise or specific time to the course of this disease, from its first ap- pearance tin its fatal termination, is impossible, the difference in this respect being great ; but, from what I have myself observed, I should be inclined to state, that cases which continue above four years from the first necessity for the operation of paracentesis, bear a small proportion to those which prove fatal before that time. OVARIAN TUMOURS. 69 Such is the more general course of this disease, but there are cases in which the latter part of the history is considerably varied ; as, for instance, we find some in which from various circumstances no attempt has been made to relieve tlie distension by operation, and then death usually follows, by the slow exhaustion of the powers of Hfe, through irritation, or through the obstruction which the pres- sure of the tumour occasions, interfering with the various essential functions, and sometimes by compressing the lacteals, positively cutting off some of the avenues by which nutriment is conveyed to the system. Other cases there are wdiere nature performing the work which is more usually attempted by art, adhesions take place, and the fluid is evacuated through the intestines — the orifice re- maining open, or being easily renewed, and a gradual decline of powers leads to the fatal termination. In some cases the cyst, through accident, or through a process of ulceration commenced in the inner Uning, bursts into the peritoneal cavity, and then death sometimes speedily follows, either by the effects of the shock, or by inflammation and its results ; or, occasionally, recovery seems most unexpectedly to follow. Too often, however, the improvement is but for a time, and the disease returns under stiU less favorable circumstances than before the rupture. In some cases, after the ' performance of paracentesis, the wound refuses to close, or bursts out afresh, and sometimes, for months or years, a discharge con- tinues ; and this event may not be peculiarly prejudicial, but rather serve to prolong the patient's life. Such then, with various modi- fications, is a short history of the disease of which I shall now proceed to give a few cases, and in the following details I intend to illustrate many of the circumstances I have stated, and to bring into view the nature and extent of the structural changes by which the disease is marked ; commencing by saying a very few words on those cases of ovarian tumour which are probably devoid of a malignant character. The cases to which I am able to refer with certainty, as those where the simple serous cyst has occurred, are aU of them instances in which it has attained a very small size, and has not been dis- covered during hfe. The patients have been of various ages, and in various conditions ; and all the circumstances of their cases have appeared so little connected with the existence of the cyst, that it is quite unnecessary to detail them. I shall simply mention 70 ON ABDOMINAL TUMOURS. two : one, on account of the tender age of the subject ; and another, from its connexion with other evidences of irritation in the uterine appendages. Case i. — I was, during the last year, called upon to attend an infant of five months of age; in whom, from the symptoms, scarcely a doubt existed that the obstructed condition of the bowels depended on some mechanical cause, and this we believed to be intus-susception. The child died on the following day ; no relief having been obtained to the obstinate constipation under which it laboured. After death our conclusions were verified to the fullest extent ; for we found the whole csecum and the arch of the colon, and a portion of the ileum, swallowed up by the descending colon. All the other organs were in perfect health ; but from the appen- dages of the uterus on the left side we discovered a cyst of the size of a pea, hanging by a footstalk half an inch in length. Case 3. — A young woman, about eighteen years of age, died worn out with chorea. " The uterus was rather large, and its cavity was extensive ; in the left corner was a deposit of as much clear transparent mucus as would cover a sixpenny -piece. The ovary of the right side con- tained a cyst of the size of a small hazel-nut, full of a tenacious, dull-red substance, of just suflicient consistence to allow of being cut. The Pallopian tube on the same side was quite pervious, admitting of the passage of air from the blowpipe; but it pre- sented a remarkable appearance, having the points of the fimbriated extremities tipped with deposits of semi-transparent bone, looking like large gi'ains of sand of irregular and rather botryoidal form ; and a deposit of the same kind was found on the outside of the broad ligament. The ovary on the opposite side was more healthy, but had in it a few vesicular bodies. The Pallopian tube on that side had none of the bony deposits. Attached to the liga- ments of the uterus, on each side, was a small vesicle of the size of a pea, hanging by a peduncle, along which vessels were seen to pass from the peritoneum." Having mentioned these two cases, I may simply refer to what I have said in page 59 ; where, likewise, will be found a few observa- tions on another form of simple cyst when it is sessile or deve- OVARIAN TUMOURS. 71 loped, apparently beneath the peritoneal covering of the broad liga- ment and the Fallopian tube ; as, likewise, some reference to the cysts which are formed by the dilatation of the Fallopian tube itself. With regard to the simply distended Graafian vesicle, without malignant tendency, the cases which have occurred to my observa- tion scarcely go further than to throw an air of probability on the occasional existence of such diseases. There is nothing like a con- vincing anatomical demonstration of the point; and, in the very next case I shaU relate, what I consider, partly from the analysis of the fluid contained, and partly from the structure, to be an early specimen of the malignant disease; though the cyst appeared, when viewed externally, so completely to arise in the situation of the Graafian vesicle, to be so simple in its structure, and to be con- nected with so healthy an appearance of the ovary, that I at first considered it a simple non-malignant ovarian cyst. It is, therefore, my intention not to separate such doubtful cases; but rather to introduce them in the following coUeetion, vrith such remarks as will show the reasons I may have for supposing it probable that they were of one character or the other. Case 3. — Incipient ovarian dropsy, probably of a malignant character. — S. P — , set. 37, was admitted, under my care, into the Chnical Ward, November i, 1837, labouring under ascites and anasarca. In the preceding August she had been delivered of a female child; and immediately afterwards profuse flooding fol- lowed, which was suppressed with difficulty ; and about one week after she rose from her bed her legs began to swell ; and in less than a month her abdomen also swelled; since that she had suf- fered from palpitation of the heart on exertion, and from prolapsus uteri. The fluctuation was very distinct in the abdomen at the time of her admission. The urine was not coagulable, and varied from one pint to two and a half. After being in the hospital nearly three weeks she was suddenly seized with hemiplegia, and entirely lost all power over the right' arm and leg, and was unable to articulate a word. About six weeks after the. hemiplegic seizure, when the ascites had almost disappeared, but the paralysis remained nearly unal- tered ; she was discovered one morning to be insensible, her eyes fixed and turned upwards, with her breathing somewhat difticult; and in two hours after she died. 72 ON ABDOMINAL TUMOURS. Sectio cadaveris.— Some serum under the arachnoid. The whole anterior lobe of the left hemisphere of the brain was reduced to the consistence of a custard; so that it was only kept in its situation by the membranes, and the cineritious substance, which was of a yellow colour. This softening included exactly the corpus striatum and the anterior lobe. In the posterior part of the corpus striatum the most material mischief seemed to have taken place; and there was a small yellow stain, as if from a slight effusion of blood some weeks previously. The heart was small and weak, and perfectly adherent to the whole pericardium. There was fluid in both cavities of the chest, of which some was evidently of long standing. The uterus was healthy. Eig. 24. Pig. 24 represents a portion of the uterus, with the Fallopian tube and one of the ovaries, beneath the peritoneal coat of which a cyst of the size of an egg was developed ; apparently, the early stage of a true malignant ovarian tumour. One of the ovaries presented a beautiful specimen of the incipient stage of ovarian dropsy. A small semi-lobulated cyst seemed to proceed from the ovary ; being completely covered by the tunic of the ovary, so as to form, apparently, a continuous portion of that organ. Its size was about that of a small hen's egg; and vessels proceeded from the ovary over* its surface. (Kg- 24.) The investing tunic of the ovary could be traced to some distance over the cyst; and then became lost in its parietes. These parietes were about as thick as two or three folds of writing-paper; and when the cyst was opened, the external lobulated appearance was OVARIAN TUMOURS. 73 found to depend, not on the existence of separate cysts, but to be tbe results of bands or folds which formed one or two imperfect septa. A few vessels were seen in the inside of the cyst likewise ; but whether these belonged to the inner surface, or were seen tlirough from without, was not quite decided (Fig. 25). When Fig- 23- Kg. 25. A section of the ovary and cjst, represented in Tig. 24, showing its partial division by septa. It was filled with a glairy fluid, of which the analysis is given above; but whether it originated in the cellular tissue of the ovary, or in one of the Graafian vesicles, is uncertain; the peritoneal coat of the ovary may be traced a short way over its surface, before it becomes lost in the cyst itself. One of the Graafian vesicles is seen in a diseased state ; and the same was observed in the ovary of the opposite side. opened, the fluid it contained, which was clear, limpid, and sKghtly mucilaginous, was carefully collected; and Dr. Eees undertook the analysis ; which wiU be found to correspond very closely with other analyses in this paper, of fluids taken from malignant ovarian tumours. "Guildford Street, Jan. nth, 1838. " My dear Sir, — I enclose the account of the fluid from the cyst developed in the ovary. It is very different from serum of blood, containing no extractive soluble in alcohol, and no alkaline phos- phate. " P.S. — I experimented on 400 grains, and have given the result in 1000 parts. " Yours very sincerely, "G. 0. Eees." 74 ON ABDOMINAL TUMOURS. ANALYSIS OF A FLUID PBOM A SMALL CYST IN AN OVARY. Water . . . • • 940-io Albumen / with traces of fatty matter of the blood, and | ^^.^^ L phosphate of lime Albumen, existing in solution as albuminate of soda . 6 69 Chloride of sodium . • • -3 7" Carbonate of soda, with traces of sulphate . .1-70 This fluid was alkaline, producing a permanent effect on reddened litmus. Its specific gravity was 1018 'S. Water being 1000. There was the distinct appearance of a diseased and thickened Graafian vesicle in the same ovary ; while in that of the opposite side four or five similar bodies were seen. From the circumstance of this cyst being developed so completely beneath the peritoneal tunic of the ovary, and from other Graafian vesicles being enlarged both in this and in the opposite ovary, I was at first inclined to consider this a case in which a collection of serum had taken place in a Graafian vesicle, in contradistinction to the more ordinary form of ovarian disease ; but the analysis of the fluid leads me to a contrary conclusion; and the structure of the cyst, though simple, bears very much the appearance which is occasionally presented in certain portions of the complicated cysts ; so that this case somewhat adds to the doubt I have already expressed, of having met with any very distinct case of dropsical accumulation in the Graafian vesicles, as distinguished from the disease which runs into the malignant ovarian tumour. Considering this, then, to be, as T believe it is, an example of a very early stage of the malignant ovarian dropsy, I introduce it here; and may just notice, that in the case of M — (Case 17), an instance of a stiU more early and partial development of the disease wiU be found associated with extensive and well-marked disease in the ovary of the other side. And, as I conceive this to be the incipient state of the disease in its mildest character, I shall follow it by a case somewhat more advanced, .and difl'ering in some respects, which well illustrates the connexion between the class of diseases which we are considering, and the truly malignant action going on in the system. The fol- lowing case I have taken from the register of Guy's Museum ; and OVARIAN TUMOURS. 70 in Pig. 26 will be found a reduced sketch of the ovary and uterus, as they are still preserved. rig. 26. Fig. 26. The uterus and ovary, from a patient wlio laboured under scirrlious mamma, and in whom other organs were similarly diseased. Tlie ovary appears to show the early stage of the malignant ovarian disease ; and several cysts are already formed. The uterus is also affected, having a fibrous tubercle in the parietes of its fundus ; and another obtruding on the cavity, which it distends. (Case 4.) This preparation is preserved in Guy's Museum ; and the length of the diseased ovary is about three inches and a half. Case 4. — Diseased ovary, with cysts, in a case of extensive ma- lignant disease of other organs. — Anne — , set. 48, admitted 30th August, 1830, into Dorcas's Ward, under Mr. C. A. Key, for scir- rhous mamma. Her health was not then much disordered ; but the existence of several hard subcutaneous tumours, of various sizes, about the abdomen, and the discovery of similar disorganization in the liver, marked the extensive natm-e of the disease. Her principal and almost only cause of complaint was, of pain in the right side. She sunk gradually on the 13th, having exhibited no remarkable symptoms. Sectio cadaveris. — The body had undergone much cadaveric change ; it was not emaciated. A hard scirrhous mass occupied the situation of the left mamma ; the right was slightly affected in the same manner. The tumours beneath the skin had the appearance of diseased absorbent glands ; sections of them showed, in all, the same scirrhous structure. The chest contained about two pints of serum, rather turbid, and much tinged with blood; probably the result of cadaveric transudation. The fluid in the pericardium was about two ounces in quantity, and also very much tinged. That in the abdomen was small in quantity, and of a reddish-brown colour. Well-developed tubera, of scirrhous character, from the size of a 76 ON ABDOMINAL TUMODRS. walnat downwards^ were found in great numbers in the liver. The smallest and latest formed of these had the appearance of round, flat, circumscribed opaque marks on the surface of the viscus ; the larger ones were flat externally, or depressed in the centre. Small bodies, of a scirrhous character, were thickly dispersed thi-oughout the omentum and mesentery, and other parts of the peritoneum; but none of a large size. Both ovaries, the right in particular, were much enlarged and indurated, their surfaces being very irregular ; the Fallopian tubes, however, seemed free from disease. The body of the uterus contained a tumour the size of an egg ; but the sur- face of the organ was sound, as were also the os tincse and vagina. No unnatural appearance of the peritoneum had taken place in any of these situations. The pleurae were partially connected by old adhesions. A few marks were found on the surface of the heart and of the spleen, resembling the commencement of disease as described in the liver. On the lungs these were more numerous ; and in some few had acquired a consistence resembling cartilage. The substance of the pancreas and spleen, the kidneys, with their tunics, and the brain and its membranes, were healthy. No fibrin or coagulum was found in. the heart or in the large vessels ; these last were stained of a red colour. All the tissues had undergone much softening. The right ovary was about three inches and a half in its largest diameter; it Was much corrugated, and raised into irregular elevations on its surface; and when cut into, showed a most diseased structure throughout ; the section laying open five or six vesicles, each approaching the surface, and about the size of a large hazel-nut, filled with fluid. These appeared to be Graafian vesicles ; but the whole structure of the ovary was a mass of hard, malignant disease. (Eig. 36.) Tliis case serves to show the connexion between the cystiform enlargement of the ovary and malignant disease, which developed itself in various parts of the body in the form of scirrhus, and in the uterus, probably, as the fibrous tubercle. Case 5. — Ovarian dropsy of eleven years' standing. — Death pro- bably from inflammatory changes going on in the interior of the cyst. — Esther "W — , a woman of light, sandy complexion, was first admitted under my care September 8, 18 24, when her age is set down at 37, and she stated she had then been ill for a period of nine years. Her gene- OVARIAN TUMOURS. 11 ral appearance was that of a woman some years more advanced in life than this statement would point out ; but if correct, she must have begun to feel her present disease at the age of eighteen. It is certain, that nearly two years before her admission, that is, in May, 1822, the operation of paracentesis had been performed, and a quantity of fluid, amounting to two pailsful and a half, or about five gallons, had then been drawn off. Nearly an equal quantity had been taken away in June, 1823; ^^ ^'xxa& quantity in December of that year, and in February and June of 1834. At the time of admission, her abdomen was generally and greatly distended; and, on even a superficial examination with the hand, three or four large masses were to be felt, which, from the situ- ation they occupied, were considered by some to be probably enlarged viscera, as the spleen and liver. However, a more atten- tive examination, together with the history of the case, easily ex- plained their nature and situation; for there could be no doubt that this was a case of ovarian tumoui", and that these were sub- ordinate cysts grovidng into the cavity from the parietes of the larger cyst. Her general health was suifering somewhat, from the pain she occasionally experienced in the abdomen; I therefore ordered her to be tapped ; and sixteen quarts of thick, opaque fluid were taken away, with great relief; and when the abdomen was examined, the hard masses were felt even more distinctly than before. After a short time she left the hospital, but returned in February, 1 835, on the 1 8th of which month twenty quarts of fluid were taken away; on the 9th of April, twenty-six quarts were drawn off; on the 5th of July, sixteen quarts ; and on the 8th of November, six- teen quarts and a half; at the next operation seventeen quarts and a half; and at the next, twenty-one quarts were removed, on July the loth, 1836. Again, in October, 1836, twenty-two quarts were taken; and in the end of January, 1837, an equal quantity. The last two or three operations had been attended with more incon- venience than the former, and the fluid had become more puriform in its appearance; and a sense of sinking and lowness, with tenderness and abdominal pain, bespoke mischief, probably of a low, inflamma- tory character, going on. AH these symptoms became aggravated after the operation in the end of January; and on the 8th of the following month she gradually sank. Thus, during a period of between four and five years, this patient had been tapped fourteen times ; and in that space had lost sixty- 78 ON ABDOMINAL TUMOURS. eiglit gallons of the thick, glutinous fluid characteristic of tlus disease. Sectio cadaveris, February i^tJi, 1837. — The general aspect greatly emaciated; no oedema in any part; the abdomen very large, but not distended, appearing quite flaccid. On opening the abdomen to the left of the umbilicus, nearly a bucket-full of turbid yellow- fluid resembHng pus in appearance, and just like that which had come away by tapping, was removed. On making an opening at the scrobi- culus cordis, in the direction of the linea alba, another cavity showed itself also, containing a fluid not very different, though somewhat less turbid and thick than that in the chief cavity. About two full wash-hand-basins of fluid were taken from this cavity. On further examination, it appeared that the first cavity opened was the chief cavity, and that from which the fluid had always been drawn by tapping. It was a completely encysted cavity ; whereas the other portion of fluid was contained in the cavity of the perito- neum itseK. With respect to the encysted cavity, it appeared, on minute examination, that it was a large cyst, arising from the situa- tion of the left ovary, and having the Pallopian tube of that side greatly elongated (not less than eight inches in length), attached along its outside ; the fimbriated extremity being plainly seen at the end. This cyst was attached most firmly and generally to the anterior parietes of the abdomen, so as to require careful dissection to detach it. It was thicker and stronger towards the left side, and in front; but was rather thin towards the right side and in the iliac region. It had formed no attachments to the viscera, except that at the upper part it was glued to the omentum; it quite filled the cavity of the right ileum; and the intestines were very much pushed aside by it towards the left side. Internally, the cyst was very vascular, and was covered, in patches, with a deposit of puriform lymph of a yeUowish-green colour ; while in many parts it was rough, as if ulcerated. In other parts, tuberculated masses of different sizes were seen t of these, two were more remaikable ; the one occupying a situation a little below the spleen, and the other a little below the Kver, between the right iUac and lumbar regions ; and as these were, in parts of the cyst, closely attached to the parietes of the abdomen, they had been per- fectly discoverable by the touch for the last two years, and did not change their position in the least at the time the fluid was drawn OVARIAN TUMOURS. 79 off. Besides these two large masses, there were four or five others, smaller in dimensions, attached to the different parts of the cyst ; one, which had been always felt about an inch above the um- bilicus. The smaller masses were like small, thick cysts ; and one of the smallest being opened, it was found filled with a straw-coloured substance, semi-transparent, of a glutinous character, which sepa- rated with some difliculty from the sides of the cavity, and then disclosed another cyst of a more rounded form, semi-trans- parent, and beautifully vascular. (Fig. 27.) This appeared to be the .more early stage of each mass — these internal cysts sprouting up from the bottom, and bursting the external cysts ; and then the sur- face, so opened, becoming a secreting surface of that semi-gelatinous matter, which, in its more diluted form, seemed to compose the fluid which had been so frequently drawn off by tapping. Fig. 27. Fig. 27. The incipient stage of a tumour analogous to that represented in Fig. 28, and taken from the same ovarian cyst. In this case, the inner lamina had been divided by the scalpel. A tenacious mucus distended the cavity ; but when this was removed, a transparent vascular cyst was seen projecting from the bottom. On examining one of the larger masses, the cyst, out of which the tubercular-looking growth had proceeded, was seen opened, forming a margin round about two thirds of the mass ; the other 80 ON ABDOMINAL TUMOURS. third became lost in the tubercular cysts ; the internal lining of this was in the highest degree vascular. These cysts rose almost like a cauliflower-head, quite opaque and vascular; and one mass, which was more advanced, showed, on the surface, an appearance of irregu- larly deposited lymph. (Fig. 38.) Each of the masses, on examination, showed the same structure, with some variation ; in some, the cysts were full of fluid or semifluid matter; while in others they were hard, and presented various approaches to the true maliguaat character. Ks. 28. Fig. 28 represents one of the diseased masses wMoh are frequently found connected with the pariefces of the large cysts of ovarian dropsy. It pro- jects from the inner surface of the cyst, originating between its laminse ; and a process of sloughing having taken place in the lamina by which it was retained, a crescentio margin is seen formed around it, witli a clean, firm edge. The diseased mass was itself a fungoid growth, probably formed originally of more transparent cysts filled with glairy mucus, now become opaque and cerebriform. The uterus, the right ovary, and the Fallopian tubes, were per- fectly healthy. The liver was pushed up to the diaphragm ; and, having formed strong adhesions, remained in that situation when all the other abdominal contents had been removed ; its lower surface apparently occupying nearly the natural position of the diaphragm itself. It OVARIAN TUMOURS. 81 was mucli enlarged^ of a yellow colour tlirougliout, and firm con- sistence, approacliing to the udder liver. The gall-bladder was filled with a full-coloured and apparently healthy bUe. Spleen quite healthy. Stomach quite healthy, internally and externally, but containing a quantity of dark matter. Intestines throughout healthy externally ; but through a considerable portion of the ileum, some feet in extent, the solitary glands were enlarged, and their orifices tinged with yellow, so as to give the appearance of pretty thickly disseminated yellow specks; this appearance diminished as you approached the jejunum. Colon healthy. Kid- neys pallid in colour ; and the tubuli uriniferi appeared blocked up with httle concretions or sandy deposits. Heart rather feeble. Lungs most perfectly healthy throughout, without the least adhesion. This case may be considered as presenting a well-marked example of the complicated ovarian tumour, which had proceeded tlu'ough many years in the successive changes of its growth; and I give it as a fair specimen of a large class of such cases. Case 6. — Ovarian dropsy, anasarca, and ascites. Death from peritonitis, after the fluid was partially drawn from the cyst. — Anne M — , set. 34, was admitted, under my care, into Guy's Hospital, March a5th, 1839, affected with ovarian dropsy, anasarca, and "ascites. Her abdomen was more distended than I ever before witnessed ; so that it hung over the tliighs, chafing the groins ; and the umbilicus was scarcely to be seen; it measured, on its most prominent parts, four feet ten inches in circumference ; the cutaneous veins were very much distended, and fluctuation very distinct in the upper part of the tumour ; but below the umbilicus the whole was hard, lobulated, and unyielding. Her general health was represented as pretty good, but she had lost flesh within the last two months ; her countenance was placid; tongue clean, but purphsh; and the respu'ation much impeded when in the recumbent posture. Pulse, 130, rather weak; urine scanty, of a dark coloui-, tinged with bile, and having a hght-reddish sediment, not coagolable by heat. Eighteen months ago, she lay-in, having been extremely large during her pregnancy, and after her confinement never diminished to her usual size. A month afterwards she was tapped in the usual place, rather below the umbilicus, but not more than a quart of yellow, gelatinous matter came away. The catamenial discharge 83 ox ABDOMINAL TUMOURS. occiuTed quite regailarly till tliree months ago, since whicli it lias ceased; and it is only for tlie last two months that her urine has been scanty and high-coloured. She took medicines, gently to regulate her bowels, and to act on her kidneys, till the 15th of April; when having had a consultation with other medical officers upon the subject, and perceiving that the abdomen increased, and the breathing had become so impeded that she was constantly obhged to sit erect in her bed, I recom- mended paracentesis. As there was no iluctiiation to be felt below the umbilicus, it was judged right to make the opening some inches above it ; and fearing the effects of the large depletion, the canula was withdrawn when eleven pints of coffee-coloured fluid had been extracted. 1 6th. — She was quite comfortable, and free from aUpain; and she remained so well till the aad, that we were abeady beginning to consider at what time the remainder of the fluid might be drawn off; but her nights now became restless, though she denied aU pain; her breathing became shorter ; and she felt generally worse. a4tli. — Pulse, feeble, 140; respiration 40; hands clammy; no tenderness on pressure of the abdomen, unless it be very heavy just below the scrobiculus cordis. She vomited once in the night. The abdomen was covered with a large mustard poultice, and simple injections were administered. The next day she seemed relieved, but gradually sank ; the tongue becoming dark ; and she denying, to the time of her death, that she suffered any pain. Sectio cadaveris, April 36th, 1829. — '^^^ distension of the abdomen was very great, and the recti muscles were spread like a panniculus carnosus over the abdomen. A puncture being made, above two pailsful of green fluid were drawn off, turbid, and containing some shreds of recent coagulable matter; the parietes were then laid open, and were found to be adherent in some parts by tolerably firm adhesions to a large sac, which now appeared to occupy the whole abdomen. The viscera were all tlirust by this so far upwards, as to lie within a line drawn across from one false rib to another. The colon was seen of a black colour, projecting at the top, greatly distended with flatus, and looking hke another large cyst. The whole of the cyst was covered with slireds of lymph, showing recent inflammatory action ; and the colon was glued to the cvst, to the liver, and to the stomach. When these adventitious unions were broken down, the whole of the small intestines were found closely OVARIAN TTJMOUllS. 83 compacted together below the inferior part of the colon, and the cysts united to each other by a dark gray or black fibrinous deposit. The cyst was separated with tolerable ease from its attachments ; and was held only by the round ligament of the uterus. Its coats were a quarter of an inch thick, and it contained several pints of grumous, brown fluid j and around the sides was deposited a light- brown, fibrous matter, like the fibrin separated from the blood; masses of which came away from cells connected with the larger cyst, and opening into it by well-defined crescent-like openings, of which the edges were entire. Some of these cells were capacious enough within to hold a quarter of a pint of such soft fibrinous matter ; and when it was emptied out, several globular, transparent cysts came into view. On the lower part of the tumour, turned towards the pubes, was situated the chief mass of globular cysts. These were situated completely between what appeared to be the laminae of the membrane composing the large cyst ; and were freely supplied with vessels from it. When this was cut tlirough by one clean incision (Fig. 29), several tumours were divided, and found Eig. 29. rig. 29 represents a mass of cysts included between the layers of a largo ovarian cyst, apparently owing their peculiar form and arrangement, in some degree, to the cellular structure connecting the layers. Some of the cysts are complete, without any opening; but many communicate freely one with the other by openings only partially closed by folds, some of which form bands and imperfect septa through the mass. 84 ON ABDOMINAL TUMOUKS. to be fuU of a yellow, glairy fluid, sometUng like oil, while others remained perfect; and some crescentic margins or bands were seen, which had half divided the cysts, laid open. A few very sniaU cysts were seen sprouting out of the parietes; and a very peculiar structure, like a network of fibres, from beneath which the cysts were in some parts seen sprouting, as if forcing open and distending the meshes. (Kg. 30.) Kg 30. Pig. 30. A porlion of tlie internal surface of a large malignant ovarian cyst, showing a peculiar but not unusual reticulated appearance, apparently tlie result of tlie thickening of cellular tissue ; and between the meshes may be seen occasiMially small cysts projecting. The whole of this diseased mass was in the exact situation of the right ovary, and appeared to be formed by a gradual distension of the broad ligament at that part, in such a way that the PaUopian tube was bound round it ; and the covering of the tumour was, to all appearance, a continuance of the covering of the ovary, very much thickened ; the ovary itself being quite lost in the mass. OVARIAN TUMOURS. 85 In this case, the whole bore the appearance of having been the result of a disease in the ovary itself ; the cells of which had been distended by an enormous secretion within them ; and the reticulated parts seemed to be little other than the cellular membrane of the part thickened into cartilaginous bands. The immediate cause of death was the extensive peritoneal inflammation, which, in all probability, was chiefly owing to the fluid not having been more completely emptied out of the cyst, and some of it consequently escaping into the peritoneal cavity. Case 7. — Ovarian dropsy of many yeari duration, showing several cysts in different conditions ; with the analysis of the fluids they con- tained. — Maria N — , Eet. 35, was admitted, under my care, into Guy's Hospital, December 3d, 1834, apparently the subject of a very large ovarian tumour ; she had been married above eight years, and had borne three living children within that period. It seems to have been about the time of her marriage that she first experienced some pain and sweUing at the left side of the abdomen, in the inguinal region; and the sweUing gradually increased so much, that about five years and a half ago, it was necessary to draw off the fluid it contained, with the trochar ; it then very slowly increased, and it was not tin after tliree years and a half that a second operation was performed. The increase was then more rapid, for she was again tapped after a year and a half, which was in June last ; so that less than six months have passed, and now she is nearly as large as she ever was. The abdomen is very greatly distended, and the fluctuation is very distinct in every part, even in the lumbar spaces ; the body is emaciated. On the 8th, four gallons of fluid were drawn off, of a dingy colour, and containing numerous small, shining flakes of what appeared to be cholesterine ; and which Dr. Eees, who col- lected a considerable quantity of this matter, and examined it more minutely, at my request, decided to be so. On the fifth day after the operation a brisk purge of rhubarb and calomel brought away much hardened faeces; and the abdomen being then flaccid, I examined it carefully, and plainly discovered three or four hardened bodies appended to the parietes of the cyst. The urine was suffi- cient in quantity, light-coloured, and not coagulable. Within a fortnight the fluid had obviously accumulated considerably ; but her feelings being very comfortable, she wished to retm-n home about tliree weeks after the operation. 86 ON ABDOMINAL TUMOUKS. August I atli, 1 835.— She was again admitted, under my care, being as large as before the last operation, but suffering less from sickness, dyspepsia, and general symptoms of oppression, tlian has usually been the case. On the 14th, four gallons and a half of fluid, mode- rately coagulable by heat, were drawn off; after which she suffered some pain and tenderness, with a quickened pulse, requiring leeches, and calomel and opium, for a few days, till the gums were very slightly affected. The two most obvious hardeued masses were to be felt ; one, low down on the right side ; the other, above the umbilicus, to the left. (Kg. 32.) She remained in the house till the 14th of September, when, although the fluid was again accumulating, she preferred going home to her family. March 9th, 1836. — She was again admitted, and on the 15th, twenty -five quarts of fluid were drawn off; after which, the two tumours, which had been before felt, were very distinctly found. In about three weeks she left the house, but the fluid was again accu- mulating. August 3d. — Again admitted ; and the following day, five gallons and a quart Avere again drawn off; which she bore without any unpleasant symptoms, and returned home in about a fortnight. November 15th. — She was again admitted; on the a^th, twenty- four quarts of fiuid were drawn off ; it was of a darkish colour, with some ropy sediment, and tinged with soye red particles. On the lath of December she returned to her family. March aad, 1B37. — She was again admitted, and again about the same quantity of fluid was drawn off, on the 30th. On the 5th of April shivering took place, accompanied by swelling, apparently glandular, in the pelvic and inguinal regions, which required a good deal of attention and treatment; however, on the 15th of May she left the hospital, in her usual state of health. Maria N — (now called Price, having lately married again) was admitted, under my care, July a6th, 1837, with the abdomen again distended to the utmost, and complaining of sickness, for which T gave the hydrocyanic acid. On the 31st of July, when the sickness had subsided, and the bowels were opened, twenty-three quarts of serum were drawn away, of a muddy colour, slightly oleaginous, and moderately coagulable by heat; after this, considerable inflammation took place, which was OVARIAN TUMOUKS. 87 subdued by calomel and opium ; but it was tliree weeks before she was able to return home. In this case, we observe a disease wliichj in all probability, depends upon a structural change in the ovary, very similar to that which was discovered in Waite, proceeding, as yet, in a comparatively mild course. That the tumour consists of a large sac, in the parietes of which hardened enlargements are developed, scarcely admits of a doubt ; but though the secretion seems to proceed with an accele- rated progress, we have reason to beUeve, from the character it bears, that the surface of the cyst has not yet uiidei'gone these changes from the bursting of the smaller cysts, wliich are apt to produce the still more irritating or less mild character in the discharge. It is, however, but too obvious, that the disease is now making inroads upon her constitution, and that the symptoms which have attended the two last operations have been more alarming than on former occasions. Up to that time, she suffered scarcely any pain from the disease, or any unpleasant results from the operation ; .iadeed, the increasing buUc of the tumour has been almost the only source of , inconvenience j and no less than nine years and a haK have now elapsed since the swelling was so large as to require the &st opera- tion, but the disease has certainly existed between eleven and twelve years. The form of this tumour is highly characteristic of an encysted accumulation of fluid j so that I have had it engraved (Kg. 31) as an example of that form, from a sketch wliich was taken Fig. 31 represents tlie abdomen distended by an ovarian cyst, -wliich, not' 88 ON ABDOMINAL TUMOURS. witlistanding its enormous size, interfered little with the posture assumed by the patient in bed. Tlie surface was covered by a network of distended veins, in consequence of the pressure of the tumour on the veins internally. They conveyed the blood from the iliac to the intercostal veins chiefly ; and as the cava is generally simply compressed in these cases, and not obliterated, the circulation is partially restored to its natural course, when the fluid is with- drawn and the pressure removed. two or three years ago ; and the patient is still able to lie recumbent on her back, as here represented, without suffering from dyspncea even when the accumulation is at its utmost. The only alteration I have had made in the sketch is, strengthening the appearance of the superficial veins, which remain nearly the same in distribution, but are more distended. Thus far I had written this case, and prepared it for publication, when, on the 13th of December, 1837, the subject of these observa- tions again applied for admission under my care; but her appear- ance was dreadfully changed. She was greatly emaciated ; her voice was feeble ; her eyes sunk; her pulse was extremely weak ; her bowels were in a state of constant irritation ; and her stomach was unable to retain the least food. The form of the tumour, however, was nearly unaltered, but a Kttle more pendulous in the lower part as she lay on her back; and the veins on the surface, though almost exactly the same in distribution as had been marked in the sketch, were become larger and more obvious ; and in some parts, owing to the thinness of the skin, from which every particle of adipose matter had been absorbed, they seemed to have communicated a stain around them by transu- dation, producing a kind of ecchymosis. The tumour was about the size which it had reached before the former operations, and the fluctuation was remarkably distinct in every part ; nor did any part yield a clear sound on percussion, though a small space in the left lumbar region was rather more resonant than the rest. I learnt that the operation of paracentesis had been performed at her own house in the end of October, just five weeks before; and that tliree pailfuls, certainly amounting to four or five gallons, had then been drawn off; but she had never left her bed till the day she came to Guy's Hospital, and had, for the last tliree weeks, been subject to constant diarrhoea. By means of gently astringent injections, the bowels became .less irritable, and her stomach was enabled to retain some small quantities of nutriment; so that for a day or two she OVARIAN TUMOURS. 89 left her bed, and sat by tlie fireside. She strongly objected to having the operation performed, nor could I, in her present emaciated and enfeebled state, press it upon her ; though I had no doubt that, if she bore the operation, she would derive much temporary relief. The amelioration of her symptoms was but of very short duration. The diarrhoea returned, and with it increased irritability of stomach. She suffered considerable pain, particularly in the right side, where tenderness was experienced. Such palliative means as appeared admissible were assiduously administered ; but she sunk on the night of the 7th of January. Sectio cadaveris. — The integuments were reduced to their utmost tenuity, and were in many parts so closely adherent to the sac of the tumour, that the thickened peritoneum seemed to split into two layers, in the attempt to remove them. ^Then the tumour came into view, it appeared to occupy the whole space of the abdomeu, forcing the ribs up, so as to give the chest a bell-Kke form. (Eig. 3a.) The adhesion of the cyst was chiefly confined to its anterior part ; and a slight evidence of recent peritonitis was found in the right lumbar space. When the tumour was removed, it was found to be appended to one ovary alone, which was considered the right; though from the twisted position of the uterus, I was not quite convinced that it was. The other ovary was small and dwindled. The tumour Kg. 32 represents the ovarian tumour when tlie integuments had been removed. 90 ON ABDOMINAL TUMOURS. did not adhere to any of the viscera, except partially to tlie omen- tum; which came into sight on opening the integuments, spread over a small extent of the apper part of the tumour. The liver lay closely driven up into the hollow of the diapliragm, encroaching on the chest as high as the fourth rib; and being sKghtly adherent, did not come into view, even after the tumour was removed. (Kg. 33.) The stomach, and the whole of the intes- I'ig- 33' Fig. 33 shows the situation which the abdominal viscera had occupied, in consequence of the pressure of the ovarian tumour during a period of several years. When this sketch was taken, nothiig had been done beyond the careful removal of the tumour, that no disturbance might be given to the viscera as they lay. The liver was seen pushing the diaphragm as high as the third rib. The stomach and intestines, greatly reduced in size, occupied the posterior and upper part of the abdomen, where they afforded hollow sound, on percussion ; and where alone the movements of the intestines were felt by the patient. tines, except the descending colon, were pushed likewise into the hollow of the diaplrragm, and were exceedingly contracted ; so that altogether they seemed to bear no proportion to the enormously increased dimension of the abdominal cavity. The stomach was contracted to one fourth its natural size ; and the colon, as well as the small intestine, had very nearly the same relative dimensions. The descending colon was seen running down, closely bound to the parietes of the right lumbar space, and terminating in a very strongly^ OVARIAN TUMOURS. 91 marked sigmoid flexure. None of tlie intestines bore marks of peritoneal infianmiation, either old or recent; and no remarkable disease was discernible in the mucous membrane of the stomach, or any part of the canal. The structure of the Hver was tolerably healthy, as was that of the spleen. The kidneys were partially absorbed, owing to the obstruction winch the ureter had suffered ; and this was particularly the case on the left side, where the ureter was not only dilated, but much thickened ; and the enlarged infun- dibula contained a puriform fluid. The bladder was contracted. The lungs adliered to the ribs, and were extremely small, from the encroachment of the tumour, but were not otherwise diseased. The heart presented a remarkable specimen of atrophy; and the aorta, through its whole extent, corresponded well with the heart. The ascending cava lay quite flat and empty, and small upon the spine : it contained neither blood nor coagula, but did not appear diseased, nor was there any approach to obliteration. The Uiac and connected veins contained firm coagula of recent red blood. The tumour itself consisted of one large cyst, which contained a bucketful of rather tenacious, straw-coloured fluid,, which towards the bottom became opaque and puriform. In its parietes, towards the left side, was a large mass, like a placenta, consisting of several semi-transparent cysts, which yielded a very transparent, gelatinous fluid, containing portions more opaque; and witlun the large cyst arose two smaller ones, each containing above a pint of fluid ; one of a limpid straw colour ; the other a more turbid fluid, loaded with little shining particles of cholesterine, con-esponding precisely with the fluid which had been drawn off, to the extent of four gallons, on the iirst admission of the patient, just tlu-ee years ago, in December, 1834. The cyst which contained this fluid was somewhat thicker than the large cyst; and it had undergone changes which seemed to bespeak that, in all probability, it had at one time been much larger than it at present was ; for many plates of a cartilaginous hardness were found imbedded in its parietes. Its external surface looked diseased and rough, and puriform matter was attached to it ; while its internal surface was smooth and polished, presenting a shining membranous appearance. One of the masses which occupied the parietes of the larger cyst had begun to sprout out, and "become opaque, yielding puriform 93 ON ABDOMINAL TUMOUES. matter, quite analogous to the change which I have described, and endeavoured to represent by an engraving, in the case of W — (Kg. 28). Thus the fatal result and consequent examination confirmed the similarity of this case to that of W — ; proving the same changes, but rather in a more advanced degree, had taken place in the large cyst; and the puriform matter which had been drawn from W — would have been exactly imitated in this case, had the operation been performed; that fluid being probably yielded, in part, by the fungoid mass growing from the surface, and, in part, by the lining- membrane of the cyst, in which a process of superficial ulceration had taken place. It was a matter of considerable interest, both with myself and Dr. Eees — who had examined the fluid, drawn at the first operation, performed under my care just three years ago — to ascertain whether any of the cysts contained cholesterine in the state we then disco- vered; for we had conjectured, from the total absence of that sub- stance in the fluid drawn on a subsequent occasion, that the same cyst could never have been again opened, as it appeared very im- probable that the fluid should have been so completely removed and never have formed agaia; and this proved to be the case; for after I had obtained specimens of the fluid from each cyst in succession, we at length (but not till the fourth cyst was opened, and I had begun to despair of finding cholesterine) came to the cyst which contained that substance. I immediately put all the four specimens into Dr. Eees's hands, whom I knew to be sufficiently interested in the case to undertake these analyses ; and of this I was the more desirous, in the hope that we might be able to derive some guide in our diagnosis between encysted dropsies and ascites, from the actual chemical properties, as we do already, to a certain degree, from the obvious and physical character of the fluids. How far this hope has been realised, must be gathered from the following analyses and observations. OVAEIAN TUMOURS, 93 .Si ^ "fe. 1^ ^ - ^ 8 S s ^ u. = Z' ^ N W5 Th vp (^ ■ijt 00 NO M b M o o eS'^ C '^ -5° .009, very us. 5 8.) « H- w 05 '*■ o • •«-83 P lo w p tri ro lo b M M b b ON * ++ o ■^ N ' i-^ r^ vp u^ N 1-^ !>• ■■+ : b b o 00 o » ^ss^is M « *-" -« t^ 1 -^ , S-S w z-%s ° S >- " N 00 N "1 « ^ 11 M b b o OS o ^ oS sB M S.^i? ^I. %n^ . 3gg o lO N 00 wi « O grH « vf) t'- ■* i ?^-^ b *-t (^ b b b o ON 1^ o i|g- w is" . ON _^ t^ 00 * 1— 1 .»j TSi-i b *-t CO b b o ON o ^-^ ^-A-^ r-^v-, ■ *s P 5J • s 73 o 1 . i^ IS S 13 -s " a c o II- rf: o c .2 11 c o •-T S CJ .^3 s . V tM 'g'S " "S ^ 13 ^-1 o ■*> <4-l o tfl ■c a cs "i ° m c , c o . jd « o O .rH • «* s-s J .B 13 T3 , 'o 09 1 T3 a 5 1^ s g £"3 ■C o S-a >-i g .5 g g 3 M i^Ja s O * S (- •- ^ .= .5 a; — 13 ^ -IS i.i§.|