HULL AND SCULCOATS DISPENSARY.

315

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and interesting features in this case which had puzzled him very much, for its progress was very different from the usual 22nd.—Much the same as yesterday; wound as open as ever; course of fatal cases. Everything had gone on prosperously and for the first time yesterday evening, nurse noticed, that in up to a period when all danger was usually deemed past. spite of all her endeavours to keep the bed clean, no sooner ’Within the first three weeks the wound had well nigh closed, and the water came chiefly by the urethra. After were fresh clothes applied, than they were covered with a things foetid, dark-coloured discharge. This morning, she has ascer- for about a fortnight remained much the same, when a train tained that the discharge alluded to is of a feculent character, of bad symptoms set in, and ultimately death supervened at the lapse of two months after the operation. The cause of and passed entirely by the wound. 24th.—Is somewhat better and stronger to-day ; was placed the unfavourable symptoms latterly had been overlooked by him. On more than one occasion he had supposed that the on a water-bed yesterday, and feels more comfortable; all the urine passes by the perinæm; wound touched with nitrate of patient had got ordinary fever, and thus, again, from the silver. symptoms disappearing so rapidly, lie had concluded he was 26th.—Considerably better to-day; tongue much cleaner; wrong. He certainly had been most inclined to think that, thirst moderate; skin cool; pulse 90-95; countenance not so combined with the effects of the operation, the great age of anxious; appetite somewhat better; takes four ounces of gin, the patient was the principal cause of the extreme prostrafour of wine, and a pint of porter, daily; bowels open; dis- tion preceding death. With the exception of the rigors, there had been little or nothing to induce the suspicion that charge from wound more healthy. 28th.—Not so well again; in much the same condition as on an abscess was forming, and the character of the matter which came by the wound was not likely to induce any such the 22nd. That there was mischief somewhere in the track of Illarch 3rd.—Has made no improvement ; is low and dewound seemed evident enough, both from its slow healing, eats but an and the nothing egg sponding ; appetite nearly gone; a small chop in the course of the day; takes all his gin, wine, i or rather from its opening up again, as also from the feculent and porter; has restless nights, and dozes a great part of the ) character of the discharges observed towards the last. Even feature appeared strange to him; for there never had day; slight oedema in right leg. 7th.—Much the same ; tongue still furred ; countenance been any indication that the rectum had been wounded during the operation; nor could he, with the finger passed per anum, haggard and sunken; pulse very feeble; urine and fscces con- ! detect opening in the gut, either at the undersurface of tinue to pass by the wound; cedema still. 10th.—Gets worse; sordes collecting about the mouth; pulsc thetrack of the wound, or where the finger could reach. Dissection, however, had revealed all. The immediate cause more feeble; takes little or no notice of anything going or around him, but answers questions rationally ; dozes much of death had evidently been the extensive abscess, and it was and when awake moans almost constantly. Takes nothing now clearly seen that the opening, or rather openings, (for there were two,) into the rectum had been the result of ulcerabut gin, wine, and porter. tion, at a point far distant from the course of the knife, finger, has he died a and llth.-Strength gradually diminished, or instruments, used during the operation. eight o’clock P.3i. Such an abscess, and occurring under such circumstances, On inspection of the body, sixteen hours after death, the was both unusual and unlooked for, and in his own practice of the abdomen a general cavity presented perfectly healthy he had not met with a similar case. He had seen patients appearance. In the pelvis, slight adhesions between the sigmoid flexure of the colon and upper part of the rectum; and die of inflammation, of urinary and of purulent infiltration; usually, such results of lithotomy, or any other interference lymph, seemingly of a recent date, was effused on the cul-de- but sac of the peritonaeum, between the rectum and bladder. A with the urethra, perinseum, or rectum, occurred very speedily lateral section of the pelvis was made, when an extensive after the primary mischief. Here, however, the patient .abscess was found, stretching from near the incision in the seemed to have got over all the early dangers, yet a larger cavity was found contiguous to the wound than perinæum, made during the operation, up as high as the ulcerated middle height of the sacrum. The interior of this cavity was could almost be imagined under any circumstances. In his the mischief had been induced by the urine causing rough, having ulcerated hollows at various parts ; its surface opinion, a little unhealthy inflammation at a certain part of the wound; was like that of a sloughing ulcer, and the matter upon it was of a dark unhealthy character, resembling exactly ulceration had then supervened, and as the space increased, a the discharge which the nurse had so frequently observed large quantity of urine had remained on the surface, causing and so, at last, a large space had been made, in the evacuations. The matter was lying in contact with further the periosteum, covering the inner surface of the left tuber and even the rectum itself had been implicated. In all prohad the patient been younger, the inflammation ischii, and also the lower part of the sacrum. The parts bability, been of a more adhesive character, and there were removed from the pelvis and carefully dissected. The would rectum and bladder were laid open, when it was found that would have been no such ravages. It could not be said that the wound in the latter had completely closed, the prostate there was urinary infiltration, yet, in all probability, the urine caused all the mischief after the operation. The danger gland seeming as if it had never been touched. In the mem- had branous portion of the urethra, a small opening, such as would from the urine producing mischief arose chiefly within the admit the pointof an ordinary sized sound, was found communi- first few hours, or days, at most; here it had seemingly not any harm until the lapse of weeks. If there had been cating infront with the wound, and below, with the cavity of the caused abscess. In the track of the original wound, the rectum was infiltration within the first two or three days, he might have it to the circumstance of not using a tube in the quite healthy, and of its natural thickness; higher up, the attributed abscess came into close contact with it, and near the upper wound to let the urine flow away; but this was a practice end of the abscess, about six inches from the anus, the peri- pursued by so few, while infiltration occurred so very rarely tonæum seemed to have been raised from the anterior surface in the numerous instances where a tube was not used, that he of the gut, at which part there were two small ulcerated could not lay any blame here. In fact, he felt unable to acfor what had happened here, and could only draw the openings into the rectum, through which the fasces had evi- count of his pupils to all the features of the case, as attention dently passed into the abscess, and so through the wound in giving an example of an unsuccessful issue to the operation of the perinæum. Remarks.—Mr. Fergusson stated his belief that it was occa- lithotomy. He would only further remind them, that in lookas to what should be done for this patient, when an operasionally the custom with some surgeons, who were anxious to, ing have the mortality resulting from lithotomy, as performed by tion was resolved upon, he had deemed lithotomy more likely than lithotrity. What might have been the themselves, appear very small, to attribute death occurring to be successful in such a case as this to any other cause than the true one-’ result, if the latter process had been followed, no one could Certainly, it could not havebeen worse than that which. the operation itself: and here such parties would say the, had had died of an the abscess in for it would be patient pelvis; observed, that the wound in the neck of the bladder-the most dangerous part in the incision for lithotomy-had enHULL AND SCULCOATS DISPENSARY. tirely healed. And besides, the external wound had at one time nearly healed too, the closure being such, that, as in MALIGNANT PELVIC TUMOUR, INVOLVING THE RIGHT OVARY. the ordinary cases of success, most of the urine had come THOMAS T. LAMBERT, Esq., House-Surgeon. away by the natural passage about the tenth or twelfth day. Reported by There was a sophistry in this, however, of which he did not; a L-, female, aged forty-six years, had been suffering approve, and he thought it best at once to admit that the for four or five years from a increasing tumour, formed death resulted from lithotomy; in other words, that the ope--in the pelvic cavity, on the right side, and which swelling ration had been unsuccessful. There were several peculiarr enlarged until it attained a Yery considerable size. Its

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316 increase was accompanied by pain, severe and occasional. The catamenia were absent. The woman’s health was delicate, her complexion sallow. The general impression in her mind, and that of a medical attendant, was, that she was then in a state of pregnancy-an opinion confirmed by her repeated assertion, that she felt the movements of a fcetus. Above a year ago she was seen by Mr. Thomas Wilson, one of the surgeons to this institution; at that time, the principal urgent symptom, beside the bulky size, under which she laboured, was a great difficulty in voiding the urine. Shortly after this time, she suffered from regular uterine pains, which continued at intervals for a period of three weeks, when they finally ceased. The patient has suffered gradually declining health until a few daysago, when she died, on the 25th inst. Post-mortem examination.—The body was examined on the 26th by Mr. T. Wilson, Mr. G. Lowther, and assistants. The tumour was forwarded to our institution, and examined by myself, in the presence of the surgeons of the institution, and several other professional gentlemen. The body measured forty-two inches around the swelling, and I have not heard that the disease had extended to any other viscus. On opening the abdomen, an immense tumour was found occupying the greater part of the pelvic and abdominal cavity, attached anteriorly by a strong fibrinous band to the posterior portion of the rectus muscle on that side. The uterus was in a normal state, and so was the left ovary; but the abdominal cavity contained a large quantity of dirty greenish serum. No symptom pointing out the disease, or giving any indication of its nature, has ever been observed, except that about two years ago she parted, per vaginam, with a cyst full of hydatids. The tumour was pendulous, with the exception before stated, it being simply attached to the pelvic structures by the usual membranes, the ovarian ligaments, which presented only an appearance of great vascularity. The tumour was consequently removed with very considerable ease, and was brought to ourinstitution in a nearly perfect state. It weighed full thirty pounds, and was from two feet and a half to three feet in circumference. It had, when removed from the body, the appearance of an enormous gourd, one side bulging considerably ; this side was the outer, and here was found a fungous portion, which had penetrated the investing membrane, and presented a rather cauliflower-like appearance. Upon being more closely examined, it was found to be of the usual brainlike structure of medullary sarcoma. By continuing the incision, a large cyst was laid open, which was found to be full of the same malignant structure, that portion of it near the sides of the cavity being arranged in layers of considerable density; and towards the centre the same structure was found much softer, suspended in a fluid evidently albuminous. Here and there were found portions of considerable density, and almost of cartilaginous hardness, which was either carcinoma, or-according to the more generally expressed opinion of those present-a condensed, or hypertrophied condition of the natural structures. Beyond this cavity was found a cyst containing hydatids, the fluid in which those parasitic structures were suspended not being the usual transparent liquor in which these bodies are generally found,but glairy, tenacious, and either albuminous or colloid fluid. It may be here remarked, that on the surface of the cavity containing the medullary mass, was presented that prominent convoluted appearance so remarkably characteristic of fungoid malignant disease. No such appearance was presented upon the surface of the hydatid cyst, which exhibited the blue semi-transparent appearance which cavities containing fluid show when this is presented through membrane. Proceeding onward, another large cavity was found, containing medullary sarcoma, and then a sac, which, when cut open, poured out a quantity of dark-brown fluid, probably melanoid matter, suspended in a glairy fluid. This cavity was capable of holding four or five ounces; the hydatid cyst, before opened, about a pint and a half. The sac next met with In another was smaller, and contained lardaceous matter. cell or cavity was found some of that gelatinous variety of cancer (the areolar of Cruveilhier), which, according to Dr. Williams, seems to represent the cancerous element in a pure state, either mixed with natural tissues or other products. Upon dividing the tumour across its diameter, from top to bottom, it was found to form a mass of medullary sarcoma, with hardened fibrinous structure interposed, forming cells of varying size, and these generally terminating in cavities containing the cerebriform matter in a state of less density, and that suspended in albuminous fluid, or in the gelatinous variety of

cancer.

respect to the nature of this disease, there be little doubt that in its character it was not simple, but malignant. It seems remarkably to suggest to the mind, Remarks.—with

can

from the fact that almost every variety of malignant structure was here present, that all these forms of disease have a common origin, and are merely processes of the same continuation of destructive agency, reaching to their utmost limits, beginning with an hypertrophied or scirrhous induration, and thence passing forward to the melanotic form, probably the lowest and most inorganic of them all. Upon the pathology of these affections this case throws certainly some, though, perhaps, not fully satisfactory, or decisive, light. It can scarcely be said to favour the conjectured parasitic origin of these structures-a theory which supposes an individual vitality existing in them, in virtue of which they luxuriate at the expense of the rest of the system. The only parasitical structures here present were the hydatids, and these can scarcely be called so, if we hold the opinion of Grant, that they are molecules of the original body, which, in consequence of its loss of vitality, have themselves assumed a proper and independent existence of their own. The facts observed seem more to favour that opinion of Hodgkin, who considers that these structures originate in cysts, and that the multiplication of other cysts, their prolongation into radiated fibres, their pressure on adjoining tissues, and consequent inflammation, induration, ulceration, atrophy, or gangrene of these textures comprises the whole history of malignant growths. Looking at this malignant tumour, and having carefully examined and traced, as well as I could, step by step, the progress of this diseased affection, as manifested by its appearance, the impression upon my mind is, that Dr. Hodgkin has given a true and highly scientific account of the nature, progress, and origin of such maladies. In this case it was all but certain that the formation of cysts at the limits of this malignant growth were present: for instance, we found some cysts nearly empty at a point where there appeared to be commencing disease, while those cavities which had been longest under malignant action were found, not in an empty, not in a partially filled state, but entirely full, and in that which appeared to be the oldest and most inveterate, the cyst was not only full, but the malignant disease actually protruded through the surface into the pelvic cavity. The progress of the disease in this case was probably the All the gentlemen presame as that described by Hodgkin. sent were convinced that the tumour was encysted; all thought that a single cyst had been formed in the first instance; all saw these various forms of disease now described; and the general opinion seemed to be in favour of a progression of disease similar to that described by the pathologist last named. The hydatid cysts alone remain to be accounted for. With respect to them we may observe, that their existence, in connexion with such disease, does not seem very difficult of explanation. We know it is the characteristic of medullary sarcoma to develop itself with considerable rapidity, and also to extend this law or principle of development to. surrounding tissues. Supposing that hydatids are of molecular origin, what is more rational than to suppose, that with such as excitant as medullary sarcoma in their locality, they should become developed? the progression of disease, at the same time, forming cysts, and thus producing that actual and existing state of things which the examination of this structure presented to the view of the medical examiner.

PRACTICAL REMARKS ON DISEASES MANIFESTED IN THE HAIR, &c. BY THOMAS CATTELL, Esq., M.D., M.R.C.S.E., &c.,

Braunston. SINCE the appearance of my paper on the Hair, in THE LANCET of July 4th, the number of correspondents seeking information and explanation from me by letter, render it compulsory that the subject should be pursued. DISCOLORATION OF THE HAIR.

White hair may be regarded as a pathological condition of the hair, whether it recognise an obvious exciting and proximate cause, or whether it exist only hereditarily. And the reason for my opinion is, that it appears unphilosophical to regard discoloration, in the one case, as a pathological affection, from the mere fact of its recognising an obvious cause, and in the other, not so, because it exists hereditarily. Such a condition of the hair must either be a pathological affection, irrespectively of its causes, or it must not. We cannot predicate a certain diagnostic, as evidence of pathological divergence, unless this sign be invariable. Though discoloration of the hair may exist hereditarily, there cannot be a doubt that in some stage of the ancesatorial