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ON THE PATHOLOGY OF THE CHRONIC FORMS OF OVARIAN DISEASE.
356
admit, and why it should be admissible in these less important, strictly analogous cases, I am at a loss to conceive. Nor
but
can I understand how resolution can ever be the natural termination of inflammation; it certainly is the most fortunate, but that is a different matter. I should as soon think of taking up the idea, that if the earth were driven from its orbit it would naturally re-enter it, no impulse being communicated to it by any other body; and I would oppose this opinion on the following grounds:1. Resolution cannot be the natural termination in those cases which spontaneously go on to suppuration. 2. Resolution follows in many cases where medicine has been freely administered, and where the body being in a nonnatural state, suppuration, and not resolution, ought to have been looked for according to such a theory. 3. In spite of all the errors of medicine and surgery, the calumnies of lioniceopathists, and the national taste for quackery, the far greater portion of mankind here know that such cases get on more favourably under the doctor’s hands than when left to nature, and to the surgeon they will turn for help and relief, excepting, of course, those whose intellects are so muddy, that the owners of them put themselves under the hands of homoeopathists, horse-doctors, quacks, and old women-a piece of fanatical delusion for which they often pay a heavy penalty. 4. That it is more natural to suppose that the cause which produced an inflammation capable of going on to suppuration would carry on that inflammation to suppuration, no check being interposed by art, nor the cause removed. I believe we may conclude that one or both of these have occurred in those cases where resolution has seemed to arise solely from the powers of nature overcoming the suppurative tendency of the
under the form of a whitlow or a pneumonia ; in an abscess of the brain, liver, or limbs. y. That tartar-emetic is the best of the antagonist remedies that can be arrayed against them. It is only by referring back to laws, and basing laws on facts, that the one can be explained and the other supported; it is only thus that THE PHILOSOPHY OF MEDICINE can acquire that strength which will enable it to resist successfully the scathing fang and destructive claw of old Time himself, and to battle with those agencies which blot out an art, subvert a dynasty, or sweep away a mighty nation from the records of man, and from the face of the earth. Jewin-street, City, Feb. 1850. ON THE
PATHOLOGY OF THE CHRONIC FORMS OF OVARIAN DISEASE. BY EDWARD JOHN
TILT, M.D,
PHYSICIAN TO THE FARRINGDON GENERAL DISPENSARY AND TO THE PADDINGTON FREE DISPENSARY FOR DISEASES OF WOMEN AND CHILDREN.
(Continued from p. 175 175.) "Interiores generationis partes, præsertim ovaria fere nunquam liberantur ab assiduo et sepius repetita irritatione et humorum congestione ; qua vitiosp tantum irritata ovula alterantur et quandoque humoribns inundata tumescunt ut hydropici status initia preebeant."—KpUGEB, Dissert.
Goettingue, 1782.)
-
PATHOLOGICAL ANATOMY.
II. Heteromorphous Cystic Tumours.-It would seem that had exhausted the catalogue of morbid changes to which the ovary is liable, but the fertility of the ovarian soil may yet disease. 5. If nature were capable of checking the progress of a surprise us by many a spurious growth of a much more comdisease, how is it that she cannot check its first advances, the plicated composition than that of the cysts we have debody then being much sounder, and necessarily more capable scribed. We term multicystic those tumours which are formed ’by a of resisting a malign influence ? Before summing up this paper, I may as well say a few certain number of distinct cavities, all contained in one tuwords on the way in which I have given the tartar-emetic. mour, reserving that of multilocular for those wherein one To full-grown persons I have never given less than half a cavity is merely partitioned into many locules or cells. In the fibro-serous structures we have described the pecu..grain; to men, three-quarters or a full grain every two hours, increasing the dose so soon as the sickness gives way. liarities which seemed to depend upon the increased vegetative Where the bowels are confined, it may be combined with power of the adventitious serous membrane, but we observed drachm doses of tartrate of soda; and when relaxed, with a a certain uniformity in the textures produced, and in the apfew minims of tincture of opium; where neither of these, but pearance of the protein compound they secreted, whether the much pain, with tincture of hyoscyamus; but I always think cyst originated in an ovarian follicle, in the cellular tissue exit acts best uncombined. With children it is apt to be very ternal to the ovary, in the broad ligaments, or in any part of violent, yet one-eighth of a grain may be safely given at the the human body. But the morbid specimens to which we alcommencement, and even those of tender age soon bear a dose lude at present are so peculiarly ovarian that they are not of half a grain to two-thirds of a grain. A carminative, or met with in any other part of the body. Heteromorphous minute dose of prussic acid, which may be given to children cystic tumours are generally considerable in size, externally more freely than is generally done, will assist in abating the lobulated, and they show, through a semi-transparent memvomiting. Placing the patient with the head lower than brane, the coloured contents of the various cysts by which the hip will almost totally prevent any vomiting, but the they are formed. On section of the tumour, it is shown to be formed of irreposition is difficult to enforce. The ether lotion in the acute, and painting with tincture of iodine, and blistering, in chronic gularly-shaped cysts, most of them divided from each other cases, are most useful auxiliaries; for if patients are left to get by strong fibrous bands; some of the cysts, however, commuice, baths with cold water, &c., it is not very often they will nicate together, and contain different amorphous substances, do it. Now, in the introduction or extension of any remedy, such as serum, a syrupy matter, jelly, fat, or a cretaceous it is always necessary to attend to three pointspaste, atheroma. If we examine the lining membrane of 1. To discover that remedy which shall most certainly cure these different cysts, it appears identical in all; but from this the greatest number of cases. uniform membrane arise dissimilar secretions. Each cell seems 2. Of two remedies of equal value, to choose that which will gifted with its particular life, and brings forth some strange cure most pleasantly and safely. production of its own. These tumours form a link between 3. To endeavour to deduce from its application and opera- those previously noticed and others which are very similar tion some law, or to illustrate some known principle. in appearance, and have been described as colloid cancer, by 1 a. The first point has already been discussed in the Cruveilhier and Rokitansky, Professor Bennet, and some answers to the objections raised against its use. others, under the name of alveolar cancer of the ovaries. 2 a. Here there can be little doubt that every voice will be III. Cancerous Cysts of the Ot’ary.-Cruveilhier was the first raised against the tartar-emetic; for perhaps if one method to delineate this variety of cyst, and has -depicted it in his could be found more unpleasant than another it would be large Atlas of Pathological Anatomy; it occurred simulthis, but the annoyance, great as it is, is but trifling compared taneously with small cancerous ulcerations of the pylorus, and with the sufferings produced by inflammation, and may with he justly compared it to that form of gelatinous cancer in care be very much shortened, complete toleration being esta- which colloid matter is deposited. This form of cancer has blished in many cases in from five to seven hours. Those been found several times in the ovary; indeed, Rokitansky organ. patients who have had one inflammation go on to suppuration asserts that it rarely occurs anywhere but in this disease will take, and continue to take, almost any remedy whatever According to the pathologist of Vienna, this form of rather than have a second; and those who have taken tartar- is characterized by an agglomeration of numerous fibrous emetic once will freely take it the next time they find the in- sacs, which contain, for the most part, a glutinous viscid flammation coming on. matter; they diminish in size from the circumference towards 3 a. Let me now ask if the facts detailed above bear out the the interior, and especially towards the pedicle of the morbid following conclusions:— growth, so that the latter presents a condensed alveolar mass; a. That phlegmon and diffuse inflammation have their heat the alveoli, or distended follicles of the tumour, consist -of a essentially in the cellular tissue. white, shining, fibrous tissue, and contain a colourless, or greyP. That they are essentially the same, whether appearing ish, yellowish, or red viscid gelatine, and .the.mostperiphe:ra1
and
we
357 converted into large sacs : this species of ovarian tested by the microscope, is often shown to be caseous matter to be malignant, not only by the simultaneous broken down. True pus, however, may at times be found, existence of cancer in some other organ, the peritonaeum, and even in quantities so considerable, that if it were not for stomach, &c., but also by microscopic observation of the the previous history of the case, it would be scarcely possible to affirm whether an abscess or encysted tumour was under cysts, and of the fluids they contain. The amber-coloured transparent jelly within the cysts of investigation. the ovaries at first appears to be structureless, but when careC-ystals, shining in an olive-green-coloured fluid, which fully examined with the rays of light directed obliquely, deli- microscopic observation has shown to be cholesterine, have cate filaments can be seen crossing each other, together with frequently been found. The density of these fluids vary, as numerous faintly-delineated cells, round in shape, about the might be supposed, from that of water to that of treacle; it has been found of specific gravity 1006, 1009,10I2, and 1025, size of pus globules, containing from one to six granules. Caseau relates a case of ovarian areolar cancer, which oc- 1017, by Dr. Rees, Professor Bennet, Mr. Nunn, and ourselves. curred at the Hotel Dieu in 1844, and describes the tumour Bone may also be met with either in amorphous masses, deas being so voluminous and irregular as to have resembled an tached from the parietes of the cysts, or it may assume regular agglomeration of tumours of various sizes. The half-trans- shapes. For, as in the bladder are sometimes found, not one parent fibrous membranes showed that the cysts contained stone, but 100 stones, as we ourselves have seen, of a cuboidal differently coloured fluids. They were elastic on pressure, form, and about half the size of an ordinary die, so in a case and on cutting open the tumour it was found to contain an in- related by Denis, surgeon to Henry III., King of Poland, numerable quantity of cysts, from the size of a cherry to that (Diet. des Sciences Med.,) a large number of smooth, polished, of an orange, each containing a differently coloured jelly, triangular stones were discovered in the locules of an ovarian red, yellow, or brown, and susceptible of being reduced to a pulp cyst. when passed between the fingers. These cavities were geneClzemicat Analysis of the Contents of Ovarian Cysts. rally separated the one from the other by the juxtaposition of Chemistry has not yet taught us much relative to ovarian their fibrous walls. Sometimes, however, they communicated. tumours and their contents; but in science we are bound to We witnessed, in 1836, at the Hotel Dieu of Paris, the postrecord the most modest and seemingly useless facts, for who mortem examination of a woman who had been a patient of or what value they Chomel. On opening the abdomen, its cavity seemed entirely can tell to what results they may lead, assume in some future theory. may occupied by thirty or forty round, red, orange-coloured, or The great proportion of that compound of protein, called yellow bodies, embedded in a whitish coagulated substance, albumen, contained in the liquid contents of the cysts, is a fact like a of This mass poached eggs. looking strange appearance and can be satisfactorily demonstrated by the known, long struck us by its singularity, but as our attention was at that time occupied by other objects, we only gave it a cnrsory in- addition of nitric acid, or by the application of heat, by which it is coagulated. spection. Dr. Rees has given an analysis of several specimens, for which we refer the reader to Guy’s Hospital Reports, vol. Anatomo-Pat7tological Investigation of the contents of Ovarian Cysts. iii. p. 204. Dr. Julia Fontanelle has also published (Archives We have thought it better to register the contents of ova- Gen. de Med.) an elaborate analysis of the coffee-ground conrian cysts under one head, for, with the exception of the con- tents of an ovarian cyst. By this he ascertained, that eight tents of the cancerous variety, there are, as yet, no specific litres, twenty-five centilitres, of this brown turbid fluid were characters by which certain fluids can safely lead us to infer composed of albumen; gelatine, 33.8; phosphate of soda, 3.5; the nature of the cyst by which they have been secreted. It hydrochlorate of soda, 1.9. We copy textually, as we do not is only within the last few years that these fluids have at- understand the calculation. The varieties of fluid we have described are found in fibrotracted particular attention, and the deep-searching investigation of the microscopist has but very lately been brought to serous cysts; they are likewise found (particularly the more bear upon them. That accomplished histologist, our friend dense parietes in multi cystic tumours) in these heteromorDr. Hughes Bennet, of Edinburgh, was the first to throw a phous tumours. Other substances are also often found, which new light upon this subject, in his paper, (Edin. Ned. and are evidently secreted by their lining membrane, and not by Burg. Jourital, vol. lxv.,) and we intend to borrow from the admixture of their contents with blood, or by the products that paper the result of his microscopical researches. We of inflammation. A thick cream, almost solid; a substance shall briefly inquire into the physical appearance, the mi-I like fat, or cheese; cretaceous matter, and, sometimes, an elastic substance, capable of being drawn into long threads, croscopic appearance, and the chemical nature of the sub- as in a case related to us by our friend Dr. Bouchut, may all stances found in ovarian cysts. 1. Serum.—It is the property of all adventitious serous be met with. With regard to the contents of the piliferous cysts, the epimembranes to secrete a liquid of variable consistency, and dermoid appendages are generally wrapped up in different this is also the most abundant product of ovarian cysts. This albumino-serous product is at times like serum, limpid, kinds of steatomatous matter; but Julia Fontenelle proved it, and citrine; but, generally speaking, it is thicker and more in one instance, to be nothing but pure fat, combined with a animal matter. oleaginous, like the white of egg, and has been found to pre- little We are indebted to the well-known scientific chemist of sent every species of consistency-glutinous, like honey, thick Mr. T. J. Herapath, for an elaborate analysis of the linseed-tea, or " like glue fresh made and hung out to dry," in Bristol, of a piliferous cyst. (Edinburgh Medical and Surgical contents which case it will not run through the canula when the cyst is punctured. Occasionally an opalescent or opaque creamy Journal, Jan. 1849.) appearance is communicated to the jelly by the formation of pus corpuscles or minute granules, and sometimes it is wholly filamentous, mixed with granular cells and other products of inflammation. This jelly-like matter, when consistent, presents all the characters of liquor sanguinis, which has not yet passed into organization. Acetic acid develops in it, or causes to be precipitated a white membrane, having all the characters of fibrous tissue. Frequently granules, cells, and filaments may be observed in it, in various stages, as in recent exudations from the serous membranes, and in other forms of hyaline blastema. These differences in the fluid seem to depend on the manner in which the serous membrane elaborates the blood it receives, but other and frequent modifications of the fluids depend on the quantity of blood-plasma which, by the rupture of bloodvessels, is poured into the sac, and which gives to the liquid the appearance of lees of wine, or of oil, of coffeegrounds, chocolate, treacle, or tar. Under the influence of mflammation, the adventitious serous membrane secretes a caseous matter, in which are patches of epithelial membrane, more or less united together by granular matter, or false membranes, which may give the liquid an unequal consistency, or cause it to resemble gruel or pus, which, when
follicles
are
cyst is proved
-
358 Wehave already seen that these cysts may be attached by 15th.—Swelling and pain of cheek much relieved; mouth inflammation; they are also liable to putrid decomposition, partially opened, and takes more food; bowels confined; an and that, on puncturing the cyst, faetid gas may pass from the active purge. Continue poultice and gargle. 25th.-An abscess behind angle of jaw, opened, with relief, canula, and may lead the surgeon to believe that he has perforated the intestines. discharge from it not great. Continue. Gloucester-road, Hyde-park, March, 1850. 30th.-Swelling much diminished; abscess last opened discharges freely; but still the mouth can be very imperfectly opened; bowels indolent. Calomel and colocynth pills, occaREPORT OF A sionally ; continue poultice and gargle. Jan. 8th, 1850.-No considerable change in the condition of CASE OF SPINA BIFIDA TREATED BY LIGAthe cheek, which is of a deep red colour, considerably swollen, TURE AND EXCISION OF THE SAC. and discharges freely; a third abscess lower in the neck BY JAMES B. MOXON, Esq., Surgeon, Brigg, Lincolnshire. opened. To take iodide of potassium, five grains, three times A FEMALE infant, one of twins, the child of Geo. H-, of a day; continue gargle and poultice. Barnetby-le-Wold, was born with a tumour in the lumbar 13th.-The abscess last opened discharges freely; the swel. region, which presented all the appearances of spina bifida. ling of cheek much lessened, and appearance more natural; It was about the size of a small egg, translucent, and evidently the inner surface of cheek remains hard, rugged, and irregular, full of a clear fluid; its form was globular, and its base narrow. projecting painfully between the teeth. A of iodide of garglecontinue The infant was, in other respects, healthy and lively, and potassium to be substituted for that of alum; the there were no symptoms of any lesion of the spinal cord. poultices and mixture.
though
desirous that the tumour should be reI had warned them of the probably unfavourable result of an operation, I acceded to their request. The operation was performed on the 21st of April, 1849, the infant being four months old. A needle, armed with a strong double ligature, was passed through the neck of the tumour, on a level with the surrounding skin, and tied tightly each way. In this manner I hoped at once to close the passage which led into the cavity of the spinal arachnoid, and to glue its sides together by the inflammation caused by the pressure of the ligature. A stroke of the scalpel a little above the ligature was sufficient to remove the sac. There was little or no bleeding, and no oozing of the spinal fluid. Dry lint and strapping were applied, and I expected that the small remaining part would be strangulated by the ligatures, and slough away in a few days. The dressings were removed on the 24th, when I found that there had been no of the spinal fluid, but that the ligatures had not been sufficiently tight to cause the death of the remaining part of the sac. I therefore cut it away, and dressed as before. The child appeared to be quite well. At the next dressing a little clear fluid escaped from two almost invisible openings on the surface of the small sore, and the mother had noticed that the dressings and bandages had been wet during the two or three previous days. The child continued quite well. I touched the surface of the sore with the nitrate of silver, and dressed as before. A further escape of fluid, in smaller quantity, took place for a few days, but another application of the caustic was sufficient to cause the complete cicatrization of the wound. Since that period the child has been in good health, and I saw it the other day running about the house. March, t8M. The parents
were
moved, and after
oozing
Hospital Reports. NEWCASTLE INFIRMARY. Reported by Mr. G. L. DRESSER.
Injury to the Mouth from a Tobacco-pipe. T-,aged 60, was admitted into the Newcastle Infirmary, Nov. 29th, 1849, under the care of T. M. Greenhow, Esq. The left side of the face much swollen, and inflamed; within the mouth a large abscess, with thick, irregular, and indurated walls; the jaws so completely fixed as to prevent almost entirely the inhibition even of liquid food, and that examination of the inner part of the cheek which is necessary to form a satisfactory opinion of its condition. The external swelling and induration extend backwards, beyond the angle of the lower jaw. About a fortnight ago, while smoking a common tobacco-pipe, he fell forward, when the shaft of the pipe was driven forcibly into the cheek, lacerating it very severely; several fragments of the pipe had been removed before his admission, and no others can be detected on careful examination. The discharge from the mouth considerable and offensive; and he complains of much pain, which prevents sleep. An alum gargle, with tincture of myrrh, a dose of calomel and Dover’s powder, at bed-time, and house medicine in the morning. Dec. 1st.—Less pain; more sleep; on careful examination no foreign body can be discovered. Continue gargle, &c. 4th.-An external abscess opened, giving discharge to a large quantity of pus; no portion of pipe discovered. Poultice externally; continue gargle. R.
19th.-Another abscess in neck
opened, and
much pus dir.-
charged ; complains of the throat; mouth still opens to a small extent only. Medicines continued. 31st.--Inflammation and swelling much subsided; less discharge, and opens his mouth with much greater freedom; his general condition much improved. Continue. Feb. 8th.-Not so well: cheek more swollen, with erysipelatous inflammation. On passing a probe into one of the external openings, a foreign substance, distinctly felt, which could not, however, be extracted in that direction; but, by pressing it with a director towards the mouth, and dividing the inner cheek with a bistoury, it was drawn out with forceps, and proved to be a portion of pipe, nearly two inches in length; a second, but much smaller piece, was also removed in the same manner; no bleeding took place, and the poultice and medi.
cines were continued. 17th.-The condition of the cheek greatly improved, having nearly lost the erysipelatous appearance, and he can now open his mouth freely, and take food in sufficient quantity; general
appearance more healthy, and strength returning. 20th.-The internal and external incisions healed; the cheek is nearly in its natural condition, and he feels well Dismissed. _____________
Rebiems and Notices. S’ome Account of the last Yellow,-Fever-Epidemic of British Cruiana. By DANIEL BLAIR, M.D., Surgeon-General, British
Guiana. Edited by JOHN DAVY, M.D., F.R.S. Lond. & Edin., Inspector-general of Army Hospitals, &c. Longman & Co., Paternoster-row, London. 1850. Royal 8vo. pp. 161. A BOOK on fever is no new thing. However meritorious its contents may be, the author and the publisher are sure to find the subject in little demand. We could wish it were other* wise, as we feel quite assured that the great question touching the essential nature of febrile affections is not so widely and thoroughly understood as to render future inquiries on the matter unimportant. In every type there is ample room for zealous investigators, and when we give it as our opinion, that in every term of years an alteration seems to be apparent in the essence of fevers, and which, it will be remembered, was the doctrine of the older physicians, the use of unprejudiced, and philosophic histories of epidemics must needs be obvious, In these days it too often happens that fancy tinges theory, and that theory influences treatment. The kind of knowledge which we require is not of speculative notions and refined hypothesis, but numerical data, and the unprejudiced declaration of facts. The work laid open before us aims at the desideratum, and its author appears fully qualified for the task which he has taken up. Yellow fever is of course the most interesting to those physicians whose sphere of action lies in the countries which are scourged by that pestilence; but here, at home, is the cradle of their education, and before they take upon themselves theactive duties to be discharged in distant lands, it is morally incumbent upon them to become familiarized as much as possible with those maladies, over whose progress it will be theirlot to watch. To such, then, the treatise now under notice-
admit, and why it should be admissible in these less important, strictly analogous cases, I am at a loss to conceive. Nor
but
can I understand how resolution can ever be the natural termination of inflammation; it certainly is the most fortunate, but that is a different matter. I should as soon think of taking up the idea, that if the earth were driven from its orbit it would naturally re-enter it, no impulse being communicated to it by any other body; and I would oppose this opinion on the following grounds:1. Resolution cannot be the natural termination in those cases which spontaneously go on to suppuration. 2. Resolution follows in many cases where medicine has been freely administered, and where the body being in a nonnatural state, suppuration, and not resolution, ought to have been looked for according to such a theory. 3. In spite of all the errors of medicine and surgery, the calumnies of lioniceopathists, and the national taste for quackery, the far greater portion of mankind here know that such cases get on more favourably under the doctor’s hands than when left to nature, and to the surgeon they will turn for help and relief, excepting, of course, those whose intellects are so muddy, that the owners of them put themselves under the hands of homoeopathists, horse-doctors, quacks, and old women-a piece of fanatical delusion for which they often pay a heavy penalty. 4. That it is more natural to suppose that the cause which produced an inflammation capable of going on to suppuration would carry on that inflammation to suppuration, no check being interposed by art, nor the cause removed. I believe we may conclude that one or both of these have occurred in those cases where resolution has seemed to arise solely from the powers of nature overcoming the suppurative tendency of the
under the form of a whitlow or a pneumonia ; in an abscess of the brain, liver, or limbs. y. That tartar-emetic is the best of the antagonist remedies that can be arrayed against them. It is only by referring back to laws, and basing laws on facts, that the one can be explained and the other supported; it is only thus that THE PHILOSOPHY OF MEDICINE can acquire that strength which will enable it to resist successfully the scathing fang and destructive claw of old Time himself, and to battle with those agencies which blot out an art, subvert a dynasty, or sweep away a mighty nation from the records of man, and from the face of the earth. Jewin-street, City, Feb. 1850. ON THE
PATHOLOGY OF THE CHRONIC FORMS OF OVARIAN DISEASE. BY EDWARD JOHN
TILT, M.D,
PHYSICIAN TO THE FARRINGDON GENERAL DISPENSARY AND TO THE PADDINGTON FREE DISPENSARY FOR DISEASES OF WOMEN AND CHILDREN.
(Continued from p. 175 175.) "Interiores generationis partes, præsertim ovaria fere nunquam liberantur ab assiduo et sepius repetita irritatione et humorum congestione ; qua vitiosp tantum irritata ovula alterantur et quandoque humoribns inundata tumescunt ut hydropici status initia preebeant."—KpUGEB, Dissert.
Goettingue, 1782.)
-
PATHOLOGICAL ANATOMY.
II. Heteromorphous Cystic Tumours.-It would seem that had exhausted the catalogue of morbid changes to which the ovary is liable, but the fertility of the ovarian soil may yet disease. 5. If nature were capable of checking the progress of a surprise us by many a spurious growth of a much more comdisease, how is it that she cannot check its first advances, the plicated composition than that of the cysts we have debody then being much sounder, and necessarily more capable scribed. We term multicystic those tumours which are formed ’by a of resisting a malign influence ? Before summing up this paper, I may as well say a few certain number of distinct cavities, all contained in one tuwords on the way in which I have given the tartar-emetic. mour, reserving that of multilocular for those wherein one To full-grown persons I have never given less than half a cavity is merely partitioned into many locules or cells. In the fibro-serous structures we have described the pecu..grain; to men, three-quarters or a full grain every two hours, increasing the dose so soon as the sickness gives way. liarities which seemed to depend upon the increased vegetative Where the bowels are confined, it may be combined with power of the adventitious serous membrane, but we observed drachm doses of tartrate of soda; and when relaxed, with a a certain uniformity in the textures produced, and in the apfew minims of tincture of opium; where neither of these, but pearance of the protein compound they secreted, whether the much pain, with tincture of hyoscyamus; but I always think cyst originated in an ovarian follicle, in the cellular tissue exit acts best uncombined. With children it is apt to be very ternal to the ovary, in the broad ligaments, or in any part of violent, yet one-eighth of a grain may be safely given at the the human body. But the morbid specimens to which we alcommencement, and even those of tender age soon bear a dose lude at present are so peculiarly ovarian that they are not of half a grain to two-thirds of a grain. A carminative, or met with in any other part of the body. Heteromorphous minute dose of prussic acid, which may be given to children cystic tumours are generally considerable in size, externally more freely than is generally done, will assist in abating the lobulated, and they show, through a semi-transparent memvomiting. Placing the patient with the head lower than brane, the coloured contents of the various cysts by which the hip will almost totally prevent any vomiting, but the they are formed. On section of the tumour, it is shown to be formed of irreposition is difficult to enforce. The ether lotion in the acute, and painting with tincture of iodine, and blistering, in chronic gularly-shaped cysts, most of them divided from each other cases, are most useful auxiliaries; for if patients are left to get by strong fibrous bands; some of the cysts, however, commuice, baths with cold water, &c., it is not very often they will nicate together, and contain different amorphous substances, do it. Now, in the introduction or extension of any remedy, such as serum, a syrupy matter, jelly, fat, or a cretaceous it is always necessary to attend to three pointspaste, atheroma. If we examine the lining membrane of 1. To discover that remedy which shall most certainly cure these different cysts, it appears identical in all; but from this the greatest number of cases. uniform membrane arise dissimilar secretions. Each cell seems 2. Of two remedies of equal value, to choose that which will gifted with its particular life, and brings forth some strange cure most pleasantly and safely. production of its own. These tumours form a link between 3. To endeavour to deduce from its application and opera- those previously noticed and others which are very similar tion some law, or to illustrate some known principle. in appearance, and have been described as colloid cancer, by 1 a. The first point has already been discussed in the Cruveilhier and Rokitansky, Professor Bennet, and some answers to the objections raised against its use. others, under the name of alveolar cancer of the ovaries. 2 a. Here there can be little doubt that every voice will be III. Cancerous Cysts of the Ot’ary.-Cruveilhier was the first raised against the tartar-emetic; for perhaps if one method to delineate this variety of cyst, and has -depicted it in his could be found more unpleasant than another it would be large Atlas of Pathological Anatomy; it occurred simulthis, but the annoyance, great as it is, is but trifling compared taneously with small cancerous ulcerations of the pylorus, and with the sufferings produced by inflammation, and may with he justly compared it to that form of gelatinous cancer in care be very much shortened, complete toleration being esta- which colloid matter is deposited. This form of cancer has blished in many cases in from five to seven hours. Those been found several times in the ovary; indeed, Rokitansky organ. patients who have had one inflammation go on to suppuration asserts that it rarely occurs anywhere but in this disease will take, and continue to take, almost any remedy whatever According to the pathologist of Vienna, this form of rather than have a second; and those who have taken tartar- is characterized by an agglomeration of numerous fibrous emetic once will freely take it the next time they find the in- sacs, which contain, for the most part, a glutinous viscid flammation coming on. matter; they diminish in size from the circumference towards 3 a. Let me now ask if the facts detailed above bear out the the interior, and especially towards the pedicle of the morbid following conclusions:— growth, so that the latter presents a condensed alveolar mass; a. That phlegmon and diffuse inflammation have their heat the alveoli, or distended follicles of the tumour, consist -of a essentially in the cellular tissue. white, shining, fibrous tissue, and contain a colourless, or greyP. That they are essentially the same, whether appearing ish, yellowish, or red viscid gelatine, and .the.mostperiphe:ra1
and
we
357 converted into large sacs : this species of ovarian tested by the microscope, is often shown to be caseous matter to be malignant, not only by the simultaneous broken down. True pus, however, may at times be found, existence of cancer in some other organ, the peritonaeum, and even in quantities so considerable, that if it were not for stomach, &c., but also by microscopic observation of the the previous history of the case, it would be scarcely possible to affirm whether an abscess or encysted tumour was under cysts, and of the fluids they contain. The amber-coloured transparent jelly within the cysts of investigation. the ovaries at first appears to be structureless, but when careC-ystals, shining in an olive-green-coloured fluid, which fully examined with the rays of light directed obliquely, deli- microscopic observation has shown to be cholesterine, have cate filaments can be seen crossing each other, together with frequently been found. The density of these fluids vary, as numerous faintly-delineated cells, round in shape, about the might be supposed, from that of water to that of treacle; it has been found of specific gravity 1006, 1009,10I2, and 1025, size of pus globules, containing from one to six granules. Caseau relates a case of ovarian areolar cancer, which oc- 1017, by Dr. Rees, Professor Bennet, Mr. Nunn, and ourselves. curred at the Hotel Dieu in 1844, and describes the tumour Bone may also be met with either in amorphous masses, deas being so voluminous and irregular as to have resembled an tached from the parietes of the cysts, or it may assume regular agglomeration of tumours of various sizes. The half-trans- shapes. For, as in the bladder are sometimes found, not one parent fibrous membranes showed that the cysts contained stone, but 100 stones, as we ourselves have seen, of a cuboidal differently coloured fluids. They were elastic on pressure, form, and about half the size of an ordinary die, so in a case and on cutting open the tumour it was found to contain an in- related by Denis, surgeon to Henry III., King of Poland, numerable quantity of cysts, from the size of a cherry to that (Diet. des Sciences Med.,) a large number of smooth, polished, of an orange, each containing a differently coloured jelly, triangular stones were discovered in the locules of an ovarian red, yellow, or brown, and susceptible of being reduced to a pulp cyst. when passed between the fingers. These cavities were geneClzemicat Analysis of the Contents of Ovarian Cysts. rally separated the one from the other by the juxtaposition of Chemistry has not yet taught us much relative to ovarian their fibrous walls. Sometimes, however, they communicated. tumours and their contents; but in science we are bound to We witnessed, in 1836, at the Hotel Dieu of Paris, the postrecord the most modest and seemingly useless facts, for who mortem examination of a woman who had been a patient of or what value they Chomel. On opening the abdomen, its cavity seemed entirely can tell to what results they may lead, assume in some future theory. may occupied by thirty or forty round, red, orange-coloured, or The great proportion of that compound of protein, called yellow bodies, embedded in a whitish coagulated substance, albumen, contained in the liquid contents of the cysts, is a fact like a of This mass poached eggs. looking strange appearance and can be satisfactorily demonstrated by the known, long struck us by its singularity, but as our attention was at that time occupied by other objects, we only gave it a cnrsory in- addition of nitric acid, or by the application of heat, by which it is coagulated. spection. Dr. Rees has given an analysis of several specimens, for which we refer the reader to Guy’s Hospital Reports, vol. Anatomo-Pat7tological Investigation of the contents of Ovarian Cysts. iii. p. 204. Dr. Julia Fontanelle has also published (Archives We have thought it better to register the contents of ova- Gen. de Med.) an elaborate analysis of the coffee-ground conrian cysts under one head, for, with the exception of the con- tents of an ovarian cyst. By this he ascertained, that eight tents of the cancerous variety, there are, as yet, no specific litres, twenty-five centilitres, of this brown turbid fluid were characters by which certain fluids can safely lead us to infer composed of albumen; gelatine, 33.8; phosphate of soda, 3.5; the nature of the cyst by which they have been secreted. It hydrochlorate of soda, 1.9. We copy textually, as we do not is only within the last few years that these fluids have at- understand the calculation. The varieties of fluid we have described are found in fibrotracted particular attention, and the deep-searching investigation of the microscopist has but very lately been brought to serous cysts; they are likewise found (particularly the more bear upon them. That accomplished histologist, our friend dense parietes in multi cystic tumours) in these heteromorDr. Hughes Bennet, of Edinburgh, was the first to throw a phous tumours. Other substances are also often found, which new light upon this subject, in his paper, (Edin. Ned. and are evidently secreted by their lining membrane, and not by Burg. Jourital, vol. lxv.,) and we intend to borrow from the admixture of their contents with blood, or by the products that paper the result of his microscopical researches. We of inflammation. A thick cream, almost solid; a substance shall briefly inquire into the physical appearance, the mi-I like fat, or cheese; cretaceous matter, and, sometimes, an elastic substance, capable of being drawn into long threads, croscopic appearance, and the chemical nature of the sub- as in a case related to us by our friend Dr. Bouchut, may all stances found in ovarian cysts. 1. Serum.—It is the property of all adventitious serous be met with. With regard to the contents of the piliferous cysts, the epimembranes to secrete a liquid of variable consistency, and dermoid appendages are generally wrapped up in different this is also the most abundant product of ovarian cysts. This albumino-serous product is at times like serum, limpid, kinds of steatomatous matter; but Julia Fontenelle proved it, and citrine; but, generally speaking, it is thicker and more in one instance, to be nothing but pure fat, combined with a animal matter. oleaginous, like the white of egg, and has been found to pre- little We are indebted to the well-known scientific chemist of sent every species of consistency-glutinous, like honey, thick Mr. T. J. Herapath, for an elaborate analysis of the linseed-tea, or " like glue fresh made and hung out to dry," in Bristol, of a piliferous cyst. (Edinburgh Medical and Surgical contents which case it will not run through the canula when the cyst is punctured. Occasionally an opalescent or opaque creamy Journal, Jan. 1849.) appearance is communicated to the jelly by the formation of pus corpuscles or minute granules, and sometimes it is wholly filamentous, mixed with granular cells and other products of inflammation. This jelly-like matter, when consistent, presents all the characters of liquor sanguinis, which has not yet passed into organization. Acetic acid develops in it, or causes to be precipitated a white membrane, having all the characters of fibrous tissue. Frequently granules, cells, and filaments may be observed in it, in various stages, as in recent exudations from the serous membranes, and in other forms of hyaline blastema. These differences in the fluid seem to depend on the manner in which the serous membrane elaborates the blood it receives, but other and frequent modifications of the fluids depend on the quantity of blood-plasma which, by the rupture of bloodvessels, is poured into the sac, and which gives to the liquid the appearance of lees of wine, or of oil, of coffeegrounds, chocolate, treacle, or tar. Under the influence of mflammation, the adventitious serous membrane secretes a caseous matter, in which are patches of epithelial membrane, more or less united together by granular matter, or false membranes, which may give the liquid an unequal consistency, or cause it to resemble gruel or pus, which, when
follicles
are
cyst is proved
-
358 Wehave already seen that these cysts may be attached by 15th.—Swelling and pain of cheek much relieved; mouth inflammation; they are also liable to putrid decomposition, partially opened, and takes more food; bowels confined; an and that, on puncturing the cyst, faetid gas may pass from the active purge. Continue poultice and gargle. 25th.-An abscess behind angle of jaw, opened, with relief, canula, and may lead the surgeon to believe that he has perforated the intestines. discharge from it not great. Continue. Gloucester-road, Hyde-park, March, 1850. 30th.-Swelling much diminished; abscess last opened discharges freely; but still the mouth can be very imperfectly opened; bowels indolent. Calomel and colocynth pills, occaREPORT OF A sionally ; continue poultice and gargle. Jan. 8th, 1850.-No considerable change in the condition of CASE OF SPINA BIFIDA TREATED BY LIGAthe cheek, which is of a deep red colour, considerably swollen, TURE AND EXCISION OF THE SAC. and discharges freely; a third abscess lower in the neck BY JAMES B. MOXON, Esq., Surgeon, Brigg, Lincolnshire. opened. To take iodide of potassium, five grains, three times A FEMALE infant, one of twins, the child of Geo. H-, of a day; continue gargle and poultice. Barnetby-le-Wold, was born with a tumour in the lumbar 13th.-The abscess last opened discharges freely; the swel. region, which presented all the appearances of spina bifida. ling of cheek much lessened, and appearance more natural; It was about the size of a small egg, translucent, and evidently the inner surface of cheek remains hard, rugged, and irregular, full of a clear fluid; its form was globular, and its base narrow. projecting painfully between the teeth. A of iodide of garglecontinue The infant was, in other respects, healthy and lively, and potassium to be substituted for that of alum; the there were no symptoms of any lesion of the spinal cord. poultices and mixture.
though
desirous that the tumour should be reI had warned them of the probably unfavourable result of an operation, I acceded to their request. The operation was performed on the 21st of April, 1849, the infant being four months old. A needle, armed with a strong double ligature, was passed through the neck of the tumour, on a level with the surrounding skin, and tied tightly each way. In this manner I hoped at once to close the passage which led into the cavity of the spinal arachnoid, and to glue its sides together by the inflammation caused by the pressure of the ligature. A stroke of the scalpel a little above the ligature was sufficient to remove the sac. There was little or no bleeding, and no oozing of the spinal fluid. Dry lint and strapping were applied, and I expected that the small remaining part would be strangulated by the ligatures, and slough away in a few days. The dressings were removed on the 24th, when I found that there had been no of the spinal fluid, but that the ligatures had not been sufficiently tight to cause the death of the remaining part of the sac. I therefore cut it away, and dressed as before. The child appeared to be quite well. At the next dressing a little clear fluid escaped from two almost invisible openings on the surface of the small sore, and the mother had noticed that the dressings and bandages had been wet during the two or three previous days. The child continued quite well. I touched the surface of the sore with the nitrate of silver, and dressed as before. A further escape of fluid, in smaller quantity, took place for a few days, but another application of the caustic was sufficient to cause the complete cicatrization of the wound. Since that period the child has been in good health, and I saw it the other day running about the house. March, t8M. The parents
were
moved, and after
oozing
Hospital Reports. NEWCASTLE INFIRMARY. Reported by Mr. G. L. DRESSER.
Injury to the Mouth from a Tobacco-pipe. T-,aged 60, was admitted into the Newcastle Infirmary, Nov. 29th, 1849, under the care of T. M. Greenhow, Esq. The left side of the face much swollen, and inflamed; within the mouth a large abscess, with thick, irregular, and indurated walls; the jaws so completely fixed as to prevent almost entirely the inhibition even of liquid food, and that examination of the inner part of the cheek which is necessary to form a satisfactory opinion of its condition. The external swelling and induration extend backwards, beyond the angle of the lower jaw. About a fortnight ago, while smoking a common tobacco-pipe, he fell forward, when the shaft of the pipe was driven forcibly into the cheek, lacerating it very severely; several fragments of the pipe had been removed before his admission, and no others can be detected on careful examination. The discharge from the mouth considerable and offensive; and he complains of much pain, which prevents sleep. An alum gargle, with tincture of myrrh, a dose of calomel and Dover’s powder, at bed-time, and house medicine in the morning. Dec. 1st.—Less pain; more sleep; on careful examination no foreign body can be discovered. Continue gargle, &c. 4th.-An external abscess opened, giving discharge to a large quantity of pus; no portion of pipe discovered. Poultice externally; continue gargle. R.
19th.-Another abscess in neck
opened, and
much pus dir.-
charged ; complains of the throat; mouth still opens to a small extent only. Medicines continued. 31st.--Inflammation and swelling much subsided; less discharge, and opens his mouth with much greater freedom; his general condition much improved. Continue. Feb. 8th.-Not so well: cheek more swollen, with erysipelatous inflammation. On passing a probe into one of the external openings, a foreign substance, distinctly felt, which could not, however, be extracted in that direction; but, by pressing it with a director towards the mouth, and dividing the inner cheek with a bistoury, it was drawn out with forceps, and proved to be a portion of pipe, nearly two inches in length; a second, but much smaller piece, was also removed in the same manner; no bleeding took place, and the poultice and medi.
cines were continued. 17th.-The condition of the cheek greatly improved, having nearly lost the erysipelatous appearance, and he can now open his mouth freely, and take food in sufficient quantity; general
appearance more healthy, and strength returning. 20th.-The internal and external incisions healed; the cheek is nearly in its natural condition, and he feels well Dismissed. _____________
Rebiems and Notices. S’ome Account of the last Yellow,-Fever-Epidemic of British Cruiana. By DANIEL BLAIR, M.D., Surgeon-General, British
Guiana. Edited by JOHN DAVY, M.D., F.R.S. Lond. & Edin., Inspector-general of Army Hospitals, &c. Longman & Co., Paternoster-row, London. 1850. Royal 8vo. pp. 161. A BOOK on fever is no new thing. However meritorious its contents may be, the author and the publisher are sure to find the subject in little demand. We could wish it were other* wise, as we feel quite assured that the great question touching the essential nature of febrile affections is not so widely and thoroughly understood as to render future inquiries on the matter unimportant. In every type there is ample room for zealous investigators, and when we give it as our opinion, that in every term of years an alteration seems to be apparent in the essence of fevers, and which, it will be remembered, was the doctrine of the older physicians, the use of unprejudiced, and philosophic histories of epidemics must needs be obvious, In these days it too often happens that fancy tinges theory, and that theory influences treatment. The kind of knowledge which we require is not of speculative notions and refined hypothesis, but numerical data, and the unprejudiced declaration of facts. The work laid open before us aims at the desideratum, and its author appears fully qualified for the task which he has taken up. Yellow fever is of course the most interesting to those physicians whose sphere of action lies in the countries which are scourged by that pestilence; but here, at home, is the cradle of their education, and before they take upon themselves theactive duties to be discharged in distant lands, it is morally incumbent upon them to become familiarized as much as possible with those maladies, over whose progress it will be theirlot to watch. To such, then, the treatise now under notice-