WESTMINSTER MEDICAL SOCIETY.

586 much to read now-a-days, that all possible pains should be taken to make " the task easy, and the burden light." Many a good thing passes unread, from the discomfort of decyphering the mean and petty lines in which it is presented.

so

WESTMINSTER MEDICAL SOCIETY.

SATURDAY,

NOVEMBER

14TH,

MR. MARSHALL related the

1846.—MR.

following’

HANCOCK, PRESIDENT.

case

of

SUDDEN DEATH.

The

subject

of the

case was a

woman,

sixty-three

years of

age, who had not enjoyed a state of good health for some years. She was rather of spare habit of body; her countenance sallow and unhealthy; and from her general appearance she would have passedfor a woman of seventy. She was subject to

and embarrassment of breathing. She was never troubled with sickness or vomiting. She made water in small quantity, but rather frequently. She would occasionally complain, " that her head was too heavy for the rest of her body." Her habits, until within the last twelve months, were regular and temperate; but latterly she had been addicted to drinking ardent spirits. About three months ago I attended her for fracture of the radius and ulna, which seemed to me to have been produced by a less degree of violence than is common in most cases of fracture. Her general ailments had rather increased for the last few weeks. On the morning of the day on which she died, she took her breakfast much as usual. In the afternoon she refused her dinner, but made no particular complaint. About six in the evening she complained of slight chilliness, and requested a little hot gin-and-water, which was given to her, and in a quarter of an hour afterwards she expired with-

cough,

contracted so much that it looked like a small intestine, except a rounded portion to the left of the cardiac orifice. It was nearly empty, containing only two or three spoonfuls of red liquid, with a vinous odour, of the consistence of gruel; the coats of the stomach were very thin, except near the pylorus, where there was a thickening of the submucous cellular tissue; the inner surface was red from arborescent vessels, more especially at the cardiac end; the mucous membrane seemed dissolved from this end, and in the other parts it was The skull so soft, that it could be scraped off with a scalpel. varied in thickness from about one-third of an inch in front to :about three-quarters of an inch at the sides and back; it was composed almost entirely of spongy texture, the outer and inner tables being scarcely apparent. It was softened so that the chisel broke, or rather dug out, portions of it in trying to lift off the skull cap, and we were able to tear it off with the hands, although the saw had not gone through it, except in front. The calvarium, when removed, was very heavy, and although sawn off at the usual place, was but little hollowed internally. The brain was smaller than usual; the sinuses were much distended with black liquid blood, although the head was raised, and a large quantity of blood had been removed from the chest. The substance of the brain was dotted with numerous dark red specks of vascularity. There was a projection upwards, and a roughness of the posterior part of the sella turcica. The petrous portions seemed also thickened. Dr. FREDERIC BIRD read

a

paper

ON THE DIAGNOSIS AND PATHOLOGY OF OVARIAN

TUMOURS, the narration of a case in which lie had recently removed a very large tumour from a patient in whom a previous attack of peritonitis had led to the formation of numerous and strong pelvic adhesions; recovery had been rapid and complete. In the first part of his paper, the author alluded to the changes in structure and secretion out a struggle. In the examination of the body, sixteen hours after death, observed in the lining membrane of ovarian cysts, under I was kindly assisted by my friend, Dr. Snow. The body the influence of certain exciting causes; and adduced cases generally was thin and emaciated, with slight cedema of the in which the same ovarian cysts had within short periods lower extremities. There was a considerable curvature for- yielded totally different secretions. In almost all such cases, wards of the tibia, which, although not examined, evidently the change could be traced to the constitutional depression depended upon an enlargement of the substance of the bone, consequent upon the exhibition of remedies supposed to be occupying its middle third, and elevated about an inch above efficacious in the treatment of ovarian disease, more especially the normal line of that bone. On making an incision through mercury and iodine; whilst, in a numerous class of cases, the skin and cellular tissue, the blood was found to be ex- similar effects had resulted from local pressure, produced tremely fluid, and flowed freely from the smaller veins. The either by great distention of the sac from contained fluid, or muscles generally were in a softened condition. The pulmo- from the employment of powerful external pressure. He renary artery and aorta -were torn by the fingers with the greatest garded the use of such means as alwaysuseless, and often ease. On opening the chest, the right lung was found adherent mischievous. He believed the duration of life in those to the pleura, but could be separated by the fingers. Emphy- affected with ovarian disease to be shorter than had generally sematous patches were found on various parts of the right been stated. In fifty of the cases occurring in his own practice, and left lungs. The structure of the lungs was otherwise in which the operation of excision had been negatived, he had healthy; but was dark coloured,in consequence of their contain- found that the average duration of life scarcely exceeded ing a large quantity of fluid blood. The trachea was in a normal three years from the commencement of abdominal enlargestate; but about an inch below its bifurcation into right and ment. He believed that almost all ovarian tumours were releft bronchi, the tubes were found distinctly ossified, and ferable to the same type, and that unilocular and simple cysts about twice the thickness of common writing paper, and giving.often assumed multilocular forms, and rapidly assumed more out, on being struck with the handle of the scalpel, a feeling marked malignancy; that the diagnosis of ovarian tumours, and sound of considerable resistance. The ossification ex- i though often difficult, might be determined in the majority of tended almost to the apices of both lungs, through the various cases with much accuracy. The author then proceeded to divisions of the bronchial tubes, rendering it somewhat difficult explain the means he employed for ascertaining the existence to cut through the lung. There were about six drachms of or non-existence of peritonæal adhesions; of the presence of clear serum in the pericardium; the heart was rather larger solid matter in the basic and parietal portions of the cyst; of than natural; the left ventricle was contracted, but the other the attachments to the uterus; and of the absence of pelvic cavities were filled with black fluid blood; the tendinous adhesions. The evidence upon which he was accustomed to cords of the mitral valve were much ossified, especially at found the diagnosis was deduced from the alteration effected their attachment to the substance of the heart; the valve in the relative position of the tumour under different freopened sufficiently, but was incapable of closing accurately. quencies of respiration and diaphragmatic movements; and The aortic valve was somewhat thickened and roughened by he exhibited apparatus employed for the purpose of treating small calcareous deposits; but it was capable of closing the the mobility of the tumour by forced respirations; whilst the orifice completely. The substance of the heart seemed softer presence of solid matter could be detected by percussing in than naturally. There were two small nbrinous concretions in right lines through different parts of the tumour, and carefully the heart, the only coagula met with. The right lobe of the estimating the amount of impulse communicated to the oppoliver was considerably enlarged; its lower edge reached to a site hand, as it would be found that the fluctuation would be level with the umbilicus; there was a deep sulcus running interrupted by the presence of solid matter; that although transversely across it, on a level with the lower edge of the marked fluctuation might be felt on one side of the abdomen cartilages of the ribs, broad enough to admit the finger. The when percussion was made over thesolid growth, yet that upon liver had a nutmeg appearance, the paler part being in reversing such manipulation, it would be found that no flucgranules; there were some portions of scirrhus hardness, one tuation could be detected at the point where solid matter had of them about as big as an orange in the median line near the! been formed. The direct tn of the os uteri and the mobility lower edge : except one or two small specks on the upper sur- of the uterus were the data from which he adduced the face, these hardened portions were below the sulcus produced ! opinion of the atsence of morbid attachment of the ovarian by the apron strings. The kidneys were somewhat larger ; mass with that organ; that such examination could be most than natural, but otherwise healthy; the spleen was dotted all satisfactorily made by the use of the uterine sound of Proover internally by small white granules. The stomach was; ! fessor Simpson, the introduction of which instrument he re-

introducing

,

.

587

garded as a most valuable and important addition to the means been exhibited to her with the effect of reducing the general of investigating diseases of the uterine organs. He was in- strength, but not the size of the tumour. He succeeded in duced to attach little or no importance to the previous history, restoring her general health by the use of iodide of iron and as he had frequently found extensive adhesions present when tonics. The compound iodine ointment applied over the the history of the case furnished no evidence of peritonitis tumour had appeared to decrease it materially in size; indeed, ever having existed. Peritonitis could occur without pain, she was two inches smaller, in six weeks, under its use. The just as adhesions might exist without crepitus; and he be- bowels and kidneys also acted better. lieved that adhesions constantly occurred in cases in which much pressure was exercised upon the sac without giving rise

causing interruption to the general opinion commonly received, ovarian tumours did not, as a general rule, appear on one side of the abdomen, nor did any anatomical reason exist for their doing so; and experience had taught him to regard unequal disten-

to acute

health.

symptoms,

Contrary to

or

the

Mr. HOLT briefly narrated two cases of ovarian disease, in which the mode of diagnosis detailed by Dr. Bird had by that gentleman been successfully employed, although the opinions he had expressed were contrary to those of others in consultation. After death, examination proved the correctness of the diagnosis which he had made. Mr. T. S. LEE said, that one of the great objections to ovariotomy was the difficulty of diagnosis which obtained in cases of ovarian disease. He agreed in the opinions and practice of Dr. Bird regarding the diagnosis of these cases, and related two instances in which that gentleman had successfully detected extensiveadhesions, as was proved by postmortem examination. Dr. F. BIRD, in relation to the effect of compound iodine ointment in Mr. May’s case, explained the apparent decrease in the tumour, by its action on a small quantity of fluid in the peritonaeum, which frequently existed in connexion with ovarian disease. i Dr. MURPHY inquired the experience of Dr. Bird with respect to moderate and early applied pressure in cases of unilocular cysts. Dr. F. BIRD believed that no degree of pressure excited any beneficial influence on the tumour. In some cases it appeared to decrease the size of the swelling, but it only lessened the circumference of the abdomen by pressing the intestines underneath the ribs. He related a case in which severe pressure produced a femoral hernia, and thereby hastened the fatal result. Some discussion took place regarding the statistics of the operation, but, as Dr. F. Bird justly observed, we necessarily had but an imperfect knowledge on this point, in consequence of the disgraceful and dishonest suppression of the reports of fatal cases by some operators.

tion of the abdomen rather as evidence of the presence of solid matter or peritonaeal adhesions. Of the propriety of performing the operation in well-selected cases, Dr. Frederic Bird believed there could be no question; and although he did not advocate its prematureperformance, yet that in all cases of ovarian disease, a period would be found to occur in which the early manifestations of constitutional suffering could be perceived, and that at such period the operation might be performed with the full probability of preserving the life of the patient. He regretted that lie could not adduce statistical tables in support of the opinions he had advanced, as. nnhappily, the unjustifiable suppression of fatal cases, in which the operation by the large incision had been performed, wholly destroyed the practical value of such records. Dr. Frederic Bird having read the details of his late operation, concluded by observing that the general result at which lie had arrived, as regarded the treatment to be adopted in ovarian disease, was to extirpate the tumour in all cases favourable for the operation, and in which no obscurity in diagnosis remained to render its performance unusually hazardous; that in nearly all cases it was the safest practice to abstain from the use of the remedies formerly advocated-as, for example, mercurials, drastic purgatives, diuretics, &c.; and that in cases in which the operation of excision was negatived, frequent and early tappings, aided by constitutional remedies, afforded the most probable means of prolonging life. The practice of employing powerful abdominal pressure by bandages, enveloping books, and such compresses, should be carefully avoided, as tending to produce adhesions and change in the character oi the cystic secretion. Still more dangerous was the practice oi forcibly compressing the abdomen by tight bandaging, and 01 administering mercury, and puncturing the cyst, whilst the patient is under the influence of mercury. He had unhappily seen several cases in which such mode of treatment had been followed by the worst effects; the infliction of a puneturec wound during a state of ptyalism had led to purulent secre. tion, and the patients had died as from the effects of a gigantic abscess. Such treatment was in itself irrational and dangerous and in nearly all cases led to the complete prostration of the vital powers the conversion of a serous into a purulen secretion-the formation of peritonaeal adhesions-and, ii several instances, to the destruction of life. Dr. MURPHY made some remarks on tne importance and difficulty of diagnosis in cases of ovarian disease. He related briefly the case of an unmarried lady, who applied to him, about two years since, with a large pelvic tumour. On examination of this swelling by the abdomen, there was no fluctuation detectable; the tumour had the situation and shape of the gravid uterus, per vaginam; the cervix and os uteri were found in the centre of that passage. Externally, the uterus might be, apparently, grasped between the two hands. It was suspected that the uterus contained an enormous fibrous tumour, though he (Dr. Murphy) had never seen or heard of a fibrous tumour of that organ of so enormous a size. Lately, he had again seen this patient, who had resided in the country. There was evident fluctu:1tion, and the true nature of the case, which was ovarian dropsy, was apparent. There could be nothing more important, with respect to the performance of the operation for removal of ovarian cyst, than an early

pads;

-

diagnosis.

Mr. BROOKE, in allusion to the mode of detecting the locality of solid matters in uterine tumours, related a case which oc-

curred in the Westminster Hospital some years since, and in which the mode recommended by Dr. Bird was employed with success. The same mode of diagnosis assisted us in determining whether the tumour consisted of one or more cysts, and even if there were a difference in the contents of the cysts. Mr. MAY said, that pressure had been early employed in the case related by Dr. Bird, but it produced vomiting, and arrested the secretion of urine. The patient had been in two of the London Hospitals, in which mercury and iodine had

MEDICAL SOCIETY OF LONDON. MONDAY, NOVEMBER 16TH.—MR. DENDY, PRESIDENT. DIAGNOSIS AND TREATMENT OF TUBERCLE.

THE discussion on Dr. Hughes’ paper was resumed. Dr. HuGHES again referred to the sudden onset of acute pneumonia in the case, to the occasional difficulty of diagnosis of tubercle from the solid encroachment, and to the formidable nature of these conditions when combined. Mr. LLOYD referred also to the difficulty of diagnosis of tubercle in the early stage of its development, and related the case of a boy who had been employed by Lieut. Waghorn on his overland route, whom he (Mr. Lloyd) saw on his arrival in England. Dulness on percussion over the apex of left lung, combined with symptoms of pneumonia, were present. The boy was bled to eight ounces, and calomel and opium were given. After a time, he (Mr. Lloyd) suspected tubercle, and changed his mode of treatment. The patient, however, died in about three weeks, and on examination, therewas purulent effusion in the left pleura, and communication with the lung. In both lungs there were tubercular cavities. Dr. WILLSHIRE did not think there was so much obscurity in the symptomatology of tubercle, and related a case which had been under his care, in which there was undoubtedly a tubercular cavity and laryngeal ulceration, and yet the patient was enabled to take voyages between Dover and Boulogne and Calais without much difficulty. Mr. HEADLAND thought that the presence of tubercle could i usually be determined from concomitant circumstances, and the general character of patients. There was no reason why a patient with tubercle should not continue to exist. He referred to three cases which a very experienced auscultator had declared ineligible for insurance; two of these patients had also been presented to himself. In these there was undoubtedly tubercular disease. He thought calomel was not advisable in these cases, but he would employ tartarized antimony and opium, and extensive vesication, or other counter-irritants. Dr. GOLDING BIRD also spoke on the difficulty of diagnosis in cases of this description. Dr. CLUTTERBUCK thought that tubercle, like most other morbid products, was the result of inflammation in persons peculiarly predisposed to disease in the lungs, and he would