No. 813.

LONDON, SATURDAY, MARCH 30, 1839. [1838-39.

CLINICAL LECTURE,DELIVERED AT UNIVERSITY COLLEGE HOSPITAL,

BY

ROBERT CARSWELL, M.D.,Professor of Pathological Anatomy in Uni

versity College, London ; and of ClinicalMedicine in University College Hospital.

MARGARET MELLOY.—CANCER OF THE UTERUS,PERITONNUM, AKO PLUURA.

GENTLEMEN :-I propose, to-day, to makea few observations on two cases which haveterminated fatally, the subject of one ofwhich, Margaret Melloy, died before thecommencement of my clinical duties; the

other, Sophia Graham, the examination ofwhose body took place yesterday. Althoughboth patients have died of a disease whichmay be said to be in almost all cases iucur-able, if not in its own nature, certainlybefore its existence can in general be de-tected by the physician, I shall not, I

believe, misemploy your time by layingbefore you a general outline of the historyof each case, the symptoms and progress ofthe disease, the treatment employed, andthe niorbid appearances found on dissection.Margaret Melloy was admitted on the

30th October, 1838, and died on the 27thDecember following, that is, after a periodof nearly two months. She was 35 years ofage, and it is stated in the case-book, thatalthough subject to a great deal of fatigue(being an itinerant vendor of caps), she hadnot undergone much hardship, and was

temperate in bPI’ habits. She could give noaccount of the health of her family ; shehad at one time suffered from ague onseveral occasions. The first appearance ofthe disease for which she was admitted intothe hospilal, and which is entered in thecase-book " morbus uteri," was observed byher twelve months previously, and consistedof a small tumour felt in the right hypogas-tric region. Along wth this she had bearing-down pains, uneasy sensations in the loins andhips, aggravated at the menstrual periods,and a constant abundant foetid dischargefrom the vagina- After the period aiiuded

to, the tumour gradually increased in Size,and at the time of her admission, occupiedthe greater part of the hypogastric regionto a little above the umbilicus. It felt hardand uneven to the touch. Ou examinationper vaginam, the cervix uteri was foundenlarged and hardened, and an abundantsanious discharge issued from the us uteri.The patient complained of sharp, lancinat-ing pain in the tumour, and likewire in thebreasts and hips. Such is the statement ofthe principal symptoms of the disease in theabdominal cavity. Those referrible to thedisease in the thoracic cavity were muchmore obscure. Indeed, the only symptomobserved referrible to the presence of thedisease in this cavity was a bellows sound,heard loudest at the base of the heart, andaccompanying the systole of that organ, andwhich, from the presence of a tumour foundafter death occupying this situation, was, inall probability, chiefly ow illg to the presenceof this mechanical cause. The respiration isstatfd to have been natnral ; the tongueclean ; appetite good ; bowels confined ; thewater considerable in quantity.

For a period of three weeks the diseasedoes not appear to have presented anymarked change. A sootliiug treatment wasat first adopted ; pain was mitigated, andrest procured by means of opiates at night,and the occasional use of the warm bathduring the day. To these means subse-quently were added the internal adminis-tration of the iodide of potassium, and theuse of the iodine ointment in friction overthe tumour in the hypogastric region. Atthe c:ose, however, of the period which Ihave named, viz., on the 24th Nuvember,an intercurrent attection presented itself,upparently bronchitis of the left lung, a

souorous rattle being then heard all over theleftside. From 120, a few days before, thepulse rose to 200, with great pain in theleft part of the cardiac region. These hitter

I symptoms, however, indicated the probableexistence of pleuritis also, although thephysical signs are not nottced. This acnte

I attack was combatted by geoerel bloodlet-ting, the exhibition of calomel, and sina-

pisms to the atiectcd side, the former treat-ment biviuir. of course, been laid aside,

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Three days after, it is stated, that the mouth of time. But, although there was a con.had become sore ; the calomel was, there- siderable quantity of yellow-coloured sero-fore, laid aside, and the iodide of potassium sity in the cavity of the abdomen, we hadresumed, although it is not stated in the no evidence of its having been the conse-report whether the signs of the bronchitis quence of peritonitis. It appeared, on thehad disappeared. However, these are contrary, to have been the consequence of aagain stated to have been present on the mechanical obstacle to the abdominal ve-15th December, that is, three weeks after- nous circulation. Nor was there observedwards, and appear to have continued to the any of the products of recent pleuritis,close of life. although, as I have already stated, there

With reference to the bellows-sound, to occurred at one period of the history of thewhich I have alluded as present at the case, great pain in the left part of the car-admission of the patient, it does not appear diac region. I shall now read to you thewhether it continued throughout the course description of the appearances found at theof the disease, as it is not afterwards noticed examination of the body, and point out toin the report, except once, and soon after you the more important physical and ana-the attack of the acute affection of the chest, tomical characters of the carcinomatouswhen it is said to have considerably in- tumours of the uterus and serous mem-

creased. branes.With regard to the progress of the primary , .

disease, or that for which the patient was Post-mortem Examination 36 hours after ,

admitted into the hospital, the only circum- Death.stances worthy of note are, the occurrence External Appearances.—Considerable ema-of pain in the left thigh, with oedema of the ciation ; oedema of the left arm and of theleg, both of which were relieved by the right leg; a number of globular elevations,application of cataplasms ; and a diminu- of a white colour, on the left side of thetion in the bulk and consistence of the neck, varying from the size of a pin’s headtumour in the abdomen. On the 8th Dec. to that of a pea.the tumour is said to have been much softer, Ileaci, not examined.and on the 18th much reduced in size. Chest.-A large quantity of greenish-co-From the history of this case, the cause of loured serosity in the cavity of each pleura.

death appears to have arisen in the inter- Pleurœ.—Circumscribed adhesion of thecurrent bronchial affection, recovery from pleurae. A great number of tumours, of awhich being probably prevented by the white or pale straw-colour, attached to thedeteriorated and weakened constitution of costal and pulmonary pleura in all direc-the patient. The progress of the original tions. They varied from the size of a peadisease, carcinoma, is, in most cases, uncer- to that of a nutmeg, and where they weretain, continuing for months or years, accord- aggregated in clusters formed masses ofing to a variety of circumstances connected considerable size. One of the single tu-with the form of the disease itself, the organ mours, measuring one inch and three-quar-affected, and the state or condition of the ters in diameter, and three-quarters of anpatient in whom it occurs. Carcinomatous inch in thickness, was attached to the costaltumours of the serous membranes, of which pleura, between the fourth and fifth ribs,this case presented us with a very remark- close to their sternal junction.able example, do not destroy life so much Lungs.-An aggregated mass, the size offrom any morbid influence which they exer- an orange, was attached to the pleura of thecise on the general constitution, as from left lung at the angle of junction of its sur-their presence as foreign bodies; and they face covered by the pericardium and theeffect this chiefly in two ways, either from diaphragm. On the left lung the tumourstheir producing inflammation, or from their were fewer in number, and smaller. Therebulk or position interfering with the accom- were several tumours about the size of theplishment of the functions of important point of the finger on the external surface oforgans. From the history of the case before the pericardium,and the cavity of this mem-us it does not appear that the physical brane contained about an ounce of fluid.effects of bulk or position had exercised any Heart.—Ventricles and auricles of theobvious injurious influence, unless in the normal capacity and thickness. The endo-abdominal cavity, where the pain, swelling, cardium opaque, and thickened towards theand nedema of the left thigh and leg, which base ; sigmoid valves rather thickened ; mi-I have noticed, were produced by pressure trcel valves and cordœ tendiniœ somewhatof the tumours found in the uterus and in thickened and rigid. These morbid condi-its vicinity on the vena cava and iliac veins. tions of the valves constituted, most proba-Inflammation of the serous membranes, that bly, another mechanical cause of the bel-is, of the pleura and peritoneum, is a not lows-sound which was first heard at the timeunfrequent occurrence when they are stud- the patient was admitted. For had it beended with carcinomatous tumours, as hap- produced by the carcinomatous tumourspened in this case ; and when it does occur, alone, we should have expected it to havegenerally terminates fatally in a short space presented a different character, that of a

35

rubbing nature, or friction-sound, as it is them a great number of tumours, varyiugcalled. from the size of a pea to that of a walnut,

Abdomen.—A great quantity of yellowish composed chiefly of the lardaceous variety ;serosity in the peritoneal cavity. The peri- and the left lung is almost entirely occupiedtoneum was covered by tumours of various by the same morbid product, with, here andsizes, similar to those found in the pleura, there, portions of the cerebriform. In thisThe surface of the liver and spleen was case the disease followed an attack of pleu-studded with them. The ttterus and ocaries ritis in a young man with fungus haema-were partly hid by a tnmour, of an elongat- todes of the shoulder on the same side, ofed form, projecting from the cavity of the which this drawing is a representation, andpelvis on the right side, and arising from which, you perceive, had acquired an im-the fundus of the uterus, the whole weigh- mense size, being at least twice as large asing four pounds nine ounces. There was, the head of an adult; and it is not merely

-also, a large mass, occupying the situation the similarity of the disease in these differ-of the lumbar glands, surrounding the infe- ent situations or tissues, viz., bone, serousrior cava, and extending along the course membrane, and pulmonary tissue, whichof the external iliac vessels, especially the renders this case interesting, as illustrativeright, which were compressed. of the facts now under your consideration.

All the tumours presented the physical It is still more interesting from the diseaseand anatomical characters of what I have having occurred in the thoracic cavitycalled the cephalomatous species of carci- within the period of a few weeks, in conse-noma, comprehending those varieties of the quence of an attack of acute inflammation,species called the mammary, lardaceous, and after the fungoid disease of the jointand cerebriform sarcoma. The greater num- had nearly acquired its maximum of deve-ber of them, however, presented, in a very lopment; for we have here, perhaps, one ofstriking manner, the characters ascribed to the most striking illustrations of the exist-the mammary, bearing a marked resem- ence of that morbid condition of the eco-blance to a section of the boiled udder of nomy which constitutes what is called thethe cow. Portions of these, as well as the cancerous diathesis, inasmuch as the diseasewhole substance of others, resembled, in of the shoulder preceded, for a considerablecolour and consistence, a section of fresh time, that which occurred in the lung andpork; while a few only presented traces of pleura, and which was known to follow thethe cerebriform or encephaloid variety, from inflammatory affection of these organs.the resemblance of the carcinomatous matter But let us return to the post-mortem ap-to soft brain. We had thus, in these tu- pearances observed in the uterus, and whichmours of the pleura and peritoneum, three you have now before you. You perceivevarieties of carcinoma, each variety exist- that a tumour, about the size and form of aning alone, or combined with another in vari- orange, and having a rather unequal sur-ous proportions in the same tumour,—cir- face, projects from the right side of thecumstances which I beg you to remember fundus, the situation in which it was feltas a strong evidence of their being merely during life; The uterus itself, of a globularmodifications of form of one and the same form, is at least four times the natural size,disease, rather than distinct morbid pro- and presents at its fundus and body severalducts accidentally combined in the same irregular elevations, varying from the sizetissue or organ. To impress this important of a flattened pea to that of a cherry. Thefact still more strongly on your minds, I left ovary is the size of a small egg. Theshow you these delineations of two cases of external surface of all these parts is gene.carcinoma of the pleura and peritoneum, in rally of a pale yellowish-white colour, with,both of which we have the same varieties here and there, vascular redness, particu-of the disease that we have seen existed in larly over the prominent parts, both of thethe case we have just been considering; large tumour, fundus, and body of theand, in addition to these, we have got the uterus. These latter feel softer than thehaematoid variety, or fungus haematodes, in paler parts, and indicate a more advancedvarious stages, in combination with the stage of the disease.others. A section of the walls of the uterus, and

In one of these delineations you perceive the tumour projecting from its fundus, pre-that the peritoneum is studded with tumours sents a remarkably fine specimen of the lar-of various sizes, and within a circumscrib- daceous and mammary varieties of cepha-ed space of a few square inches there are loma. Indeed, it is rare to meet with theseen all the varieties of carcinoma which I disease, in any of its forms, in the walls ofhave named, viz., the mammary, lardace- the fundus and body of this organ; andous, and medullary sarcoma, and fungus never have I seen it more marked than inhaematodes, in their successive stages of de- this case, in which you perceive the neck,velopment. In the other delineation the that portion of the uterus in which carci-pathological appearances are equally, if not noma is so frequent, is here but slightlystill more, interesting. The pleura costalis altered from its natural state. And I mayand pleura pulmonalis have attached to further remark, that the physical characters

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of the lardaceous variety in the walls of the uterus, are even more marked than in thetumours on the serous membranes. Itscolour has somewhat of a rose-grey tint,like that of fresh pork, of which it has alsothe consistence and transparency ; and, as itis surrounded and intersected bv bands of afibrous tissue, presents the appearance ofwhat is commonly called scirrhus.

Hesides this state of the walls of theuterus, there is seen in the cavity of thisorgan, and attached to its fundus by a

broad basis, an oblong tumour, or polypus,the size of a hen’s egg, the basis of whichis confounded with the morbid tissue of theuterus, of which it appears to be a prolonga-tion. In contact with this tumour is seenanother of similar dimensions, the greaterportion of which, however, has undergonethe processes of softening and sloughing;and these changes are most extensive at thepart where it is connected with the fundusof the uterus and the external tumour whicltoccupies this situation, and a portion ofwhich exhibits the same appearances. Thevascular organisation of the carcinomatoustissue in the walls of the uterus is verymuch marked, as well as in the dependingportions of the polypi.

These, Gentlemen, are the only observa-tions which our time will permit me to offerBou to.day on this very interesting case.

C LINICAL REMARKS

BY

SIR B. C. BRODIE,

DELIVERED AT

ST. GEORGE’S HOSPITAL.

A HSCFSSrS.

A BECTSSFS are formed by suppuration, andby the removal of solids by ulceration. Atthat part where the preceding inflammationhas been greatest, you will find that suppu-rdtiuu and ulceration are present, and nexttu that, and surrounding the former parts,)uu will tind lymph and serum ertused; be-yond this, again, you tind serum effused intothe cellular texture, and the parts in theimmediate vicinity perfectly oedematous.I some cases where the previous itiflamma-tion has beeu severe, suppuration follows asa natural consequence immediutely upon it,and pus gues on forming from one cell inthe cellular membrane to another. Whenabscess furms it commences in the innerstructure of the part ati’ected, but does notextend its ulcerating influence in every di-lectioii. If you trace it closely you will1;od it tends most to the nearest point ofsurface, as in that direction it meets withthe least resistance. Sometimes the previ-uns ulceration begins on the surface of theskin or mucous tnembrnnP but theuit forms

an ulcer, not an abscess. An abscess gcne-rally continues to discharge its contents for

a longer or shorter period. Sometimes itshows no disposition whatever to heal, whichmay be occasioned by any foreign body,such as the presence of a ball or a piece ofcloth, or from there not being a free egressfor the matter, or from the parts among whichthe abscess is situated being in motion, orfrom a weakened state of the powers of theconstitution. These various causes mayalso teml to prevent the healing of an ab-scess, but in the generality of cases the ab-scess will heat of its own accord. The sameremark will also apply to ulcers.

Ulcers and abscesses are iilled np by newSesh springing up on their surfaces, and bygranulations formed originally by coagu-lable lymph becoming vascular. When gra-nulations are healthy they are small, point-ed, and vascular, they are slow in growth,and when once formed they remain periiia-nent. At other times, when they are un-

healthy they are large and loose, very pale,quick and rapid in their growth, aud havebut little vascularity. Granulations are

covered by a thin delicate membrane, whichsecretes pus. When an ulcer becomes thus

(illed op by granulations, it cicatrises, thecovering membrane becomes thicker, andmore opaque, and thus, by degrees, newskin is formed. The new cuticle is secretedfrom the surface which protects the new

cutis. On the surface of the new cutis thereare no liairs or nervous papillæ. At firstthe cicatrix is more vascular than the sur-rounding parts. Ulceration and suppura-tion are not always conjoined together. In-flammation will sometimes assume a varietyof different characters in different diseases ;it may he simple phlegmonous inflammation,or it may be that kind which more purticu-larly attends upon measles and small-pox.In some cases it runs its course more ra-pidly than in others. When it is acute itsprogress is very rapid, and when chronic it

develops its powers very slowly. Chronicinflammation differs from acute, as its ter-

mination may end in effusion of lymph,serum, or pus, or in a watery fluid contain-ing flakes of coagulable lymph, Inflamma-tion of an acute form generally disturbs thehealthy balance of the conatitation, and se-vere and protracted fevers frequently followin its train.

THE TRFATMENT OF INFLAMMATION.

You should ever remember, Gentlemen,that in the cure of any inflammation, whe-ther general or local, your attention shouldbe first directed towards removing the excit-ing cause which produces it; and, indeed,this is an axiom which you will do well toremember iu the treatment of every disease.The animal system in general cases possessessutiicient cis ritce to right itself; and thegeneral remedies of your art to assist this