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The ulcer was examined microscopically by Dr. Ritchie, who has kindly provided us with the slides we have this evening.
The treatment consisted in, at first, the use of remedies said to be of service in dyspepsia and constipation, afterwards opiates internally, as well as many anodyne applications. Of the latter, the best one, was a mixture of 7 parts of Lin Bellad., and 1 part of Chloroform, sprinkled on spongiopiline. The last ten weeks of her illness, she was fed almost entirely by the rectum.
A few remarks on the diagnosis of this case. As you perceive, the early symptoms were misleading. From their persistence and from the progressive cachexia, one was forced into the conviction that there was malignant disease in some part of the alimentary canal. But in what part ? Examining the symptoms one by one we shall find that scarcely any of them point to the stomach.
1. Pain was not of its usual character, nor did it occupy its usual site. Only at times severe, it was absent during the latter part of the patient's illness.
Habershon regards pain in such cases as being due to exposure of the vagus to the irritating contents of the stomach. The pain ceases when the branches are divided by the progress of the disease.
2. Vomiting, though occasionally present, was never urgent. 3. Hæmatemesis was entirely absent. 4. No tumour could be felt.
The probabilities of the disease being in the colon were very great.
1. The colon is a favorite site.
2. Typanites was an urgent symptom, inclining one to think that there was some obstruction in the course of the gut.
3. Pain was complained of in the left hypochondrium, and in the left lumbar region.
4. There was obstinate constipation. The bowels were emptied about every
4th or 5th day, by an enema of soap and water. This day was looked forward to with dread. Great relief followed the removal of an accumulation of fæces.
5. Tenesmus accompanied the diarrhoea and the passage of bloody stools, and was at times present throughout the course of the disease. She often strained for hours without effect.
6. A small tumour in the left hypochondrium could at times be felt. This afterwards was proved to be fæcal, yet at the time it was very deceptive.
7. The presence of blood in the evacuations.
CASE III.-M. B., æt. 36, came to the Montreal Dispensary on the 18th of March, 1879. Her father had died from an anknown cause. Her mother and several brothers and sisters were alive, and in good health. Married eleven years. Four healthy children. No miscarriages. Labours always uncomplicated.
From early girlhood has had a small tumour on right side of chest. This commenced as a little wart, increased to the size of a walnut, and gradually acquired a pedicle. It was never painful, but it used to catch in her dress and she found this very inconvenient.
In the beginning of last autumn, her left breast began to get hard. There was not much pain in it at first. So she postponed from day to day seeking advice about it. She is five months pregnant. Cannot say which began first, the pregnancy or the hard breast.
Present Condition.—A pendulous lipoma grows from a thin pedicle on the right side of the chest, under the axilla at the level of the eighth rib. Complains of pain in the left breast, which is uniformly enlarged. The skin is tightly drawn over it and has a glazed appearance. The nipple is not retracted. There is no puckering of the mammæ. The whole breast is extremely hard throughout. On the surface the skin a firmly adherent to subjacent tissue. There is no adhesion to the ribs. The margins of the breast are hard, and cease abruptly in healthy tissue. Two small glands in the axilla are enlarged and hard.
I cut off the lipoma, and sent her up to Dr. Roddick, to show to his class, and also in order that I might have the benefit of his advice.
On the 10th April she was complaining of pain and debility. About four weeks after that I went to see her but found that she had moved. I found a sister of hers, and from her I obtained the following history. The debility had greatly increased. The axillary glands in the left side had become enlarged. The other breast had become similarly affected. At the seventh month of pregnancy labour set in. Both mother and child died about twelve hours afterwards.
Cancer of the breast occurring in pregnancy, is I think, a rarity, though I cannot understand why such should be the case. Very little mention of pregnancy is made in the many work srelating to disease of the breast. Mr. Heath* in one of his clinical lectures states that two conditions are not incompatible, and mentions the case of such a patient who went the full time and gave birth to a healthy child. Mr. John Woodf records a case where scirrhus occurring after pregnancy became complicated with milk abscess.
Mr. Nuun in his synopsis of 50 cases of cancer of the breast, mentions a patient who in September noticed her tumour, had it removed in January, and in the following April was delivered of a healthy child. The next June the right breast was attacked. I
* Lancet, Vol. 1, 71. p. 849.
I In the discussion which followed the reading of this paper, Dr. R. P. Howard and Dr. Hingston both mentioned cases where the two conditions co-existed.
Hospital Reports. MEDICAL AND SURGICAL CASES OCCURRING IN THE PRACTICE OF THE
MONTREAL GENERAL HOSPITAL.
Strangulated, oblique Inguinal Hernia.—Congenital.— Opera
tion.-Death.—Under the care of G. E. FENWICK, M.D.
Reported by A. W. Imrie, M.D., Assistant House Surgeon. R. M., a strongly-built machinist, aged 38 years, was admitted to the Hospital on Friday afternoon, June 6th, with the following symptoms and history:
Symptoms.—Excruciating pain, radiating from an elongated tense tumour in the right inguinal region—throughout the abdomen and down the thigh. Occasional vomiting, unattended by nausea, and obstinate constipation. Patient felt weak; extremites cold; countenance haggard and inanimate. Pulse regular and full, at 85 to the minute. Temperature 990.
History.-On the Wednesday evening previous, while working with an axe, he felt his rupture (present since childhood) suddenly grow unusually large and painful, and experiencing a sensation of faintness, he took to his bed, and so soon as he felt somewhat recovered from the shock, endeavoured by manipulation to return the intestine to the abdomen. Failing on this he soon had violent pain in his abdomen and thighs, and began to vomit, and these symptoms (vomiting and pain) he states persisted. On Thursday he sent for surgical aid, and the same evening an attempt was made to reduce the hernia under chloroform. A small portion of bowel appeared to slip back into the abdomen, and the tumour grew softer. Patient was advised to have himself removed to the Hospital where an operation would be done to relieve him. This he obstinately refused to do until this afternoon.
Diary and Treatment.—On admission the hernia was found to extend from anterior superior spinous process of the right ilium to the scrotum, to be uniformly smooth and tense. But one testicle could be felt, and that high up on the right side. The scrotum did not seem to be occupied by the bowel. Ice cloths were ordered to be kept constantly applied. Ice and milk in small quantities to be fed to the patient, and grain doses of opium administered every hour. On Saturday pain had subsided. Tumour felt softer; vomiting continued, and patient was somewhat exhausted. Hypodermic injections of morphia were substituted for the opium. On Sunday, the pulse (previously full and regular at 85 or 90 to the minute) had quickened and became somewhat easily compressible and irregular. Temperature 100° ; pain slight. Tumour soft. Vomiting and constipation persistent. Extremities blue and cold. Patient, after much persuasion, consented to submitt to the operation.
At four P.M., Dr. Fenwick proceeded to the operation. After ether had been administered, he made a free incision cutting through the structures, layer by layer, until he reached the sac. This was freely opened ; it contained a large quantity of serum, and nearly two feet of small intestine. The stricture at the internal ring, was very tight and unyielding, and had to be freely incised. A portion of the intestine was drawn through the stricture and examined, when it was deemed sufficiently healthy to return into the peritoneal cavity. This was done without difficulty, a drainage tube was placed in the wound which was closed with cat-gut sutures and the patient returned to his bed. The operation was performed with antiseptic precautions, but the patient never rallied, sinking gradually until seven o'clock, when he died.
AUTOPSY BY DR. OSLER. Body, that of a powerfully-built man ; no hair on the face ; only a few bristles on chin.
On opening the abdomen, omentum is injected and is attached in right inguinal canal. Lower coils of intestine injected, and toward the ileo-cacal valve dark-coloured, and at one point there is a definite constriction, immediately above which is seen a tiny orifice through which the contents of the bowel are escaping. On removal and careful inspection of this part of the bowel, it is seen that the nipping has taken place just three feet from the valve ; at the point of constriction the tissues are soft and necrotic in a band extending round the gut and about three lines in width. For eight inches below this the bowel is dark-coloured, peritoneum opaque, and intestinal wall sodden, but scarcely looks gangrenous; the next twelve inches are not so dark. The perforation is just above the constriction and is not much larger than the head of a pin. The intestine beyond it is tolerably natural, walls relaxed, and here and there are a few ecchymoses. A few ounces of dirty semi-feculent fluid in pelvic cavity. Very little lymph. Right inguinal canal is large, readily admitting two fingers, and leads to a large scrotal sac.
On examination it was seen that the patient has been the subject of undescended testes, the right organ lay just at the