to the conclusion that ovarian cystic tumors are generally of a malignant nature, which is known to be the opinion entertained by Dr. Hodgkin, we should at once decide against the propriety of extirpation in any case, for it would always be impossible to ascertain beforehand that the disease is limited to the ovary. But, notwithstanding the high authority of Dr. Bright and Dr. Hodgkin, we have no hesitation in expressing the opinion that the ordinary cystic enlargement of the ovary is not of a malignant character, and may be extirpated without risk of leaving behind the germs of future disease in other parts.

With regard to the operation which should be selected, a point on which it appears that much difference of opinion exists, the calculations from the table tell, as we have already shown, rather in favour of the minor operation; the proportion of recoveries being forty-eight per cent, whilst in the cases of the major operation it was forty-two. Mr. Phillips's observation of the smaller incision is much more favourable: the operations being six, the successful cases five. Cases, however, may occur, in which an enlargement of the incision is absolutely required, as when the contents of the cyst, instead of being fluid, prove to be solid; but he observes, that circumstance does not in any way militate against the plan of making as small an incision as is consistent with the easy removal of an emptied cyst, provided it be large enough for the convenient application of the ligature round the peduncle. The statistics of the operation at present are by no means sufficient to decide this question. The length of the incision seems to us of less importance than the gentle manipulation of the parts, as we believe that the risk of peritonitis is very slightly if at all increased by the extension of the incision, certainly not so much so as by any force or rough handling which may be necessary if the space allowed for the manœuvres of the operator be too limited.

The author's tables are defective in some particulars, which it is impossible for him at the present time to supply, but which we hope may be obtained at some future period, as they are of the utmost importance in determining the utility and necessity of the operation. It is desirable to know the duration of life and state of health enjoyed by patients after the operation, and whether persons, one of whose ovaries has been extirpated, have suffered any serious inconvenience from the incision in the abdomen and adhesions between the viscera, the result of peritonitis.

It must be observed, in conclusion, that the members of the Society, and indeed the profession, are under obligations to Mr. Phillips for the information which he has submitted to their consideration, and the importance of the subject and the many interesting points sub judice, upon which the facts accumulated in this paper bear, have led us to quote largely from it. It is not difficult to perceive that the tenour of the author's remarks is in favour of the operation, but it might have been expected that he would have given an opinion on the subject, based on the facts which he has taken so much pains to collect. Mr. Phillips has himself extirpated an ovarian cyst, has witnessed its performance by others in several cases; he is a lecturer on surgery, and is known to have paid considerable attention to the statistics of operations. We think therefore that he might without presumption have expressed something like a confident opinion on the propriety and value of the operation. For our own part we have for some time come to the

conclusion, which is rather confirmed by the facts here presented to us, that, under the circumstances of a disease which, on the one hand, may not destroy life for years, and commonly admits of palliative treatment and temporary relief; and, on the other, can only be radically cured by means which it is nearly an even chance will destroy life within a week, the surgeon is not warranted in recommending so dangerous an operation to his patient. At the same time we do not altogether object to its performance. It sometimes happens that persons have to decide for themselves on what terms they will continue to enjoy life. What is tolerable to one may be in tolerable to another, and many look with dismay on an operation to which others would cheerfully submit in order to be relieved from distress and inconvenience. A person with a large incurable ulcer on the leg, or with a permanent contraction of the knee-joint, will sometimes desire amputation rather than bear the constant annoyance of these complaints, and though the operation is one dangerous to life, the surgeon is held to be justified in complying with the wishes of the patient in performing it. The case of an ovarian tumor appears to us to belong to this class. We should not recommend the operation, but if a patient of sound constitution be anxious, after the risks of an operation have been fairly stated to her, to incur these risks in order to get rid of so serious, and in the end so fatal a malady as this disease, it is the duty of the surgeon to operate. We know of a case of recent occurrence in the country, in which a talented surgeon most reluctantly undertook the operation at the urgent desire of the patient. The result was perfectly successful, and no one who contrasts the present healthy condition of this person with her former state and prospects, notwithstanding the dangers incurred, can question the discretion of the operator in yielding to the pressing wishes of the sufferer.

XII. ON THE STATE IN WHICH THE URIC ACID EXISTS IN THE Urine. By Henry Bence Jones, M.A. Cantab.

The author first gives the opinions of the chief chemists on this subject. Berzelius mentions Dr. Prout's view of the uric acid existing as urate of ammonia, and then states his own, that uric acid most frequently is in an uncombined state; but perhaps modified by the presence of other matters. Dr. Simon thinks that urine may contain free uric acid, and also urate of ammonia. Becquerel says, that the ordinary fine amorphous powder which is deposited from acid urine, consists of uric acid combined with colouring matter and the (so called) extractive matters of the urine. We shall not follow the author in the analyses detailed in this paper, but must refer those interested in the subject to the work itself. It will be sufficient to observe that, from his experiments, it appears, that urate of ammonia, when dissolved with about an equal weight of salt, acquires a greater degree of solubility in water, and a difference in appearance from pure urate of ammonia. The appearance is identical with that deposit which can be ob tained from urine, and the solubility is more than double the solubility in distilled water. The author tried what effect the salt would have on pure uric acid. He found one part of uric acid remained in 8.941 parts of water, at 68° F., and one part of uric acid, with salt, remained in 7.199

parts of water at 64° F. These results tend to establish Dr. Prout's opinion, by showing how urate of ammonia is modified in form and solubility. The experiments made by Dr. Jones may give a further insight into the various cause of that frequent deposit of urate of ammonia which occurs in health. A small quantity of salt increases the solubility of this substance; the muriate, the sulphate, and the acetate of ammonia, lessen the dissolving power of distilled water. He concludes, " it is most probable, that each salt that occurs in the urine has some effect on the solubility of the urate of ammonia; and it may be by a very extended inquiry into the relative re-action of the different salts, more particularly the phosphates and sulphates, that we may arrive at an accurate knowledge of the causes of the frequent deposit of urate of ammonia in the urine."

XIII. CARCINOMA OF THE LUNGS. By George Burrows, M.D.

In the mamma, In the lungs, and

Carcinoma in any part of the body is a terrible disease. the uterus, even in the lip, it is a horrible affliction. especially in its open state, it is the most direful of all. A few years ago we attended a young married lady, who laboured under this disease. The breath and the expectoration emitted such a malaria, that it was scarcely possible to stay a quarter of an hour in the same room with her, and the effluvium was so dreadful to herself, that she twice attempted suicide! The odour of cancer is so peculiar that no person can mistake it. It differs totally from that horrible stench attendant on gangrene of the lung, and is, alas! much more lasting before life becomes extinct. This lady laboured under the malady for years before death terminated her sufferings.

The case which Dr. Burrows relates, did not, apparently, arrive at the state of open cancer, and did not present the fætid breath to which we have alluded. It was a young married female, aged 20 years, who entered St. Bartholomew's Hospital 22nd April, 1843. She had been ill only six months. She complained, at first, of pain beneath the sternum, loss of appetite, cough, and some expectoration, followed by want of sleep, emaciation, and perspiration. A month previous to admission, had an attack of hæmoptysis, succeeded by a pink-coloured sputum. She suckled a healthy child three months old. On admission, she presented the following phenomena :

"The face pallid, rather full and oedematous, with a dark areola around the eyes; the lips rather livid; the alæ nasi acting violently with each inspiration; respirations 40 in a minute; the pulse 132, rather small, bounding, but soft, and increased to 160 when she assumed the sitting posture in bed; the decubitus on the back, but inclining to the right side.

"She complains of weakness, pain between the shoulders, and gnawing pain in the epigastrium; also of shortness of breath and of frequent prolonged paroxysms of ineffectual cough, which are followed by urgent dyspnoea amounting to panting; the sputa are scanty, glairy, intimately blended with blood, and of a uniform pink colour, resembling currant-juice; the glandulæ concatenatæ on the right side of the neck are swollen, hard and tender, with some distended veins passing over them. The glands on the left side of the neck are also slightly enlarged, and the left external jugular vein distended. The tongue clean and moist, the abdomen full, soft and rather tender on pressure in the umbilical

region; the bowels open twice daily; the catamenia had not appeared since parturition." 122.

On auscultation, a clear exaggerated respiration, with an increased resonance on percussion, were audible over the left lung-on the other side, a diminished resonance in the upper part; while below the third rib, in front, and beneath the spine of the scapula, there was complete dulnessthis dulness extending down to the right hypochondrium. There was a feeble respiratory murmur in the upper part of the right lung. The heart's sounds were natural. The diagnosis was, that she laboured under "extensive malignant disease of the right lung."

We need not follow the details. She died on the fifteenth day after admission.

"The right pleura was distended by Oiv. of an olive brown coloured serum. In spite of this large collection of fluid, the right lung had not collapsed, but stood out firm and prominent into the pleural cavity. The upper lobe of the lung was not much altered: its substance was tough and crepitating on pressure, the middle and lower lobes when handled felt solid. A white lobulated tumor of a dull white colour, something like a mass of suet, projected from the middle lobe of the lung; it was somewhat yielding on pressure, and in close apposition with the right side of the pericardium. Towards the root of this lung was another similar tumor, which forced the lung upwards from the spinal column. The middle lobe was intimately connected with these tumors, and much resembled them in external appearance. The pleura covering the lower lobe was rough and dark-coloured, with enlarged, congested, varicose blood-vessels, ramifying on the surface.

"When sections of the middle lobe and tumors were made, they appeared one continuous mass of carcinoma. Their substance was mostly of an uniform dull white colour, and rather soft; in some parts the substance was pinkish or red, as if vascular, and in other points, especially in the situation of the bronchial glands, the cut surfaces were streaked with black lines and spots, and divided into oval segments. The surfaces yielded on compression a white creamy fluid in considerable quantity." 127.

The diagnosis formed at the beginning, was, if no good luck occurred, one of those extreme instances of auscultic science, which happen once in a century, and to one in a thousand practitioners. We would not advise the tyros of the profession to stake their diagnostic knowledge every day on such minute distinctions. It is only by the “tactus eruditus" and the exquisite ear of a master in the art of percussion and auscultation, that a man can hope to predict with the accuracy presented in the foregoing case. We agree with the talented author, that when such a malignant disease as the above is detected during life, the exhibition of mercury, long repeated counter-irritation, frequent blood-letting, &c. " can only impair the vital powers, without arresting the local complaint." But is not the same reasoning to be applied to almost every disease so interfering with the functions of respiration? Can we cure old-standing consolidation or tubercular infiltration of the lungs by medicine? We fear not. "Optima hic est medicina, medicinam non facere."

XIV. CASES OF ACUTE DISEASE IN THE THROAT AND LARYNX. By Dr. James Arthur Wilson, Physician to St. George's Hospital.

There can be no doubt that many lives are lost by the above inflammations for want of tracheotomy. In Nov. 1830, Dr. Wilson, with Dr. Nevenson and Mr. Keate, attended a gentleman who died of cynanche supervening on erysipelas. On examination, the epiglottis and posterior membrane of the tongue were found to be highly vascular and thickened, and pus was infiltrated in the cellular membrane of the fauces. The larynx, below the corda, vocales, and the trachea were free from disease or obstruction. Here was a case where tracheotomy would have saved life, almost to a certainty. The event made a deep impression on Dr. W.'s mind, and was of service thirteen years afterwards.

Case. Mr. W. C. aged 27, full habit, got heated at a ball, and caught cold going home. He was unable to sleep, from general uneasiness and sense of choking on attempting to swallow. Leeches, calomel, and other measures, were employed; but the breathing was not relieved, even by the abstraction of twenty-four ounces of blood from the arm. In the evening of July 8, 1843, he was in extremis, and Mr. Keate exposed the trachea below the thyroid gland, and made an opening into it, inserting a canula in the aperture. Instantaneous relief was the consequence.

"On the first rush of air into the trachea, the patient appeared to feel instant relief, and his countenance began at once to assume its natural expression; but from this time not two minutes could have elapsed, when he was suddenly attacked by most violent spasms of his whole frame, with a struggle for breath, as if threatening immediate suffocation. All consciousness directly ceased, the eyelids closed, the face was livid, the features were distorted, the blood, still bubbling from the wound, became suddenly black as ink. The breath was drawn convulsively, and at long intervals. All movement, excepting that of the pulse, had ceased, and the patient appeared, literally, at his last gasp. During this awful crisis of the young man's fate, which lasted for perhaps a minute, (seemingly for a much longer time,) his head was held forcibly back,-the canula was withdrawn, and the orifice in the trachea cleared from blood, and kept widely open. The breathing at length became more natural; the face, no longer ghastly, began to resume the character and tint of life. Not long after this most fearful convulsion, a large quantity of mucus, mixed in part with blood, was rejected, in long viscid ropes, from the mouth; and it was then found that the patient again breathed through the larynx. Upon this, the canula was finally withdrawn. A profuse perspiration now burst forth from the face, neck, and chest of the patient, who gradually recovered his consciousness, and expressed by writing that his 'breathing was quite easy.' He slept at intervals during the night, and was convalescent from this time.” 140.

Although, as Dr. Wilson remarks, the operation can hardly be too late, yet the chance of success is greatly lessened by delay, because the patient is being poisoned by his own blood. There is a good deal of management necessary in preventing the blood from flowing down the trachea into the lungs. The operation of tracheotomy has now been so often performed with success, that no patient should be allowed to be suffocated by obstruction about the throat, without opening the wind-pipe. A gentleman of our acquaintance breathed more than twenty years through a tube.