in the absence of symptoms of peritonitis are by no means common. It is then mainly upon this point that we must rely before proceeding to operation." 485.

We quite agree with the author that the adhesions are rarely extensive without previous symptoms of peritonitis, and, allowing the extirpation of the diseased ovary to be a justifiable operation, we think that, in the absence of these symptoms, it may be undertaken with every prospect of being completed, and the operator may find encouragement in the fact furnished by Mr. Phillips's tables, that of the forty cases in which adhesions were found, twenty-six survived, which is at the rate of sixty per cent., whereas of the whole eighty-one operations, forty-seven recovered, or fifty-eight per cent. The great danger of this operation arises from peritonitis, and so far as our present experience warrants a conclusion, that danger is not increased by previous inflammation of the serous membrane and its consequences, adhesions, though their existence necessarily leads to greater disturbance of the important parts exposed in the operation.

The next point considered is whether the results on record justify us in preferring extraction to any other plan of treatment. We know that the operation for extraction is one of a very serious nature, but have we any other means of cure to propose? All internal and external remedies have failed. We may advise the patient to bear her sufferings, reminding her that large tumours of the kind have remained stationary for twenty years and more. But these are exceptions, and when the case gets worse, will you advise tapping, or the more serious operation of extracting the cyst? The tumour may not be fluid, but if it be so and you tap it, the cyst be comes refilled, it may be slowly, but usually in a few weeks, and thus repeated tapping is necessary, the intervals between the operations diminishing until the patient dies, worn out, the average duration of life from the first tapping not exceeding four years. On the other hand, "extraction, though not a very painful, is a dangerous operation: the experience we possess justifies us in the expectation that, in forty-four cases out of one hundred, the tumour may be extracted, and life saved: but at the same time it cannot be concealed that, out of the eighty-one operations to which we have referred, thirty-two died, and that soon-in fact in a few days."

The author remarks that, in many cases where disease affects one ovary to a large extent, it affects the other, though to a smaller extent; and it is possible that when the disease is removed from one ovary, the nutritive action which was previously directed upon it, may afterwards be concentrated on the remaining point, and cause its rapid development. This ground of apprehension appears to us chimerical. It would be as reasonable to decline an operation for lithotomy because of the liability which must remain to the formation of a fresh concretion, as to object to the extirpation of one enlarged ovary, in consequence of the remaining one being liable to become affected with a similar disease.

There is one material point bearing on this operation, overlooked by Mr. Phillips, which it may be as well to notice here, viz. whether the cystic disease to which the ovary is subject, is of a malignant character or not. Mr. Cooper states, in the paper which we have reviewed, that Dr. Bright, Dr. Hodgkin and Mr. T. King believe it to be so. There can be no doubt but that the ovary is liable to malignant disease, and that a malignant growth sometimes co-exists with the cystic disease; but if we could come

to the conclusion that ovarian cystic tumours 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 intolerable 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 tumour 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 analysis 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 obtained 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 the 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.

Carcinoma in any part of the body is a terrible disease. In the mamma, the uterus, even in the lip, it is a horrible affliction. In the lungs, and 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 fetid breath to which we have alluded. It was a young married female, aged 20 years, who entered St. Bartholomew's Hospital 22d 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 ala 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 dyspnea 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 par

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."

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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 tumour 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 tumour, which forced the lung upwards from the spinal column. The middle lobe was intimately connected with these tumours, 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 tumours were made, they appeared one continuous mass of carcinoma. Their substance was mostly of a 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."