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On examination, I discovered that the abdomen was tense and larger than I had seen it five months and a half before; the tumor had increased in size, it was painful, and the abdominal veins were prominent, a fact which I attributed to an interference in the circulation due to mechanical pressure exerted by the tumor upon the visceral organs, and probably more so upon the vena cava. The child was at the time frequently passing large quantities of urine very highly colored; the tongue was coated and there was some pyrexia of a hectic type. My diagnosis was displacement of the right kidney and probably pyelitis, an abscess, or the formation of a phlegmon about the said organ due to the direct injury inflicted by his having fallen the second time. The child continued suffering, became very much emaciated, vomited, had oedema of the feet and legs, slight convulsions, and finally died, seven and a half months after the first accident and three months after the second; having enjoyed between these two periods excellent health for two and a half months.

I am somewhat gratified at having the opportunity of presenting to you to-night the abdominal tumor, which proves to be a pyelonephritis of the right kidney, and regret much at the same time my inability to impart to you the result of the post-mortem examination, inasmuch as I have not been favored with the desired report, as might have been expected under ordinary circumstances, notwithstanding my most sincere efforts. Without wishing to become poetical, I trust that you will permit me to quote the following lines:

"He either fears his fate too much,

Or his desserts are small,

Who dare not put it to the touch

And win, or lose it all!"

I am therefore forced to accept the information volunteered to me by the child's grandmother, who naturally is an intelligent person, of clear perceptions, and reliable as to her statements. She informs me as follows:

"I witnessed the post-mortem examination on account of it being my personal desire to ascertain what really was the disease the child had; I did not wish to be told, I wanted to see. When the abdominal cavity was opened, I saw a large tumor, the one you now possess, bulge out; and I then suggested that I wanted to see the kidneys. The doctor was very kind, and showed me the left kidney, then the spleen. I then asked to see the other kidney. The operator passed one of his hands under the tumor that I had seen when the abdominal cavity was opened, and, after some delay, plainly remarked: The right kidney is not here.' I then asked, Where is it? Is it that tumor?

I was told, 'Yes, this must be the kidney!' The tumor was then removed and cut into on one side; but I really did not see anything suggestive to my mind that looked like a kidney. I have seen many animals butchered; and from what I can remember all the other organs appeared healthy."

[graphic][subsumed]

Incision found made into the pelvis of the kidney, showing nothing be-
yond a mass of coagulated fibrin.

The tumor weighed, when I became the possessor of it, two pounds and eight ounces, and was as large as a child's head. On one side of it there was a fluctuating prominence; on the other, it was discovered

that an incision had been made at the post-mortem examination, with the object, probably, of ascertaining its nature.

On examination, I found that the cavity thus made was filled with large masses of what I supposed to be coagulated fibrin. In my judgment, quite a large amount of blood and pus must have been found

[graphic][subsumed]

Incision made into the fluctuating prominence, showing the kidney
previously conjectured.

when the tumor was incised. Externally, the tumor presented a thick fibrous membrane or capsule, and the surface thereof remnants of a pre-existing amount of inflammatory adhesions. There was no evidence at all, however, as it will be apparent to you on examination of the tumor, of it being or having been a kidney, such an assumption could only have been the result of a hasty examination, or the earnest

necessity or desire to account for the organ sought after. An incision similar to that found was made into the fluctuating prominence previously referred to, from which about two or three ounces of pus and blood escaped, and within the kidney, previously conjectured but not demonstrated, was discovered. It then became evident that the incision previously noticed had been made lengthwise and into the pelvis of said organ, revealing, as it does, nothing beyond a mass of

[graphic][subsumed][merged small]

coagulated fibrin and inflammatory products, evidently due to a hæmorrhage immediately following the last injury. The microscopical examination reveals a general parenchymatous nephritis. The epithelium is found generally detached from the uriniferous tubules, and to have undergone a granular and fatty degeneration. Within the tubules, epithelial casts are quite abundant. The capillary blood-vessels are distended and filled with blood corpuscles, due to a congestion and probably to an interference in the return of the circulation. Between the tubules there is to be seen an abundant increase of connectivetissue and some astray leucocytes infiltrating the parenchyma generally. Examination of the supposed masses of fibrin found within the cavity corresponding to the pelvis of the organ, into which an exploratory incision had been made at the post-mortem examination, verifies the previous belief of it being composed of coagulated fibrin, holding in its meshes blood corpuscles and leucocytes. There was nothing found

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indicative of tuberculosis or of a malignant nature.

The spleen

weighed twelve ounces; it was firm, and its capsule had undergone a fibroid thickening. The cut surface is smooth, sharp, shining, and presents a fleshy appearance, marked with whitish stræ, due to thickening of the trabecule. The only change observed, microscopically, is an overgrowth of such tissue-elements as normally exists; the stromæ, however, is well defined fibrous. The sinuses are distended and contain loose endothelial cells, blood corpuscles, and leucocytes; the latter are especially noticeable in the neighborhood of blood-vessels. The pathological conditions herein observed are probably due to a chronic venous congestion.

REPORT OF CASES OF CARCINOMA OF THE BREAST,
OBSTRUCTION OF THE BOWELS, TIGHT STRICTURE
OF THE DEEP URETHRA AND STONE IN THE
BLADDER OPERATED UPON DURING THE
YEAR 1889.

BY LEWIS S. PILCHER, M.D.

Read before the Brooklyn Surgical Society, February 20, 1890.

CARCINOMA OF THE BREAST.

Five cases of carcinoma mammæ et axillæ have been subjected to operation during the year 1889. In all the disease had been allowed. to run on unchecked until the amount of gross infiltration of the breast and of the axilla had become quite extensive. One patient, forty-three years of age, had become aware of a hard nodule in the right breast fourteen months previously. Little attention was paid to this tumor, until at the end of a year some oedema of the inner side of the arm awakened alarm, and I saw her for the first time. Extirpation of the mammary growth, together with complete cleaning out of the axilla, was done at once. A fine line of induration was traced up beneath the clavicle, and a second incision along the under edge of the clavicle was made, giving access to the space between the deltoid and clavicular portions of the pectoralis major. At this point, from under the clavicle, a minute indurated gland, the size of a linseed, was extirpated. Six weeks later, attention was called to an indurated nodule, which could be felt deep in the neck behind the clavicle, beneath the outer border of the clavicular insertion of the sterno-cleido-mastoid. An immediate attempt to remove this was then made. The parts were exposed

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