Hackney Road, London, E., April 10th, 1886.

THE GEDDES MANUFACTURING CO.,

College Chambers, 249 High Holborn, London, W.C.

Gentlemen,

I have used Geddes' Extract of Hemlock Bark in the most stubborn case of chronic Leucorrhoea, accompanied with ulceration, which had come under my observation during five and thirty years of constant practice. The case was that of a married lady, thirty-three years of age, whom I had given up as past recovery, and on whom I had exhausted every manner of treatment then known to medical science, but happily the new discovery of your Extract has enabled me to effect a perfect cure of my patient. I have no hesitation in saying your Extract saved this lady's life. I have much pleasure, gentlemen, in wishing you great success.

Yours very truly,

H. P. MACKENZIE, M.D.

FOR INFLAMMATION OF THE WOMB, VAGINAL AND UTERINE LEUCORRHEA, and other conditions of a similar nature. First cleanse the parts thoroughly with vaginal injection of warm water and white castile soap; this being done, use as a vaginal injection two table-spoonfuls of Extract to one quart of luke-warm water, morning and night. In severe cases, use three times daily, and oftener, if necessary. If the parts are highly inflamed, use a weaker solution at first, which gradually ncrease to above.

THE GEDDES MANUFACTURING CO.,

COLLEGE CHAMBERS, 249 HIGH HOLBORN, LONDON, W.C.

DUBLIN DEPOT:-R. SIMPSON & CO., 16 HENRY-STREET.

Medical Gentlemen who are unacquainted with the nature of our Extract, and wish to give it a trial. will, on application to our London Office only, be furnished with one regular-sized bottle free of cost, by parcels post (wherever the parcels post system exists).

MEDICAL OBSERVATION

MEDICAL SCIENCE.

JULY 2, 1888.

PART I.

ORIGINAL COMMUNICATIONS.

ART. I.-The Diagnosis of Cancer of the Testis. By WILLIAM COLLES, M.D., Univ. Dubl.; Fellow and Secretary, R.C.S.I.; Surgeon-in-Ordinary to Her Majesty the Queen in Ireland; Regius Professor of Surgery in the University of Dublin; Surgeon to Steevens' Hospital.

I FEAR surgeons of the present day have little cause for congratulating themselves on an improved knowledge in the diagnosis and treatment of Malignant Disease. Although the subject has engaged the attention of many surgeons, and many elaborate works have been written, chiefly on that part relating to cancer of the breast, our present experience as to diagnosis and treatment seems to differ little from the experience of a century ago.

A female complains of a tumour in the breast; this, especially if attended with any pain, is at once suspected to be of a cancerous nature, and its speedy removal is recommended. To this proceeding the patient, alarmed at the very mention of the disease, often readily consents; and it has been even added that, if not absolutely cancer, if left it may become changed and assume the malignant type. Should the operation be successful, and should no sign of the reappearance of the disease occur for two or three years, it is considered as a triumph of surgery, and the eradication of a malignant disease; whereas what has happened is perhaps more readily explained by considering the part removed was of the nature of a benign tumour, the idea never suggesting itself to the mind of the VOL. LXXXVI.—NO. 199, THIRD SERIES.

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surgeon that had he allowed the tumour to remain the result might have been the same. Should the disease return after a year or two, the surgeon regrets that he had not seen the case early enough, or that he had not removed a sufficient portion of the patient's body; and thus he is encouraged to seek earlier operation and more extensive excision, ignoring the fact that it is the nature of a malignant tumour to return in a longer or shorter time, and this could not be prevented had he operated, no matter how early. He should consider that the tumour differed from the former case, although he could not find out the difference between the two forms of disease. A question still remains to be considered-Had he known the real nature of the disease, ought he in every case to recommend an operation to remove a disease which he knows will certainly reappear in an average space of two years?

All authors are agreed that there are a very great number of cases in which the patient refuses to submit to operation, or an opinion is given adverse to this proceeding, in which the patient has lived from ten to fifteen years afterwards, and has suffered at times very little pain. In this case an operation would be often very injudicious, and would perhaps deprive the patient of some years of existence.

May it not be the case that, as we see in adenoid tumours of the breast, the advent of puberty often has the effect of removing these tumours; so in adult age, the cessation of menstruation may have some effect in mitigating the virulence and activity of the disease, as we find to occur in some tumours of the uterus? We hence require further investigation to enable us to distinguish— (1) what tumour may remain in the breast and not interfere with the patient's health, or, if removed, will not return; (2) in what tumours an operation will benefit the patient, andalthough not prolonging life-will render it more endurable; and (3) in what cases the operation will be injurious, when it seems to accelerate the activity of the morbid changes, and hasten the return of the disease.

I regret I am unable to make any suggestions as to the means of investigation requisite to clear up these difficulties. At present I wish to draw attention to a more malignant form of disease, and one in which a surgeon is at times exposed to much obloquy. I allude to the malignant disease of the testis known as cerebriform or encephaloid cancer of the organ. In general the commencement of the disease is denoted by the occurrence of a hydrocele,

which is probably the result of the irritation produced by the altered condition of the organ.

The course of events, then, is as follows:-The patient applies to the surgeon for the treatment of a hydrocele apparently simple, the transparency of the tumour, situation of testis, and all other symptoms being present.

The surgeon does not hesitate as to the nature or treatment of the disease, and proceeds to tapping, which operation he performs to his own and the patient's satisfaction. Before leaving he tells the patient that only a palliative treatment has been adopted; that he must expect the fluid to be again secreted, and that the tumour will require to be tapped again in from four to six months.

About this period the patient returns, the tumour apparently having regained the size it formerly possessed. The surgeon, feeling the tumour soft and fluctuating, has not much doubt on the subject, and again proceeds to endeavour to draw off the fluid. He passes in the trochar and canula, but on withdrawing the trochar he observes some blood to flow, and at times this alarms him, and he withdraws the canula and closes the wound. I have seen a case in which, however, suspecting that some blood may have been mixed with the fluid, either from some injury or the trochar wounding a vein, he had allowed blood to flow to the extent of a few ounces, till he saw that, although the blood came away, there was no diminution in the size or tension of the tumour; finally, the patient becoming weak from loss of blood, he became alarmed and closed the wound.

The surgeon then tries to find the cause of this failure and to investigate the nature of the disease, but he finds much difficulty in distinguishing between the symptoms of hydrocele and those of malignant disease, a few drops of blood or slight thickening in the sac rendering the ordinary test of transparency unavailing. There may be a slight blush of dusky-red colour on the scrotum, and the veins may appear slightly enlarged and more numerous. We must therefore come to examine more closely the symptoms which may distinguish the two diseases.

In hydrocele, the testis can be grasped at the lower and back part of the tumour; and by forcing the fluid from its proximity, it feels quite smooth, and gives the patient the sensation of pressure on the organ. In encephaloid, the testis cannot be so readily separated; the tumour may be felt, but is hard, irregular on its surface, and does not give the same sensation to the patient. In

examining the bulk of the tumour in malignant disease the sense of fluctuation is most deceptive. Still it is not so soft and yielding as in hydrocele; in the latter it can be moved about from one part to another, and may change its form on change of position. On palpation, also, it will feel much more yielding, and give the sensation of undulatory motion in the fluid. In the malignant disease the semi-fluid substance cannot be moved from its position, because it is confined by the tunica albuginea of the testis.

In the hydrocele the fluid is very movable, yielding in every direction, especially if the patient be standing; it can be pushed up so as to fill the upper part of the tunica vaginalis, and distend the sac up to the external ring.

The condition of the inguinal region affords us much assistance in our diagnosis. In malignant disease, the cord is readily felt; it may be enlarged, but it can be moved under the fingers, and no other substance can be felt. In the hydrocele, at first when small the cord may be felt, but we always feel a portion of the tunica vaginalis more or less distended with fluid. As the hydrocele increases it expands all the cavity of the sac up to the ring; this acts as a wedge separating the integuments from the abdominal parietes, and by this means burying the penis, so that when the hydrocele becomes of great size the organ is invisible, its outline can be marked or felt by a ridge of integuments along the inner side of the tumour, and several concentric folds of integument alone mark the orifice from which the urine flows. In this case, when the fluid is drawn off, the penis is gradually restored to sight, and the patient rejoices to see his old friend return. This burying of the penis is much more marked, or occurs much more rapidly in large scrotal hernia when irreducible or left without a truss, because the force distending the canal is much more effectual, as it is more solid and irresistible.

These are the principal points which will guide our diagnosis in this form of disease. As to progress and treatment, little remains to be recorded. The disease may have a fatal termination, either by local or by constitutional contamination. I have seen a tumour of the liver of great size show itself before the wound made by the operation was healed; the glands deep in the pelvis also become much engorged; or the patient may die from acute lung disease. Nor is this last-named termination to be regretted, for nothing can exceed the misery of the patient when the return of the disease