we must follow it through the rent into that cavity, or, if this cannot be done, the Cæsarian section may be had recourse to, which also affords the only means of treating rupture of the uterus occurring during gestation.

6. Vesico-vaginal Fistula.-These accidents, so deplorable in their effects upon the woman's comfort, are not rare. Some one of the following circumstances may give rise to them: wounds and injuries of the vagina by instruments, pessaries, &c. or from the pressure of the child's head-too prolonged retention of urine-laceration of the bladder, &c. The following rule is a good one.

"In all cases, a careful examination should be made, by passing the catheter into the bladder, and a finger into the vagina; then placing the points of both in apposition, the whole posterior surface of the bladder should be passed over, and carefully examined.* At some one point the finger and catheter will come in contact: the catheter may then be passed into the vagina, and the extent of the damage ascertained." 384.

We will not follow the author in his long and interesting detail of the various means which have been tried for the cure of these dreadful cases.— Indeed, upon this point we are almost in despair, having witnessed how little success attended the persevering efforts of the late lamented Mr. Earle, who brought to the task all that a sympathising humanity, unwearied patience, great mechanical skill, and a profound acquaintance with the powers and resources of nature could furnish. However, much may be done for palliation of this disgusting and distressing infirmity, and we will extract the author's description of some of the means.

"Dr. Gooch, in 1814, suggested to Mr. Barnes the employment of an Indiarubber bottle, of sufficient size to fill the vagina, and having upon one side of it a small piece of sponge, to be applied to the fistulous opening. Mr. Barnes used this with great benefit to his patient."-Med. Chir. Trans. Vol. 6, p. 586.

"Dr. Evory Kennedy has succeeded in taking casts (with wax) of the vagina with the fistula, in several cases; and from them he made moulds, and had caoutchouc bottles cast in the moulds. These were large enough to fill the vagina, and to close the outer opening, so as entirely to prevent the escape of urine.

I have attained the same object by means of a piece of sponge covered with thin bladder. It should be large enough to fill the vagina and of a suitable shape. A narrow neck, of the dimensions of the vaginal orifice, is to be formed, by wrapping it with twine, which is to be covered with lint. The whole has much the shape of an egg-cup. It should be dipped in oil previous to being used, and then it can be easily introduced, and the stalk filling up the external orifice, no urine can escape. It can be removed and replaced by the patient herself." 400.

7. Laceration of the Perineum.-This is most likely to happen in first

*"This is the more necessary, inasmuch as a temporary incontinence of urine is not uncommon after delivery. It generally also comes on soon after labor, so that at first either may be mistaken for the other. A vesico-vaginal examination will always enable us to distinguish them. This incontinence, which arises from a species of paralysis of the bladder, is best treated by the frequent evacuation of the urine-rest-and, when the lochia have ceased, by cold bathing."

labors. Its extent is very various; thus, the rent may extend only to the sphincter ani, or it may involve it; in other cases the rupture may take place centrally, having the fourchette and the sphincter untouched; again, the posterior part of the sphincter may be torn open into the rectum, leaving the anterior part of the plane of the perineum untouched.

The causes of the accident enumerated by the author are numerous. Thus the sacrum may be too perpendicular, so that the head will be forced down upon the posterior part of the perineum; so also, if the arch of the pubis be too acute, preventing the head fitting into it, it will be forced with more than ordinary violence against the perineum; the too rapid progress of the head, either on account of the violence of the pains, or from its too small size, will throw it too directly upon the perineum, without its having received the requisite changes of position during its passage through the pelvis ; excessive breadth of perineum may produce the accident, by letting the head rest on the centre instead of gliding towards the anterior edge; again, rigidity of the perineum, an old cicatrix, pelvic exostosis, a weakening of the perineal tissue by previous disease, an occlusion of the hymen may each be a cause, as also may malposition of the child's head, by presenting a too long diameter. Præternatural presentations, by not adapting themselves to the configuration of the parts, are more likely to cause the rupture than head-presentations. The awkward position of the woman, her starting away, or employing too strong bearing-down efforts, may each contribute to the production of this disaster. Lastly, it may be torn by instruments, which should, as a general rule, be removed just before the head passes through the vaginal orifice. We copy the author's valuable directions for the

I

"Preventive Management.-1. Defects in the passages, which render the mechanism of expulsion inefficient, may often be remedied by the application of the hand in such a manner as to give a direction forward to the head. 2. Direct support should be given to the perineum when distended; but this is frequently carried to excess, and produces the accident it is intended to prevent; it should be moderate and gentle-just so much as to support the parts and no more. must altogether object to any attempt to retard the passage of the child as erroneous in theory and mischievous in practice. 3. When the perineum is rigid and undilatable, benefit may be derived from fomentations with hot water, the use of warm oil, lard, or pomatum. 4. Under no circumstances is it justifiable to dilate the external orifice with the hand, as formerly recommended; on the contrary, instead of drawing back the perineum, it ought to be carried forward 5. If laceration be threatened in consequence of the persistence of the hymen, it may be incised with a blunt-pointed bistoury. 6. The patient should always cease forcing, and remain perfectly quiet during the exit of the child."

408.

As to the means to be employed for the curative treatment we must refer to the work itself, merely observing that slight cases require little or nothing to be done.

8. Phlegmasia Dolens.--Although this may occur after a first labor, it is more frequent in women who have borne several children. Delicate women are especially liable to it, and particularly if they have suffered from uterine irritation during or after labor. After taking an historical survey of the various opinions as to the nature of phlegmasia dolens, the author thus expresses his own.

"It is evident, that if we take pathological anatomy for our guide, we must conclude the disease to consist in inflammation of the veins of the lower extremities, in many cases propagated from the veins of the uterus; and that the interruption of the circulation through these vessels gives rise to the effusion in the cellular tissue. This view also derives some support from the phenomena which result from phlebitis in other situations. At the same time it is not impossible that some further information may be necessary, before we fully comprehend the true nature of the disease." 419.,

We think the author's prognosis is rather too favourable.

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Though we cannot say that the disease is without danger altogether, when severe, yet the proportion of deaths is so small, that in the great majority of even severe cases, our prognosis may be favorable; still more decidedly when the attack is slight." 425.

Treatment.-Depletion is to be performed rather by leeches than by the lancet; while cathartics, combined with tartar-emetic, are often useful. There is much difference of opinion as to the propriety of blistering the extremity; some, as Dewees, condemning the practice, while others consider it as a specific ;* opiates must be employed if required, and the blandest diet insisted upon. After the acute stage has passed, gentle support, counterirritation, and tonics are desirable.

Dr. Churchill, we think, altogether takes too light a view of the danger of this disease. He has not sufficiently alluded to those examples of it, in which typhoid symptoms rapidly replace the acute inflammatory stage, requiring a much more early and active exhibition of stimuli and tonics, than would be proper in a common simple case. These cases are especially likely to occur in the epidemic constitution of the atmosphere, which favors the occurrence of puerperal fever, to which indeed they are nearly allied.

9. Puerperal Mania.-Of the mania occuring during labor, the author thus speaks:

"The temporary delirium, or mania, which occurs during labor, was, I believe, first recorded by my friend, Dr. Montgomery. It appears at two particular periods of the labor-first, as the head passes through the os uteri and again, at its exit through the os externum. It would appear to be owing to the extreme suffering at these times, acting upon an irritable and nervous temperament. It is very temporary, generally lasting but a few minutes, and then subsiding. The most curious point about it is, that the patient is generally conscious of her incoherence. A lady whom I attended a short time ago, and in whom this delirium occurred, assured me that she knew she was talking nonsense, but that she could not resist it." 430.

Puerperal mania, after delivery, is not rare. It usually comes on before the secretion of milk is established, but it may appear much later, nay, even as the result of weaning. The phenomena do not differ from those seen in ordinary insanity. There are two classes of cases, in one of which a quick pulse and fever are present, another in which they are not. In treating

* See Wyer, London Med. Phys. Journal, 134; and Edinb. Med. Surg. Journ. vol. 15, p. 156. Sankey, Ed. Journ. vol. x. p. 402.

†Dublin Journal, vol. v. p. 51.

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these cases, depletion must be very cautiously employed. The most benefit seems to be derived from cleaning out the bowels by purgatives and enemata, and then administering an opiate, when the pulse does not forbid. spasmodics and diffusible stimuli, combined with opiates, have also proved useful. When the pulse is very quick, small doses of tartar emetic are of great benefit. The greatest quietude and attention to diet must be attended to, and eventually tonics will be required. Waller recommends the child should cease sucking. The moral treatment requires great judgment; but generally, more good is got by seeming to humour, than by resisting the patient.

We do not doubt that long before this, the reader has been convinced of the justice of the opinion we pronounced upon this work in commencing our analysis. Although this analysis is a very full one, it has by no means exhausted the treasures of the book, and every one, who wishes to make himself master of the subjects upon which it treats, will do well to obtain it. The arrangement is a little faulty, but that is a subject hardly worth naming in a work of this kind.

ON THE NATURE AND STRUCTURAL CHARACTERISTICS OF CAncer, AND OF THOSE MORBID GROWTHS WHICH MAY BE CONFOUNDED WITH IT. By J. Müller, M.D. Professor of Anatomy and Physiology in the University of Berlin, &c. &c. Translated from the German, with Notes, by Charles West. M.D. Graduate in Medicine of the University of Berlin. Illustrated with numerous Steel Plates and Wood Engravings. Part I. Octavo, pp. 182. London. Sherwood & Co. 1840.

On the reputation of Professor Müller as a profound physiologist, we need not speak. He has united the laborious accuracy of the German with the common-sense and matter-of-fact mind of the Englishman. Such a man must carry to the department of pathology a spirit of investigation eminently calculated to achieve great results, at least if any such can be obtained by careful observation and a sound judgment.

It must be owned that the intimate nature of cancer and of the morbid growths which may be confounded with it, is at once an inviting and a forbidding subject-inviting, because it is a sort of El Dorado of pathological adventure-forbidding, because so many inquirers have made shipwreck of their labors on its confines. Will this new voyager share their fortunes?

1. Uncertain External Characters of Morbid Growths.

Professor Müller begins by some observations on the uncertainty which has attended, still attends, and, we fear, will continue to attend, the diag nosis of tumors, founded on their external characters, or on their internal appearances. So numerous, he justly observes, are the transitions into

each other of those general mechanical differences which the exterior or interior of morbid growths presents, that the observation of the abovementioned characteristics is alone insufficient for the purposes of accurate diagnosis. Growths, indeed, which are peculiar to certain tissues may often be distinguished with certainty without minute examination, as is the case with neuroma in nerves, and with polypi in mucous membranes. If, however, any organic tissue is subject to many and various changes, some of which are peculiar to it, while others occur also in different tissues, then does accurate diagnosis often become exceedingly difficult, or, in the present state of our knowledge, even impossible. These difficulties are greatest in the case of tumors which do not owe their existence to the peculiarities of any particular structure, but which may occur at the same time in many and very different tissues. A tumor of a non-malignant nature may readily assume the appearance of one that is carcinomatous, and be easily mistaken for it. The different stages of development of tumors are a further cause of the great confusion which prevails throughout this subject.

The causes of these difficulties are set forth by Müller. Many innocent growths, he remarks, have the peculiarity of progressing in their development with greater or less rapidity. If inflammation should be set up in their substance, solution of continuity may take place in the parts covering them, and a fungoid growth with an ulcerated surface may be formed. The more independent, however, that a growth has become, the further is it removed from the healing, restorative influence of the organism. Moreover, a tumor originally not malignant may, owing to the decomposition which goes on in its inflamed and diseased interior, as well as on its ulcerated surface, exert an injurious influence on the whole constitution; it may give rise to repeated hemorrhages from its surface, and may induce a state of general cachexy. Should, however, the nidus of these morbid changes be extirpated, their cause is removed; the health will, under favourable circumstances, be restored; and the tumor will not return, unless there exist in the constitution a tendency to the local deposition and organization of the substance which formed the growth. The tumor of aneurism by anastomosis affords an instance of this, as do albuminous sarcoma, and the tumor fibrosus s. desmoides.

The difficulty of diagnosis is greatly increased by the analogous appearance which the malignant and non-malignant tumors often assume when once they have passed into the open state, and continue to grow with an ulcerated and decomposed surface. Thus, aneurism by anastomosis becomes, when in the open state, very similar to fungus hæmatodes in the same condition.

Usually it is regarded as an infallible sign of malignity if a tumor, after having been extirpated once or twice, returns at the same spot, as is so often observed in the case of carcinomatous tumors; but even on this point it is possible to be deceived. The tumor may return because it is not completely extirpated; any part that is left, such is their independence of the general organism, furnishing the nucleus of a future growth.

The diagnosis of morbid growths, Müller goes on to remark, is rendered still more difficult, by the circumstance that, though carcinoma is generally a constitutional disease, yet, under certain circumstances, non-carcinomatous growths may be so too, without necessarily assuming the nature of carcinoma. Tumors formed of tubercular matter, imply the previous existence of the