cases, and Lee marks of phlebitis in 24 out of 45 cases. The latter believes, besides the usual causes of puerperal fever in general, that this form may arise from mechanical injury inflicted on the uterus, either during labor, or by the extraction of the placenta. The pain is generally more limited and local than in peritonitis, but the diagnosis is often obscure in the early stages; while in the latter, the nature of the disease is elucidated by the production of various diseased actions, accompanied usually by purulent depositions in remote organs, as the brain, lungs, heart, joints, &c. Severe and epidemic cases defy our resources, and, in all, it is necessary to have a speedy recourse to stimuli.

(e.) Inflammation of Uterine Lymphatics.-This too has been observed by several French writers, and by Dr. Lee.* The local symptoms are very severe, and the constitutional ones identical with those of uterine phlebitis.

5. Rupture of the Uterus and Vagina.—This is a most elaborate chapter. The accident has occurred 65 times in about 42,768 patients, that is, once in 657. It rarely happens in a first pregnancy. The uterus may be ruptured during labor in consequence of a diseased state of its tissue having existed during gestation,† or on account of the narrowed state of the upper outlet of the pelvis, or again, according to some, from the oblique position of the uterus, directing the child's head against the side of the cervix. Sometimes one of the component structures of the uterus, as the peritoneal, or muscular, has been torn without other portions suffering, but the accident is just as dangerous. In several cases the os uteri has been completely torn off during labor, and, indeed, whenever it occurs from mechanical causes, the vagina is usually involved. The circumstances which should excite our fears, are the occurrence of hysteritis, imperfectly cured, during gestation, and the coincidence of very violent labor-pains with a narrow pelvis. There is always more or less blood effused, which may lead to peritonitis. Rupture of the uterus may also occur during gestation from hysteritis, accidents, or without obvious cause; and, again, it may occur, independently of pregnancy, at an advanced period of life, arising from a process of absorption or thinning of the uterine parietes, produced by distention from the uterine mucus or other fluids being debarred their natural exit, owing to the thickened state of the os uteri, reducing or obliterating the passage. The principal symptoms are the occurrence of a most dreadful cramp-like pain-the sense of something giving way, accompanied sometimes by a noise audible to the patient-the suspension of the labor-pains-hemorrhage and rapid collapse -the presentation no longer to be felt from the vagina, providing the rupture be complete.

In treating these cases the first question is as to delivery, and, wherever the os uteri has not been in an undilated state, all experience has been in favour of this being performed instantly; for, in nearly all cases of recovery, delivery has been accomplished. The forceps, or perforator, according to circumstances, must be used, and, when the child has escaped into the abdomen,

* Medico Chirurg. Trans. vol. 15, p. 64. † Murphy, Dublin Journ. vol. 7. Medico Chir. Trans. vol. 11, and Dublin Journal, vol. 16, p. 54 and 154.

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

"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. I 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.

M

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 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 occurring during labor, the author thus speaks :

"The temporary delirium, or mania, which occurs during labor, was, I be lieve, 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.

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., Antispasmodics 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 labours 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 diagnosis of tumors, founded on their external characters, or on their internal appearances. So numerous, he justly observes, are the transitions into