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1847]

Its essential Infectiousness questioned.

497

"I have hesitated to consider these arguments (adduced by those who contend that infection is not the chief agent in the propagation of the disease--Rev.) at all; because, when a matter is fully and irrefragably established on facts, any argument which can be brought against it-all special pleadings, however ingenious, argue either the fractious spirit of the objector, or some motive actuating him to prevent a belief in the truth. On this account, therefore, the arguments -or rather the sophistical puerilities, which have been adduced by ignorant, interested, or captious and splenetic persons, hardly deserve a notice, and only when they seem to possess an air of importance-an importance derived only from unwarranted assumptions, confident assertions, and ill-founded pretension; and, in some instances, also from the official or professional position of some of those who have ventured into the field of controversy-and not from any solid array of facts or of inferences logically drawn from facts. But irrespective of the want of every claimant of sound argument, a very large proportion of the Antiinfectionists betray, as shewn above, an utter ignorance of the distempers respecting the nature of which they speak with confidence, and even with disgusting pretension-and not only of these distempers, but even of others, either allied or analogous to them, of which they have incidentally taken notice. This assertion may be conceived by some, who have not had opportunities of judging for themselves in the matter, as severe or ill-founded; but it could be very easily proved, if it deserved the space which would be wasted in proving it."

The only comment we shall make upon this passage is to quote the opinion of a gentleman who has, within the last few years, had a good deal of experience in the disease of which he treats, but to whom Dr. Copland makes no reference; we mean Dr. Robertson, deputy-inspector of hospitals, who served with our troops lately engaged in Syria. In 1841, he thus expressed himself in his official report to the Government:

"In reference to the contagious or non-contagious* nature of this at times frightful disease, I beg to state that the result of all my experience leads me to believe that the disease originates in local causes, and that it is endemic in Syria and Egypt; that it is not of a highly contagious nature; and that, if ever so at all, some other concurrent circumstances are necessary to render it so. Extreme and exclusive opinions on the doctrine of contagion are hardly warranted by the present state of our knowledge. My own firm conviction is, that the Plague cannot be communicated from one person to another in a pure atmosphere, even by contact; but I am not prepared to assert that, if plague-patients are crowded together in confined and ill-ventilated apartments, infection will not be produced, just as happens in Typhus fever."

We are glad to observe that our Government evinces every disposition to introduce a relaxation of the existing Quarantine Regulations. The recent removal of all quarantine upon vessels (with a clean Bill of Health) arriving from any port in the Turkish dominions, is but an earnest of still greater and more important alterations.

We have now examined the history of two of the Pestilences described by Dr. Copland; in our next we propose to bring the third, viz. the Yellow Fever, under the notice of our readers.

* These words are here used in the general sense of "transmissible" and "non-transmissible."-Rev.

ON TUMOURS OF THE UTERUS AND ITS APPENDAGES. (Jacksonian Prize Dissertation.) By Thomas Stafford Lee, M.R.C.S. E., &c. London: John Churchill, 1847.

MR. LEE was induced to publish this Essay from its having been selected for the Jacksonian Prize. The author appears to have been a diligent student of obstetric medicine, as he tells us that he gained Dr. Murphy's gold medal at the London University some years since, and that he has availed himself of opportunities, both in Paris and London, for becoming practically acquainted with diseases of the female sexual organs. In estimating the merit of the work, it is necessary to bear in mind that the author is still young-that his experience on the diseases he writes upon is necessarily limited—and that he has had to collect materials principally from other resources, and to arrange, record, and compile them in an exact and faithful manner. The class of diseases which the Essay comprises is the least accessible, for practical investigation, to the student or general practitioner, of any which come before him; and novel views, or new facts of importance, are not to be expected, excepting where the field for observation is extensive. Mr. Lee has had the wisdom not to attempt too much. He appears to have assigned himself a very useful and important task; and, without straining after the display which so often dazzles the young author of being an original observer, he has investigated with much diligence the preparations in some of the best museums in London, and has taken great pains to collect authentic information on the subject of his dissertation. Hence it is that the body of the work is good, and one or two subjects, particularly that on the diseases of the ovary, is entitled to a still higher commendation. The chapter on Ovarian Dropsy is the fullest and the best we have yet met with; and, with the interest which at present attaches to cystic diseases of the ovary, it is one which well supplies a want which was generally felt. But, while it is our pleasing duty thus favourably to notice the most important part of Mr. Lee's Dissertation, we feel it equally incumbent on us to reprehend his style of composition. It is not only slovenly but faulty, and sometimes ungrammatical. There are numerous errors which even a superficial revision ought to have corrected; and we have grievously to complain of the perplexing way in which the personal pronouns I, we, and you, are used. We do not wish to attach too much importance to mere style, and we are far from being over-fastidious about it. We would carefully discriminate between the substantial merits of a work like Mr. Lee's, and the defect we have hinted at. But a clear perspicuous composition-an easy expression of thought or narration of facts-ought to be the first attainment, an educational rudiment, of every member of the medical profession.

The harmful and comparatively harmless qualities of the tumours which attack the uterus form the main division of this part of the Essay. The latter or benign tumours are first considered-and subsequently the more malignant growths. The five chapters which include the subdivisions under these two primary heads, refer respectively to Fibrous TumoursPolypoid Tumours-Soft Polypi-Cauliflower Excrescence of the Os Uteri -and Encephaloid Polypi.

1847]

On Fibrous Tumours of the Uterus.

499

Mr. Lee ranges the fibrous tumours, as other authors have done, according to their situation. Some spring from the sub-peritoneal tissue and grow outwards, carrying the serous membrane before them, which first partially and then completely covers them, and forms a moveable stalk connecting them to the womb. Others, again, are imbedded in the proper structure of the uterus, which forms a loose investment around them, from which they may be enucleated: and, lastly, they may grow inwards towards the cavity of the womb-the lining membrane of which becomes their superficial covering. Our author says that the latter variety is the most frequent; in proof of which, he has tabulated 74 museum preparations-from which it appears, that 19 distend the cavity, 18 are attached to the anterior wall, 18 to the fundus externally, 4 only to the anterior wall, 4 to the posterior part of the cervix, and 5 in all parts of the womb. This table is interesting, as shewing what we believe a far more extended numerical investigation would prove correct; namely, the comparative immunity from these growths, which the front wall of the body and the neck of the womb enjoy. But we doubt the other alleged fact-of the greater frequency of the submucous variety over the central and subserous situations. If Bayle be right in declaring that the fifth part of women, above the age of 35 years, are affected with fibrous tumours-and Dr. Lee does not think he has over-estimated their frequency-we need scarcely say that such a meagre table as 74 museum preparations are just as likely to prove what is false as what is true. The fact is, in the large hospitals, there is a wholesale annual waste of these tumours, and those only are preserved which exhibit some peculiarity or special mark of interest. And hence we believe that Mr. Lee's table has been constructed from picked cases, to which the hundreds which have been destroyed ought to have been added before any undeniable inference could be made out. So far as our own experience goes, the submucous variety is happily the most rare, and we say this not only from our general impression from post-mortem examinations, but also from the practical fact that fibrous growths which cause bleeding from the uterus (the symptom which mostly attends the submucous tumours) are not very frequent. Our author has described very fully the morbid anatomy of these growths, and the changes they undergo. A microscopic analysis of them, from various situations in the uterus, "invariably presents a cellulo-fibrous appearance." Their tendency to pass into a cartilaginous or bony state, and the way in which the calcareous deposit sometimes forms a superficial layer, enclosing or shelling a growth, is noticed, and illustrative preparations referred to. The vascularity of fibrous tumours has been denied, but Mr. Lee correctly, we think, believes them to have a supply of arteries, the veins being collected around them.

"At no distant period was it affirmed that fibrous tumours were not vascular, and that they could not be injected: and this opinion was confirmed by the fact, that they remained uninjected, while all other parts of the womb had become quite red with injection. A preparation of this sort is preserved in the Museum of St. Bartholomew's Hospital, No. 10, Series 26. But, however, this art of injecting, during the last few years, has been better understood, and structures before considered non-vascular have been completely injected: and this is the case with fibrous tumours of the uterus. In the Museum of Guy's Hospital there are three preparations illustrating this fact, 2268*, 2270, and 2266**; in all these cases the injection has penetrated the morbid mass.

66

Although uterine tumours can be injected, the vessels which are distributed to them are very small and few in number; and some tumours (even in the same uterus) cannot be injected at all. The vessels which penetrate the tumour are given off from the cellular cyst around them, which is extremely vascular: and it is from this layer that those fearful hæmorrhages arise when the tumour protrudes into the cavity of the uterus. We are thus supplied with the reason why these bodies do not undergo the changes consequent on inflammation, but only those of disorganization; for, if inflammatory action is set up in the cyst and the surrounding tissues of the womb, the small vessels passing to the tumour become obliterated, the supply of blood to the tumour is cut off, and the tumour itself dies.

"No veins are observed in the structure of these tumours; they only appear to be collected on their surface, where they are large and varicose: Savrard states that they are sometimes as large as the crural veins. They have been carefully injected, but no injection passes into the tumour." P. 9.

The general symptoms which accompany fibrous tumours of the uterus are common to other affections, and a vaginal examination, with the assistance of the uterine sound, afford the principal means of diagnosis. Mr. Lee extols the use of the sound in the investigation of uterine tumours, and he expresses an opinion that, when "the profession becomes more acquainted with the instrument, the diagnosis of abdominal tumours will be more correct." There are several affections with which fibrous tumours of the uterus may be confounded, and Mr. Lee marks the means of diagnosis in inflammatory indurations of the uterus, pregnancy, ovarian dropsy, other abdominal tumours not connected with the uterus, and polypi within the cavity of the womb. Of these, the most important in a practical point of view are the circumscribed indurations which follow inflammatory attacks, or even congestions of the womb, and which closely simulate fibrous growths. M. Lisfranc has directed attention to this subject, and it is well worthy careful consideration. This author notices the great difficulty in distinguishing between the two, and he mentions the fact, that in his earlier practice he perpetually regarded these indurations as fibrous growths. Mr. Lee describes the diagnostic marks of these affections in the following manner :

"The difficulty of diagnosis between these two diseases is so great, that it led M. Lisfranc to believe that they could not be distinguished, except when the fibrous tumour became polypoid. But in inflammatory action of the uterus the constitutional fever appears at the commencement of the disease, almost before the swelling; while in fibrous tumour the mass is distinctly felt before the constitutional symptoms arise: there is also great pain on pressure. In hard tumours the swelling is more defined, and they are not usually painful on pressure. But the most diagnostic mark between these diseases is the effect of treatment on them. If the one yields to treatment, it may then be considered to depend on induration; as fibrous tumour has, according to some, never been reduced." P. 19.

In the diagnosis between pregnancy and fibrous growths, Mr. Lee depends a great deal on the areolar changes. He says that, in cases of fibrous tumour of the uterus when the disease has caused sufficient irritation as to induce the patient to apply for advice, he has found “that the breasts have, in a great majority of cases, been enlarged and tumid, that the areola has, in eight cases out of ten, been enlarged and darkened: that,

1847]

On the Treatment of Uterine Tumours.

501 in the same number, the follicles have been more or less numerous, in some they have been remarkably distinct: but that in only one case out of ten (and that a very suspicious case) was there any moisture or cedema of the nipple or areola present." Besides, the fresh, raised, varnished look of the areola (for we do not think the word œdema describes the change fairly), the character of the swelling of the gravid womb, its even surface, regular development, elastic and doughy feel, forms an appreciable difference between pregnancy and large fibrous growths. "In disease," says our author, the tumour is irregular and of a stony hardness, no placental murmur or fœtal heart is heard." Undoubtedly the main sign of pregnancy, which outweighs all others in value and easy appreciation, is the fœtal heart-but we think our author has fallen into a practical error when he says there is no "placental murmur" when fibrous tumours are present. Of course we mean that a sound closely resembling the uterine soundwhich our author calls placental murmur (although its mechanism is not yet clearly made out)-is undoubtedly to be heard where fibrous tumours press on the large vessels in or on the margin of the pelvis; so much alike are the murmurs in these two cases, that we have ourselves listened to the inguinal regions of two women, the one pregnant and the other with a fibrous tumour inclined to the right side, in adjoining beds, and we could not distinguish any difference between them. We look upon the so-called placental murmur as utterly useless in the diagnosis of pregnancy from other abdominal tumours.

The Treatment of Uterine Tumours.-Some authors suppose that fibrous tumours may be entirely absorbed-which we conclude is now to be interpreted into the fact that, under treatment, indurations of the womb have been reduced, which have been mistaken for fibrous growths.

"Local depletion, by the aid of leeches, is the best method of treatment; but these must be applied to the tumour itself; in a robust patient, of bloated habit, with great pain in the tumour, and with the signs of local congestion, as piles, the application of six leeches twice a-week to the neck or body of the womb will not be at all too much; but if the patient is anemic, one application weekly is sufficient. The introduction of the leeches to the tumour itself is of great importance: I have seen relays of them applied to the perinæum, rectum, and groins be of little use, while one depletion from the tumour itself has been of the utmost service. A hip bath, after the leeches come away, is very beneficial; it encourages the bleeding and relaxes the parts, and by these means removes the excessive pain which is usually present.

"During the intervals of the leechings, mercury or iodine should be applied to the womb itself, either in its pure state, or made more consistent with wax. The ointment used at the Red Lion Hospital for women is mixed with one part of the Ung. Hyd. Fort., one part of Cera Flava, and one part of lard. This is rolled up in the form of a ball, and introduced into the vagina every night, as high up as possible, in order that it may envelop the os and cervix of the uterus: this remains for twenty-four hours, when it has generally disappeared-it may then be repeated." P. 25.

Under this plan of treatment the cervix, which before may have been obliterated, again bulges below the tumour, and the mass itself sometimes rises above the brim of the pelvis, affording marked relief to the pelvic organs. It appears that Dr. Rigby has, in some cases, injected the strong

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