section, "the stomach was.distended with fluid, and at its pyloric extremity a scirrhous enlargement existed of about the size of an egg: the passage from the stomach to the duodenum was consequently constricted, but not to such an extent as to prevent the transmission of its contents."

IV. CLINICAL REPORT OF CASES ADMITTED INTO THE PETERSHAM WARD. By John C. W. Lever, M.D.

This report contains the account of 74 cases treated by Dr. L. in the female or obstetric ward during twelve months, from June 1845 to June 1846. The cases are much more carefully drawn up, and the information is greatly more satisfactory than in the preceding reports of the Clinical Society.

A. Under the head of Ovarian Dropsy, is related a case of Fungoid Disease of the Uterus and left Ovary, and involving more or less all the pelvic viscera. During life fluctuation had been felt distinctly per vaginam, as well as per rectum and accordingly with a trocar, introduced into the former passage, a puncture was made, and a dark-coloured fluid was evacuated. She continued better for about four months afterwards, when it was again deemed necessary to repeat the operation, and about 12 oz. of a lightish yellow-brown fluid were drawn off. She was seized with diarrhoea a week or two subsequently, and died. On dissection, the disease of the uterus was of two kinds, "the soft medullary fungus, and the hard cartilaginous scirrhus; and a point of special interest was the development of cysts, containing clear serous fluid, and having the cerebriform fungoid masses projecting from the walls: such a one was found at the post-mortem examination, and was doubtless similar to that which had been punctured during life, and the walls of which had subsequently taken on a sloughing

action."

Dr. Lever frankly confesses that he was mistaken in his diagnosis of this case; having regarded it, during the life of the patient, as one of encysted Dropsy of the ovary. He omits to tell us, by the bye, whether the fluid, discharged by the operation, was examined with the microscope : but the following is the account of the microscopic appearances observed on examining the parts after death. "The soft medullary tumours were made up of cells, having thick walls, giving them a double outline, and containing one, two, or three nucleated cells: there seemed to be no connecting tissue, which accounts for its soft and cerebriform character. They may be taken as a type of malignant formation."

With respect to the treatment adopted, Dr. L. remarks :—

"I conceive that it was the best that could have been employed under the circumstances; and, in my opinion, interference was necessary; for the fæces when solid, were of tape-like form; and, as the patient had but slight control over the sphincter-ani, they were, when fluid, frequently passed before she could reach the water-closet. The bladder and urethra were subjected to undue pressure and irritation; a catheter could with difficulty be introduced; the nerves were injuriously acted upon; there were numbness and weakness of the right lower extremity, causing her to limp. On each occasion when the fluid was drawn off, she recovered the perfect command of the sphincter-ani, the calls to

1847]

Dr. Lever's Report of Diseases of the Uterus, &c.

105 void the urine were less frequent; the numbness and weakness of the right leg were lost; and she had as perfect control over its movements as over those of the left."-P. 194.

B. Two interesting cases of Pelvic Abscess-both in the left iliac fossa -are recorded. In one, the abscess burst into the gut and was discharged per anum; in the other, it was opened externally, and a quantity of pus, mixed with fætid gas, was evacuated. Both patients did well.

c. Two examples of Vascular Tumour of the Urethra in the female are related. As this malady is apt to be overlooked by medical men, and is perhaps scarcely known to many of them, it will be useful to mention briefly the particulars of one of the cases.

"A woman, æt. 67, had been obliged to relinquish her occupation as a semp. stress in consequence of severe pain in the urethra, irritability of bladder, and constant desire to void her urine, which she attempted every five minutes; difficulty, but no pain, was experienced in passing her motions. After the trial of various popular remedies, as well as submitting herself to the care of surgeons, she applied at a dispensary at the west-end of London: there the cause of her sufferings was detected. Her general health was tolerably good, and there was no discharge of any kind at the time of her admission. She had constant calls to void her urine, the passage of which occasioned her great pain, occasionally of a shooting character, extending upwards to the abdomen, outwards to the hips, and backwards to the perinæum. On separating the external labia, a vascular tumour was seen protruding through the meatus urinarius, of a florid red colour, and about the size of a kidney bean. On minute examination, which was with difficulty permitted, on account of the exquisite sensitiveness of the growth, it was found that it passed some little distance into the urethra, and was so vascular that it bled upon the slightest touch; the suffering occasioned by the examination was considerable.

"The patient was placed on her back, and the brane of the urethra attached to it, was removed. applied, and she was desired to keep the part lotion."-P. 219.

tumour, with the lining memThe nitrate of silver was then constantly wetted with white

The operation caused much pain, which continued all night. The nitrate required to be applied, at intervals of three or four days, several times. At length, in the course of about a month, a cure was effected.

D. We regret to observe that, in one case of Scirrhus of the Os Uteri, Dr. Lever thought it "advisable to make the experiment of removing the diseased portion. This was accomplished by Mr. Hilton, who, failing to draw down the uterus so as to protrude the os uteri through the external parts, removed the disease with this organ in situ. Considerable hæmorrhage attended and followed the operation, but was arrested by a large and firm vaginal plug. The operation was followed by peritonitis, which was treated by repeated leechings and the administration of calomel, antimony and opium. When convalescing from this, she was attacked with dysentery of a most aggravated and fearful character, and for some days her life was in extreme peril; but she slowly recovered, and left the hospital to undertake the duties of a turnkey at one of the metropolitan prisons. The womb, however, was not freed from disease; for on making an examination some time after she had been performing her public duties, I found the discharge copious and offensive, with a return of the scirrhus." E. A number of cases of Simple Ulceration of the Cervix Uteri are re

lated. All were relieved or cured by the application of the nitrate of silver, &c. through a glass speculum, every second or third day, and attention to the general health. Even in instances where the ulceration was of a more unhealthy, and even a very suspicious character, much benefit was obtained from the occasional application of pure nitric acid to the seat of the disease, and the internal administration of alterative tonic medicine, along with nourishing diet, &c.

V. ON THE PHYSIOLOGY OF CELLS, WITH THE VIEW TO ELUCIDATE THE LAWS REGULATING THE STRUCTURE AND FUNCTION OF GLANDS. By Thomas Williams, M.D.

The great object of the author, in this elaborate paper, is to endeavour to determine the true laws regulating the organisation and function of the Liver, by tracing its development and condition through the various classes of animals, from the simple Actinia up to the highest order of the Vertebrata. The comparative anatomist will not fail to appreciate the value of the minute details and numerous illustrative wood-cuts which Dr. Williams has given; but they are quite unsuited to the pages of this Journal. Indeed, some readers may be tempted to ask, how it comes to pass that a paper like this should find a place in the Reports of a Hospital? We shall give but one extract, as it bears upon some disputed points in General Physiology.

"From the description of all preceding observers of the structure and peculiarities of these humble organisms, it was confidently expected that the biliary system in the actinia would be discovered under circumstances of the greatest practicable simplicity,-under the form, namely, of a follicle' in the walls of the digestive sac. Practical enquiries will indisputably prove that such statements are founded only on theoretical suppositions. Each succeeding author on comparative physiology has at once admitted and transmitted the errors of his predecessor; so that it has actually become an axiom, that, however inextricably complex an organ may be in the highest order of animals, its remote submultiple, its rudest dawning in the distant extremity of the declining scale, will be found, without a solitary exception to diversify the monotonous law, to consist of a follicle. This is the invariable terminus of all researches afrer the analogous' and morphological reductions of organs, which acquire complexity of internal arrangement. In regard to the provisions made for the supply of secretions in animals, of which the body altogether is no more involved than a large follicle, it seems superfluous to urge the argument, that, if a follicle, with its component machinery of cells, membranes, and vessels, were furnished for the exclusive purpose of elaborating a single secretion, a subordinate organ, subservient to uses of a minor importance, would exceed, in complexity of structure, the organism viewed as a whole. In the minute structure of the actinian polype direct proofs may be obtained to confirm the view, that a follicle is not the ultimate link in the chain of morphological reductions. Aggregations of nucleated cells occur in the depressions between the vertical duplications of the digestive membrane, which in their intimate organisation, seem, in a very obvious manner, to unite all the requisite of a gland. These cells are held together by, and are lodged in, a semi-fluid plasma of extremely tenacious property;—a property which acquires importance in the use apparently assigned as one of its functions of holding the cells in situ, and of preventing displacement and injury during the dilatations and contractions which the stomach is destined to undergo."-P. 282.

1847] Interesting Case of Ulceration of the Stomach.

107

VI. The case of "Supposed Spontaneous Perforation of the Stomach terminating successfully," related with great minuteness by Dr. Hughes, is one which will be viewed very differently by different readers.* That the symptoms, which usually attend sudden rupture of some part of the alimentary canal, were present in the present case cannot be disputed; and the treatment adopted by our author, on the suspicion that this most alarming lesion existed, was the very best that could be followed.

"Opium, quiet, and starvation were the three remedies employed. The opium was administered in moderate doses only, as they appeared to have the desired effect; and those doses were diminished as soon as the symptoms appeared to justify the reduction. In the first twenty-four hours the patient took between seven and eight grains of the drug, without any of the ordinary effects of opium upon the brain, the iris, or the tongue, being at any time noticed. This fact itself appears to indicate that some very severe disturbance existed in the system. After the first twenty-four hours, the patient took only four grains in the day and night, and this quantity was soon reduced to three grains. By the mouth she took no other medicine of any kind. Warned by the unfortunate experience of Dr. Stokes in one of his cases, it was determined to administer no aperient. On the seventh day the bowels acted spontaneously.

"For a period of eighteen days the patient was not allowed to move or to be moved, in the slightest degree, from the supine recumbent position. When the bed became hard and uncomfortable she was removed in a sheet, without any alteration of her position, to another already prepared for her. The enemata were administered as she lay on her back.

"For a period of forty-eight hours the only sustenance allowed her was two teaspoonfuls of toast-water, given every hour."-P. 341.

Nourishment was given by the administration of beef-tea enemata.

Dr. Hughes very judiciously cautions the reader against the use of stimulants and purgatives in all cases, where there is the slightest ground for apprehension that perforation of part of the alimentary canal either is imminent, or has taken place. We are inclined to extend the same advice to very many cases of Ileus, or Obstruction of the Bowels, when there is any tendency to inflammatory symptoms supervening. A vast deal of mischief is continually done by persisting in the use of powerful doses of drastic purgatives, when the bowels refuse to act after 24 or 36 hours' administration of those in ordinary use. It is a dangerous error to attribute the constipation to mere sluggishness or torpor of the intestinal tube. There may be, if not mechanical obstruction, spasm or incipient inflammation; and certainly violent drastics are not the best or safest remedies for the treatment of either of these morbid states.

VII. The case of "Ulcer of the Stomach, leading to Perforation and Death in 19 hours," related by Mr. Ray and Mr. Hilton, exhibits several points of resemblance to the case of supposed rupture just given. Both patients were young women, the one 28 and the other 27 years of age;

*Does not the circumstance of the catamenia having appeared within 60 hours from the invasion of the alarming symptoms, and continuing to flow for,two days as in health, argue somewhat against the idea that so serious an accident as rupture of the stomach was present?

In

and both had been suffering from symptoms of stomach ailment. both, the attack of pain in the epigastrium was sudden and so severe as to occasion alarming prostration. (We had written so far before we discovered that the patient was the same in both cases; the second and fatal attack occurred four months after the first; she survived only eighteen hours.

Dissection.-On opening the abdomen, a quantity of turbid fluid, containing portions of gooseberries, cherries and strawberries, in addition to very numerous small shreds of soft lymph, was found extravasated among the viscera. Besides the appearances of very recent inflammation, there were extensive old cellular adhesions of the stomach to the liver, and of the stomach and intestines to the abdominal parietes.

"The stomach presented a central constriction, known as the hour-glass contraction of the stomach, but not in the extreme degree. A little gentle pressure upon the stomach, caused some air and fluid to escape from amongst the old adhesions at the smaller curvature of the stomach, and so discovered to us the abnormal opening from it into the peritoneum, about midway between the œsophageal and pyloric apertures. A long incision was then made through the anterior wall of the stomach near its lower edge, parallel with the larger curvature; and on turning this part upwards the contents of the stomach were seen, composed of cherries, strawberries, and gooseberries, scarcely broken. These were aggregated at the pyloric extremity of the stomach, and completely filled it. The abnormal opening from the stomach at its smaller curvature was also immediately seen, occupied by a piece of a strawberry."

"The mucous surface of the stomach was healthy, except at about midway between the œsophagus and pylorus (at which parts the circumference of the stomach was diminished, corresponding to the external hour-glass-like constriction), and towards the smallest curvature, where it presented the ruge of the mucous membrane radiating towards the pylorus from a small surface, which had all the appearance of a cicatrix of an old ulcer; half an inch below this part was seen a recent ulcer, about the size of a fourpenny-piece, irregular in outline, its edges unequal in thickness, and highly vascular: it had extended through the mucous membrane, the sub-mucous fibrous structure, as far as the muscular fibre. On looking to the peritoneal surface of the stomach corresponding to the internal position of this ulcer there was no evidence of any recent inflammation. About half an inch above the cicatrix, to which reference has been made, was placed the base of the conical canal, passing upwards and backwards obliquely through the stomach, which had allowed the escape of some of its contents into the peritoneum, and so caused the death of the patient.”—P. 346.

Mr. Hilton is of opinion, from the consideration of all the phenomena exhibited on dissection, that "the perforating ulcer, which caused the patient's death, was the same which induced her previous illness; and that the peritoneal opening became closed by the deposition of adhesive matter around it, fixing it to the nearest organ, the liver; and that the occlusion was complete up to the period of the beginning of the recent fatal symptoms, when some of the old adhesions were detached or broken through, from the distention of the stomach by a large quantity of fruit, or possibly by some other mechanical cause, which does not appear, and so allowed the second escape of the contents of the stomach into the peritoneum. This latter is the explanation at which I arrive, because the cicatrix, to which reference has been made, does not extend through the entire thickness of the walls of the stomach, which negatives altogether the idea of