After describing the dangers of the operation by means of the knife, and the treatment of the case preparatory to its performance, the value of caustics in general, their advantages and inconveniences, form a subject for consideration.

. Upon the practical value of the use of caustics M. Velpeau thus remarks:

"The result of my experience proves that they should not be rejected absolutely as a curative means. That they are preferable to a cutting instrument,-1st. When the cancer is ulcerated in patches, and when more widely spread than deep; 2nd. When, even by the cutting instrument, there is no chance of preserving a part of the integuments attacked by the tumour; 3rd. When the cancer is fungating, exactly limited, and when the patient dreads much more the use of the knife; 4th. Ulcerated scirrhus, irregular or disseminated, can be better attacked by caustics than by operation; 5th. The same may be said of ulcerated cancer adherent to the summit of the axilla under the clavicle, or in the neighbourhood of bone." (p. 663.)

The effects produced by various kinds of caustics are then described, and their individual advantages examined.

Congelation, by means of the application of pounded ice and salt, has, according to M. Velpeau, certain advantages, which may be regarded as palliative, if not, even in some cases, as a means of cure. And, although the author has little experience in its application, the effects which he has seen produced would induce him to employ the frigorific mixture before entirely rejecting it, especially as a succedaneum to caustics.

"When a true cancer " has been operated upon, there always remains the sad expectation of a recurrence, and therefore M. Velpeau next takes into consideration the means to be adopted in the hope of arresting or preventing this distressing result.

After speaking of the employment of counter irritation, regimen, and syphilization, he thus very justly denounces the last :

"Syphilization, with the intention of curing or preventing cancer, is then one of the thousand chimeras which arise, from time to time, as an exhalation from the brain of certain

men.

"In conclusion, science does not yet possess any means which may serve as a preservative from cancer, or prevent the recurrence of this terrible disease." (p. 682.)

The propriety of removing secondary developments forms the subject of the next section, and M. Velpeau is in favour of a second or even third operation, when practicable. He supports this doctrine by the relation of a case entitled "Encephaloid tumour, extirpated three times, and at last radically cured."

A lady, sixty-six years of age, had had a tumour removed from the breast a year before she consulted M. Velpeau. He removed the second development, which was in the lower edge of the cicatrix. The axillary glands were not diseased, nor was there a tumour elsewhere. The growth M. Velpeau removed exhibited "all the characters of encephaloid tissue. Soft, fungous, medullary, red, vascular on its external surface, it was lardaceous, homogeneous, brownish in places, and continuous everywhere with the thick layer of mammary tissue which was removed with it."

A third growth formed in eighteen months, was removed, and exactly resembled the last described. The lady had enjoyed perfectly good health since, and there is no new growth in 1853, ten years having elapsed since the last operation.

If we accept this case as one of encephaloid cancer, it does not prove more than that a patient may be free from the disease for ten years, even after the removal of a third development. It does not prove that she will continue free from cancer the rest of her life, nor that the disease is radically cured, because there are cases on record in which a cancer having been excised, and the patient having continued free from disease in the part primarily involved, has fallen a sacrifice to the development of internal cancer after a longer period than ten years had elapsed.

In the absence, however, of positive evidence, by minute examination of their structure, that these growths were cancer, we cannot accept this case in evidence merely because M. Velpeau states that, in his opinion, the growth was an "encephaloid tumour," -which it might indeed have been without being a cancer, for many of the forms of

i

mammary glandular tumour are brain-like, but their minute anatomy at once demonstrates that they are not cancer.

A table of 146 cases concludes the subject of cancer. In an analysis of this table, M. Velpeau begins by stating that in a given year we find a certain proportion of cases reported. But the author's enumeration appears strangely inaccurate. Between the years 1824 and 1852, inclusive, M. Velpeau enumerates 190 cases; whereas the table includes only 146. Of 197 cases, 57 were not operated upon, and the operation, or cauterization, was performed in 140 cases. Of these 140, exactly half, 70, continued well, or were in progress of cure when they were lost sight of. Thus only 70 cases remain which can be of any use to determine the advantage or disadvantage of any operation in the treatment of cancer. Of these 70 cases, in 22 the disease had returned, and 30 patients were dead, leaving 18 concerning whom there is no more history.

Another equally unsatisfactory table of cases of encephaloid disease is given. In this, of 45 cases operated upon 9 died: 3 of erysipelas, 3 of purulent infection, 2 of pleurisy, 1 of hospital gangrene; 20 are said to have left the hospital cured, leaving 16 of which no further result is stated.

These tables appear to us to be valueless for want of accurate and minute investigation of the structure of the growth removed, as well as from the insufficient details relating to the progress and termination of the cases.

The work concludes with some brief details in reference to the diseases which affect the mammilla of the male, and the rudimentary organ of the infant.

John Birkett.

REVIEW IV.

Klinik der Geburtshilfe und Gynækologie. Von Med. und Chir. Dr. J. CHIARI, Med. und Chir. Dr. CARL BRAUN, und von Med. und Chir. Dr. J. SPAETH.Erlangen, 1853. Clinical Observations on Obstetric Medicine. By Drs. CHIARI, BRAUN, and SPAETH. THE book whose title we have given above, the result of the labours of celebrated German physicians, is now on our table, and we propose giving our readers an insight into its contents. There is much in it which has been well known, and equally well described, by writers of our own country; but we are bound to acknowledge that, in the obstetric department of our profession, we are behind-hand in works of easy reference and practical utility. Our systematic treatises on the science and art of midwifery are probably the best of their kind in any language, and leave scarcely anything to be desired in their particular sphere; but we possess no dictionary of midwifery, like our dictionaries of medicine and surgery; and the clinical reports published from time to time in our journals do not compensate the busy and anxious general practitioner for the want of such works on practical midwifery as are published by the Germans. We should hail with pleasure the appearance of a work on midwifery in our own language, on the principle of Busch and Moser's 'Handbuch der Geburtskunde,' containing a good practical article on each subject connected with obstetricy, written by our best authorities, and arranged in alphabetical order; it would prove a boon to students, and form an acceptable book of reference to such as are engaged in the toilsome and anxious labour of midwifery practice. In the volume before us, numerous subjects are treated of in a very creditable manner, and it is somewhat difficult to make a selection. Hæmorrhage occupies an important part; and as there is one form of it which has rarely been described, and of which four cases are related, we transcribe one of them for the information of our readers.

"N. N., æt. 26 years, was delivered of a female living child of the usual size, after a natural and regular first labour. Soon after the expulsion of the placenta, which took place naturally, the patient complained of pain in the genital organs, which, becoming more severe, led to an examination, and to the discovery of a large, firm swelling in the vagina, supposed, from the manner of its origin, to be a thrombus. In order to prevent its increase, cold applications were made use of; but notwithstanding this, it had increased so much the next

day, as to fill the cavity of the pelvis, the right labium being swelled to the size of a fist, and the swelling extending beyond the perineum backwards into the right buttock. The uterus was pushed upwards, and the pressure upon the bladder was sufficient to require the use of the catheter. The following day the swelling became of a violet colour, and on the third day it burst, about an inch behind the entrance into the vagina, and a good deal of coagulated blood was removed by the fingers. Meanwhile, all the symptoms of a severe metro-phlebitis appeared, and the large irregular cavity of the thrombus soon secreted very offensive matter. The patient died on the seventh day. The treatment of the thrombus consisted in cold applications during its formation, and frequently-repeated warm injections into its cavity for the removal of a foul discharge, after it had opened. Dissection exhibited the usual results of endometritis septica and metro-phlebitis; and between the vagina and pelvis, the irregular cavity of the thrombus, extending along the psoas upwards towards the right kidney. The surrounding parts, and even a portion of the mesentery, were stained of a violet colour by the sanguineous effusion."

This disease, or rather this accidental complication of labour, has rarely been noticed by authors, and must be of very unfrequent occurrence. It is said to originate in the rupture of large vessels, but whether arteries or veins is a matter of doubt, and perhaps of no great practical importance to be known. The period at which it has been observed to take place is either during or after labour; and most frequently in first labours, when the head has been forced down quickly, and the vessels have not had time to accommodate themselves to the increased quantity of blood they have to contain, and therefore give way. It is remarked, however, that individuals subject to varicose veins around the vagina are not thereby predisposed to this accident. The thrombus generally makes its appearance in some part nearest the genitals; indeed, most frequently in the cellular membrane between the vagina and pelvis, near the rectum, labia, and perineum, and is discovered about the period when the afterbirth is expelled; for it requires some little time to develop itself. The extravasation sometimes extends outwards over the back and thighs, and internally to the peritoneum, and along the psoas muscle towards the kidney, but seldom into the texture of the uterus. The diagnostic signs are, the sudden appearance of a swelling during labour, more or lest firm to the touch, and increasing in size during the pains; the pain belonging to the disease itself, if any, being obscured by the pains of labour. The bluish colour of the skin does not appear until the effusion has made its way nearly to the surface.

When the extravasation is of slight extent, it may be absorbed; or the disease may result in the gradual escape of the extravasated blood by a spontaneous or artificial opening, with subsequent suppuration, terminating either in a cure, or pyæmia, and death. The treatment consists in endeavouring, in the first place, to prevent the increase of the tumour, as soon as it has been discovered. Compression of the swelling with cloth dipped in cold water has been recommended, but unfortunately can seldom be carried into effect, from the peculiar situation of the thrombus; and if pressure be applied externally without closing the bleeding vessels, matters may be made worse, by forcing the blood internally under the peritoneum. When cold and pressure cannot be applied directly upon the bleeding point, our treatment has to be limited to cold lotions, injections, and the introduction of pieces of ice into the vagina, in order to promote the coagulation of the extravasated blood. If a thrombus occurs during labour, and causes obstruction to the passage of the child, we are advised to hasten delivery, and if necessary, to open the tumour. If the tumour does not soon give way spontaneously, we are recommended to persevere with the cold applications for several days, and not open the cavity before the vessels are closed by coagula; but afterwards it may be opened, some of the coagulated blood removed, and a healthy suppuration promoted by warm injections and fomentations. Should the cavity be slow in filling up, weak astringent injections may be employed.

The volume before us also contains an elaborate article on the nature and treatment of convulsions occurring in the generative period of women, either during pregnancy, in the various stages of labour, or after delivery, by Dr. Carl Braun. The results of his own experience, in the observation of 52 cases of convulsion occurring in 24,132 labours, have led him to differ somewhat from former prevailing opinions. He arranges the cases as follows, according to their causes:

"A. Convulsions occurring without the co-existence of morbus Brightii.

1. Hysterical convulsions.

2. Epileptic

ditto.

3. Convulsions from cerebral diseases-as hyperæmia, apoplexy, meningitis, encephalitis.

4.

from the inhalation of irrespirable gases, or from the effects of poisonous substances,

"B. Convulsions which are connected with Bright's disease-as uræmic intoxication, under the name of eclampsia. "C. This division includes those cases where, notwithstanding the presence of Bright's disease, the act of labour occurs normally, and, with the exception of certain disorders of the senses during pregnancy-as amaurosis, amblyopia, hemeralopia, deafness, &c.—no other functional disturbance is produced.

"D. Natural parturition during the existence of Bright's disease, without convulsions.” Several writers in this and other countries have remarked upon the presence of albuminuria in connexion with puerperal convulsions, but the subject is still in considerable obscurity, and is of sufficient importance to demand further investigation. Dr. Carl Braun has thrown new light upon the influence of uræmic intoxication in the production of eclampsia; and although it must be admitted that some of his propositions require further testing before they can be fully accepted, we think it worth while to place before our readers such an analysis of his interesting paper as will induce them to devote their attention to the practical questions involved. To be enabled to distinguish clearly between the various kinds of puerperal convulsions, and at once decide upon the befitting treatment, is a most desirable qualification for an obstetric practitioner; for a mistake in the application of remedies in a disease of such severity would often, probably, be attended with fatal consequences; and when we consider that, with a train of external phenomena very similar in appearance, one case may demand venesection to as great an extent, perhaps, as almost any other disease whatever, whilst another requires an exactly opposite method of treatment; when, too, the nature of the symptoms is such, that delay in determining upon the proper management of the patient may lead to the most serious consequences, we cannot but hail with pleasure every philosophical or scientific attempt to elucidate the causes, diagnosis, and prognosis, of the different kinds of puerperal convulsions.

It has generally been supposed that the presence of albumen in the urine of pregnant woman has been due to congestion of the kidneys, from the pressure of the enlarged uterus; or to a general congestion of the system during the pregnant state, often producing anasarcous swellings, or effusions into serous cavities. Cases of this description are familiar to us all; but it will be found that, in some cases, disease of a more serious character is at the bottom of it all, and that in such our prognosis, as concerns the safety both of mother and child, must necessarily be of a much more unfavourable character. We now proceed to describe the symptoms of eclampsia, or uræmic convulsions, according to our author.

Symptoms.-Eclampsia, or puerperal or uræmic convulsions, occur suddenly at some period of the generative process, and consist of a more or less regular succession of phenomena, amongst which loss of consciousness is the most prominent. During the attack, the head and neck appear swollen, red, and livid; the eyes move rapidly in various directions, or remain fixed in their orbits with a vacant stare; the conjunctivæ are generally injected, the tongue protruded, and frequently wounded by the teeth, so that bloody froth escapes from the mouth; it is sometimes, also, considerably swelled. The muscles of the face are convulsed, and the extremities are affected with rapid movements of flexion and extension, alternating with each other. The whole trunk is also thrown backwards and forwards, or else immovably and stiffly bent backwards, or to one side. The carotids pulsate strongly; the jugular veins become distended; the respiratory muscles, especially the diaphragm, are in a state of spasm, threatening suffocation. Generally, there is vomiting, and the urine and fæces are passed involuntarily. The skin is covered with perspiration, and its temperature altered. Reflex sensibility is arrested during the attacks. The pulse may be either frequent or slow. After these symptoms, an interval of variable duration follows, in which the patient

42

Reviews.

lies in a soporose condition, with extended, stiffened limbs, difficult, frequent, and stertorous breathing, and continued loss of sensation and consciousness. The duration of the attack may be a quarter or half an hour, or a whole day, the coma remaining uninterruptedly, so as to simulate a severe attack of apoplexy.

Should the first attack not terminate fatally, a remission ensues; the breathing The abdomen seems becomes less impeded, the muscular rigidity disappears, consciousness sometimes returns, but is often imperfect, and the frequency of the pulse diminishes. tender to the touch, and reflex sensibility, during the intervals, is generally exalted. The patient mostly complains of confused, dull headache, and great exhaustion; and In this this continues until a degree of restlessness, stretching of the limbs, convulsive movements of the eyelids, and turgescence of the features, announce a fresh attack. The outbreak of the manner, the paroxysms are repeated often in the day, sometimes from ten to fifty times, a state of unconsciousness remaining during the intervals.

paroxysm itself is occasionally preceded by precursory symptoms, such as headache, vertigo, heat of skin, hallucinations, scintillations, imperfect vision, ringing in the ears, difficult articulation, mental irritability, pain in the præcordial region, nausea, vomiting, irregular pulse, and considerable lassitude without any apparent cause.

The paroxysms generally occur either in the latter months of pregnancy, or during or soon after labour; they are commonly preceded, sometimes for several weeks, by oedematous swellings in various parts of the body, although this is not always the case. The oedema occurs less frequently in the upper half of the body than in the ankles and labia; but in the latter months it is sometimes diffused over the whole body. With oedema of the face there is generally more fever, suffusion of the eyes, and redness of the cheeks, so that the countenance assumes a bloated appearance. These dropsical swellings are very uncertain, sometimes diminishing, or even entirely disappearing towards the completion of labour; whilst the quantity of albumen in the urine, and the disease of the kidneys themselves, may be on the increase. The skin of those parts of the body which are not oedematous is dry, and frequently assumes a chlorotic appearance, its temperature being at the same time reduced. The oedema which is connected with albumen and fibrinous cylinders in the urine stands in intimate relation with eclampsia. Anasarca of the lower limbs and hydramnios are frequently met with without a trace of albumen or casts of tubes in the urine, and are then never accompanied with eclampsia during the several periods of pregnancy or labour.

In eclampsia the urine is generally acid, always deposits, with nitric acid and heat, a large quantity of albumen, and exhibits under the microscope fibrinous cylinders, and often also blood corpuscles. The quantity of albumen corresponds with the extent and duration of Bright's disease; and increases in the latter months of pregnancy, and with the attacks of eclampsia.

The normal proportion of the constituents of the urine undergoes the following alterations, viz. :

The uric acid is diminished.

Urea diminished or almost wanting.

Chlorides but little altered.

Sulphates and phosphates either diminished or increased.

Uroxanthin increased.

The specific gravity of the urine varies from 1010 to 1030. If the sediment of the urine be examined in the first 24 hours, blood and mucous corpuscles and epithelial scales will be found, but these disappear when decomposition ensues. The more acute the disease of the kidney, the more cloudy the urine, and the greater number of blood-corpuscles. There is frequently also increased sensibility of one or both kidneys under pressure externally, and sometimes various affections of the digestive organs. Eclampsia often occurs in the first labours, but seldom recurs in future ones.

As neither time nor space will allow us to enter fully into the consideration of each division of Dr. Braun's interesting article, we shall, on the present occasion, content ourselves with presenting to our readers a recapitulation only of the views he entertains upon the subject.

1. Convulsions in females during the generative period, depend either upon hysteria,