"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 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,

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On the Treatment of Uterine Tumours.

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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 oedema of the nipple or areola present." Besides, the fresh, raised, varnished look of the areola (for we do not think the word oedema 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 foetal heart is heard." Undoubtedly the main sign of pregnancy, which outweighs all others in value and easy appreciation, is the foetal 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 sound-which 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

mercurial ointment into the cavity of the uterus with manifest advantage. In one case, a single large solid growth appeared to separate into distinct parts, and to become less. Mr. Lee discards the use of mercury internally, but he speaks favourably of the treatment by iodine, which has been of late years the most usual remedy for these growths. Mr. Lee only passingly mentions the plan of enucleating fibrous tumours when they can be got at with the scalpel, although we think he would have done wisely and contributed some useful information had he carefully investigated the cases in which this practice has been adopted.

The several varieties of polypi, as described by different authors, are succinctly noticed by Mr. Lee. Thus we have the fibrous tumour growing inwards towards the cavity of the uterus, acquiring a stalk, and thus becoming a polypus. Mr. Lee, unnecessarily we think, calls this variety polypoid; then we have the vesicular polypi, polypi from the enlargement of the Nabothian glands, fibro-cellular polypi, cellulo-vascular polypi, mucous polypi, and the channelled polypi of the cervix. This latter variety consists of a polypus springing from the neck of the womb, the substance of which is traversed by large channels, terminating by open mouths on the surface of the growth, and filled with thick clear mucus. It was first noticed and described by Dr. Oldham.

Mr. Lee has omitted to consider the influence of pregnancy on the growth of polypi, beyond, at least, a mere incidental allusion to it. The subject is interesting and important, and undoubtedly it came within the scope of the subject of the Essay.

Cauliflower excrescence of the os uteri is supposed by Mr. Lee to be a distinct affection from fungoid disease of this part, although the only distinguishing marks between the two are stated in the following paragraph:

"If a proper examination be made on this disease, it is not difficult to distinguish it; but it has been mistaken for other growths. The most likely one is that arising from fungoid cancer: a case of this kind occurred to myself. A patient presented herself with all the symptoms of cauliflower excrescence, profuse watery discharge, no pain, health good, &c., and had from the os uteri fungoid granulations, some of which broke down upon examination: but on viewing the growths by the speculum the error was immediately corrected-they were large, fiat, and not prominent."-P. 93.

For our own part we can see no reason why these two affections should not be grouped together. The difference between them is very slight; and, indeed, in reading Dr. Clarke's description of the cauliflower excrescence, and comparing it with cases of fungoid disease, which are by no means rare, no essential distinction can be made between them. Perhaps the one may feel a little more like a cauliflower than the other-but the seat, development, symptoms, and general character of the growths are so much alike that it appears to us to be unnecessary to separate them. Mr. Lee has altogether omitted the description of fungoid cancer, for assuredly the encephaloid tumour, the most frequent, he says, of polypoid growths, is perfectly distinct from it. We think he might just as well have begun a chapter on "fungoid disease of the uterus," and then have added, vide cauliflower excrescence of the os uteri. There appears to us to be a want, in this part of the Essay, of clear, well-defined views on the subject of malignant growths. If, as our author says, cauliflower excres

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cence is a very rare disease, and that the encephaloid growth, such as he has described it, is the next variety, we are well persuaded that he has perfectly missed a class of cases which frequently come under observation, and which the term fungoid very well designates. These growths are not confined to the os or cervix uteri, for they sometimes spring from the cavity of the womb. They occur in women with full capillary circulation, and generally wearing the aspect of good health. They are bleeding growths-bleeding when touched during a vaginal examination, or sexual coitus, or by the pipe of an injecting syringe, bleeding, too, sometimes spontaneously; and so full are they of blood-vessels that when, by the act of coughing, sneezing, or lifting weights, &c., an increased flow of blood is derived towards them, the capillaries give way, and again they bleed. They are growths, too, attended by a watery discharge, sometimes very fœtid and acrimonious. They are a species of soft cancer, and are shaped and contracted by the vagina. By degrees the loss which is sustained by bleeding and discharge brings on anæmia, then the severe pains of cancer are felt, and death takes place. If a ligature is placed around even a large growth, it shrinks to nothing, and after death it appears flocculent like the villi of the chorion. Wherein is the difference between cauliflower excrescence and this fungoid disease? and yet, we repeat, these latter cases are very far from rare. The excision of these growths, or their removal by ligature, is advocated by Mr. Lee in accordance with the published cases of several obstetric physicians. Here and there an apparently complete success has followed this practice, and appears to us quite to justify the operation. Even the partial success which attends a removal of the mass prolongs life by taking away for a time the source of hæmorrhage and watery discharge. The difficulty in the operation consists in noosing or excising the entire diseased portion, and the principal danger is from hæmorrhage, which can, however be controlled by the plug.

The second part of the work is devoted to tumours connected with the appendages of the womb, and of these the most important is the encysted ovarian dropsy. Mr. Lee has collected one hundred and forty cases of this disease, some of which have passed under his own notice, and others have been recorded in medical journals, and these have formed the data of his observations on the subject. These 140 cases are tabulated in several ways, so as numerically to prove, where the details of them have been sufficiently explicit, the various facts which are stated. Thus it is that, at the commencement, we meet with a disputed point, which is settled by a statistical table of 136 cases. Dr. Burns thinks that married women are most liable to this disease, whilst Dr. Ashwell believes that it attacks the single most frequently. Mr. Lee's table shows that, of one hundred and thirty-six cases, eighty-eight were married, eleven were widows, and only thirty-seven were single, thus giving a decided preponderance to the married. Then again, with reference to the age of patients with the disease, it appears that of one hundred and twenty-six cases, only three occurred in women under twenty years of age; thirty-seven between 20 and 30; forty-five between 30 and 40; twenty-six between 40 and 50; nineteen between 50 and 60; three between 60 and 70; two between 70 and 80. Hence it seems that the disease is particularly rife during the child-bearing period; when the sexual organs are in their fullest vigour. There is ano

ther table showing the duration of ovarian dropsy, from whence it appears "that out of 131 cases, the disease lasted only one year in 38, only two years in 25: 17 patients survived three years, 10 four years, 3 five years, 5 six years, 4 seven years, 3 eight years, 1 nine years, 1 ten years, 1 eleven years, 5 twelve years, 5 sixteen years, 1 twenty years, 1 twenty-two years, 2 twenty-five years, and 1 thirty years."

Table No. 4, is headed "of the imputed causes of ovarian dropsy in thirty-six cases. Fourteen cases are ascribed to marriage or its consequences-that is, five followed marriage, and the patients regarded it as the cause, and nine followed parturition. Seven cases were supposed to be caused by a sudden suppression of the menses. Two cases were traced to abortion; three to exposure to cold; two to falls or blows; one to a violent fit of anger; one to an eruption, and one to disappointed love. There were only two which were assigned to the catamenial decline, which Denman thought the most frequent cause. A Table is prepared to show the frequency of ovarian disease in the right, left, or both ovaries, the inference from which is, that the right is affected in frequency to the left, and to both ovaries as 50 is to 35 and 8. This conclusion is at variance with Mr. B. Cooper's results in 50 cases, from which it appeared that the left ovary was more commonly diseased than the right. We look upon it that Mr. Lee's table is no more secure with his 93 cases of a truthful result than Mr. Cooper's, and that the question is still quite undecided. We shall not follow our author into the pathology of ovarian dropsy, which has been so fully written upon by several authors, more especially by Dr. Hodgkin. The diagnosis of this disease is carefully described; but the most important part of this Chapter is on its treatment. Mr. Lee has not entered so fully into the subject of the treatment of this disease in its early stages as he should have done. A little of the industry which has been spent on the attractive subject of Ovariotomy, might have been advantageously employed in collecting some facts on the influence of leeching, mercury, and counter-irritants, in checking the growth of small tumours. It is well known that the late Dr. Hamilton treated ovarian cysts by bandaging, percussion, and the internal use of the muriate of lime; but the success which followed its adoption in Dr. Hamilton's hands has not been copied in England, and it has fallen into desuetude. Mr. J. Brown, of London, is said to have cured several cases, by tapping the cyst, after giving the patient mercury and diuretics, and then tightly bandaging the abdomen. We transcribe a short outline of his practice from Mr. Lee's book.

"I divide," says Mr. Brown, "my treatment into constitutional and local treatment, and treatment after tapping.

"1. The constitutional one consists in the administration of mercurials, internally as alteratives, and externally by friction over the abdomen, and continued until the gums are slightly but decidedly affected: and this must be continued for some weeks. I lay particular stress upon this point: at the same time diuretics must be given, and after the first week tonics must be combined with them. The food should consist of light animal diet, and should be unstimulating; and the patient should take daily exercise in the air."

"2. Local treatment. This consists of the careful application of a tight flannel bandage, so as to produce considerable pressure over the tumour. When it is found that the abdominal action has been checked by a positive decrease in