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, flat, 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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On Encysted Dropsy of the Ovary.

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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 foetid 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 diureties, 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

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On the Treatment of Ovarian Dropsy.

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the tumour, and a continuation of such decrease, or by a positive non-increase for some weeks, then the cyst should be tapped and all its fluid evacuated."

"3. Treatment after tapping consists of accurate padding and tight bandaging over the cyst and body generally for two or three weeks; and the medicines and position ought to be continued for at least six weeks. I would particularly wish to enforce the importance of the after-treatment, as on that depends very much the success or failure of the case."-P. 161.

Certainly, the system of tight bandaging and padding, after a patient has been salivated is very formidable, and the recital of the sufferings and dangers to which patients have been exposed is sufficient to make any judicious practitioner seriously pause before he sanctions it. Mr. Lee seems to question the successful issue of Mr. Brown's cases, and on the authority of a physician, whose name however does not appear, he mentions two of the successful" cases-one of which has again been tapped; and, after the death of the other, the cyst was found as large as ever. Then, again, much doubt seems to hang on the genuineness of the cases, as to whether they have all been ovarian cysts, or some other abdominal enlargement, so that altogether, Mr. Brown's success appears to have been sometimes temporary only and altogether very equivocal.

Of the surgical means for the cure of ovarian dropsy, there are two particularly described, viz. tapping and the excision of the cyst. As a palliative means tapping is sometimes very successful; and cases are recorded where patients have lived many years, the fluid of the cyst being frequently drawn off by the trocar. In Mr. Martineau's case, 13 hogsheads of fluid were taken away from an ovarian cyst in eighty different tappings. But tapping is not without its danger-syncope, and speedy exhaustion may sometimes follow the evacuation of the fluid-a large vessel may be punctured, the cyst may inflame, and peritonitis may ensue. It sometimes is only partially successful, when the tumour is multilocular. Mr. Lee is favourable to an early recourse to paracentesis; and he thinks that, when the tumour can be felt from the posterior wall of the vagina, and fluctuation is distinct, it ought to be tapped. We could have wished Mr. Lee to have collected more facts, to show the results of this early tapping, on the value of which he speaks authoritatively and without doubt.

In order to clear the way for a correct appreciation of the operation of ovariotomy, Mr. Lee has collected a number of cases in which tapping was performed, and he has noted the duration of life after it has been had recourse to.

Putting together 57 cases of this kind, taken from Mr. Lee's own table and Mr. Southam's, in which death occurred, it appears" that 24 of the 57 died after the first tapping-that they all died in eight months—that 20 of the 24 died within one month—and 12 of the 20 within seven days.' Mr. Lee thinks it possible that many of the cases from which his table has been framed, may have been published as peculiar cases, which would of course vitiate the truth of the conclusions. Many eminent men whom he spoke to about it, thought the mortality after the first tapping was too great; but he is himself disposed to think it correct. We must own that

the numbers appear very startling, and do not accord with our general impression; but we think that it discloses a far larger mortality, admitting even the possible errors in it, than is generally supposed. Our author concludes that, "taken at its best, tapping is a very dangerous means of

palliating ovarian dropsy; that, when it is had recourse to, it will have to be frequently repeated; that the relief afforded between each operation will become gradually less, and the dangers consequently greater. This, then, is a valuable argument in favour of some other means of treating ovarian dropsy."

We must now advert to the other operation-namely, the removal of the disease by excision. Mr. Lee's views on this subject are founded on one hundred and eighteen cases in which gastrotomy has been performed, which he has collected with much diligence, and carefully tabulated. Of these 78 have recovered, and 40 have died; in ninety-two the tumour has been removed: in nineteen it was not extracted; and in six there was no tumour to be found. But we meet at once with a source of error in the fact, that (according to Mr. Phillips, Dr. Bird, and Mr. Lee) there are several unsuccessful operations which are not recorded-augmenting, of course, the mortality of the operation, without, we fear, being paired by a corresponding omission of the more fortunate cases. Of these 118 cases of gastrotomy, sixty-nine were for the removal of encysted tumours of the ovary; sixteen for solid tumours of the ovary; six for uterine tumours (fibrous growths); one for an omental tumour; one for the cyst of an ovarian abscess; in six no tumour was found; and the particular disease is not mentioned in 19. Of the 69 cases of encysted dropsy, 48 recovered and 21 died. Of the 16 cases of solid tumours, nine recovered and seven died; and of the six cases of fibrous tumour of the uterus, two recovered and four died.

There are two or three important and obvious points on which Mr. Lee makes some observations. One of them is on the mortality after ovariotomy, another, on the difficulties in the diagnosis of ovarian dropsy, and particularly on the means of ascertaining the presence of adhesions, which have proved the principal hindrance in the uncompleted cases. Mr. Lee estimates the average mortality in ovariotomy as one in three; and, comparing this with the mortality in other capital operations, it appears to be rather under than above the mark. Malgaigne has computed the deaths after amputations, of all kinds, in the Parisian hospitals, as four in every ten cases; and it is much the same in the Glasgow and Edinburgh Infirmaries. In the tying of arteries, the deaths have been 3 in 10; and in cases of hernia, 5 in 10.

The tendency which ovarian tumours have to contract adhesions to the structures and viscera adjacent to them, is a formidable impediment to their extraction. In the cases which have been recorded, they were found to exist in more than one-half of the number. They may be numerous and firm, without any previous known inflammatory attack; and it is a mistake to suppose that tapping causes adhesion. In the latter case, the collapsed and empty cyst sinks down into the pelvis, away from the opening which has been made by the trocar.

There have been several supposed signs of adhesion, on which, however, as single signs, no absolute reliance can be placed. An ovarian sac may be moveable, and yet adhesions, probably long and firm, may be present. Dr. Bright's sign of the new-leather creaking or crepitation as demonstrating adhesions, may not be heard; first, because it is principally to be heard if the adhesions are recent, or, according to Mr. Southam, only when