rity, that these vesicles ever originate merely in diseased action of the lining membrane of the uterus: certainly the chorion to which they are attached, and from which as a root they grow, can only exist as the product of .conception. The chorion, unlike the decidua, is an entirely fœtal production, and we are therefore constrained to believe, that these vesicular hydatids, invariably found in connection with it, must be fœtal, also; or rather the blighted remains of the embryo. But Dr. Ashwell shall speak for himself. "Pathology.-These formations are placed in the second species of moles, because I have seen at least one example where they were the result of diseased action of the uterine lining membrane, independently of sexual intercourse. The patient was the widow of a surgeon, and of undoubted reputation. Her husband had been dead two years and a half when the abdomen began to enlarge. She had nausea, but no vomiting, from which she had always suffered in her pregnancies. The increase of size was very rapid, and at three months and a half from the first stoppage of menstruation, the bulk of the uterus had reached that of a seventh month's pregnancy. The abdominal tumor was flaccid, and the os closed. At the fourth month, after more than ordinary exertion, there was a gush of blood from the vagina, followed by the immediate escape of a considerable quantity of vesicular hydatids.

"The recovery was good. Iron was afterwards given, she was sent to the sea-side, and now, at the expiration of several years, there has been no return of the malady.

"Mr. Douglas Fox, surgeon to the Derbyshire Infirmary, gave me the particulars of a case where a large mass of vesicular hydatids was expelled from the uterus of a maiden lady, where the hymen was unruptured, and of whose chastity there could not be a suspicion.

"Sir Charles Clarke and Dr. Blundell unite in opinion, that conception is not a necessary condition; while Madame Boivin, Capuron, Duges, and even our own countrymen, Denman and Burns, have arrived at an opposite conclusion. Dr. Evory Kennedy says, that hydatids may occur in virgins'; while Dr. Montgomery believes, that they invariably result from impregnation.' It were to be wished that every disputed physiological point admitted, as this does, of a settlement by the observation of facts.

"Women are liable to a repetition of this vesicular formation, where it has resulted from conception. The few exceptions, where the hydatids have formed independently of pregnancy, forbid at present any decided opinion as to the probability of their recurrence."

We regret, that want of space compels us to pass over several chapters of great practical value, especially the long and most able section on the various displacements of the uterus: in future editions we shall remedy this omission. At present we must content ourselves by a long extract, in every word of which we agree, on the now fashionable and frequently entirely unwarrantable operation of ovariotomy. We are truly glad, that Dr. Ashwell has given to the profession this most temperate and accurate opinion, and has thus thrown the weight of his great experience and reputation into the scale against this most formidable and unsuccessful operation. We prognosticate that, like extirpation of the uterus, in a few years extirpation of the ovary will be scarcely heard of, except as a matter of medical history.

"The progress and termination of encysted ovarian dropsy, have become subjects of the deepest interest, owing to the efforts lately made to cure the disease by extirpation. Whether this be a desirable, or even a defensible operation, must mainly depend on the known course of the disease, when either left to itself or treated with a view to palliation only. If it could be proved, in the majority

of cases, that the malady did not shorten life nor induce severe suffering, few more operations would be undertaken. But the examples of this kind are, it is to be feared, only exceptional; and yet I cannot divest myself of the idea, if our records were accurately kept, that a more favourable view might be correctly taken of the palliative, or indeed of any treatment which did not involve the necessity for this hazardous extirpation. Certain it is, that many women have lived to old age, who were the subjects of the disease; and although a less number comparatively survive many years after tapping has become necessary, yet a collection even of these would go far to prove, that paracentesis is not by any means so fatal in this respect as has been supposed. Sabatier examined the bodies of several women who had carried these encysted tumors during half a century, without alarming derangement of health; and the memoirs of the French Academy of Surgeons prove, that it may last 58 years; while Nauche, as a summary of his own views, says, dropsy of the ovary, then, is not a very alarming disease, unless it be very ancient and very voluminous.' The cases of frequent tapping recorded by Martineau, Portal, and many other surgeons, amply attest the protracted duration of life in association even with this stage of the affection. Nor, in a calculation of this kind, must it be forgotten, that numerous women have become pregnant, and have been many times safely delivered, notwithstanding a dropsy of one of the ovaries. Such cases have fallen under my own observation, and I could add others also where the malady, although of a considerable size, has existed many years without tapping, and without indeed any other than mere palliative treatment.

ope

"These considerations are entitled to great weight when determining the propriety of extirpation, uncalled for by present and great evils; or where the ration, from the enthusiastic views of its patrons, is urgently recommended as a preventive of mischiefs which they deem, but not always on good grounds, to be prospectively inevitable. To operate, where the patient strongly desires it, from a conviction that her sufferings and the frequent repetitions of paracentesis, will otherwise prove speedily fatal, may not involve any distressing responsibility, especially where the condition of the tumor leads to the supposition, that the case is pathologically a favourable one. But there are examples selected for operation far different from this. Take, for instance, a case which occurred to me a few months ago. A lady travelled to town from a considerable distance, anxious to have extirpation performed. On inquiry, I found she was 62 years of age, had never been tapped, although ovarian dropsy had existed for more than half her life. There was scarcely any suffering beyond weight and pressure, although the tumor was of immense size and partly solid. In such a case, it would have been highly culpable to have operated; and yet a surgeon, over zealous about the removal of ovaries, had induced the firm belief that it ought to be done. I need scarcely add that the patient, after being made acquainted with the great danger of the operation, was perfectly satisfied to remain as she was. Nor will the practitioner be less perplexed and distressed by such a case as the following, which occurred within my observation not long since :-A young woman, under 22, had ovarian dropsy; her countenance bespeaking excellent health, and her history confirming the impression. Without interference, many years might have been added to her existence; and as one of the fortunate incidents of life, it might have so happened, that the tumor should cease to grow. But unhappily she was convinced that extirpation was proper; the operation was most ably performed, and in a few days she died. These certainly are not the cases in which removal ought to be practised. If the operation is to become established, of which I have the strongest doubt, it must be confined to examples of the malady where tapping has already been so often performed as to preclude, from the experience of similar cases, any idea that it can ever be dispensed with; and where, we are confident, that great suffering must lead to early death. Perhaps this may be regarded as too limited a view of the value of extirpation, but it is, I think, the correct one. In such cases, if the diagnosis excludes the belief that there are

serious adhesions, or malignant and solid growths complicating the tumor, and if the patient strongly desires it, the operation is defensible. In all other examples it can only rest on the patient's own views of her future prospects, and on a calculation of chances. She might live many years and without much suffering; but she may die in a few years after great suffering: she determines, therefore, being courageous, and probably strongly urged by her surgeon, to run the risk of immediate death for the hope of immediate and radical cure. Whether she has done wisely to submit to such a hazard, a successful operation can scarcely prove; that she has happily secured her safety, through imminent peril, such an operation does prove. Lithotomy, operations for hernia, and for securing large arteries, rest on different grounds. That they are essential to the patient's life, is a full justification of their performance; for in all, even if not dangerous at the moment, it is certainly known that life will soon be destroyed, either by fever, gangrene, or loss of blood. Such, it has been proved, has not been the case in many of the fatal operations lately performed for extirpation of ovarian encysted tumors. It does not appear that statistics more favourable even than we have any right to expect, will materially change the aspect of the circumstances under which this operation is to be performed. It must, probably, from the impossibility of determining the real character and adhesions of the growth, ever remain an eminently uncertain operation. The extirpation, we are assured, by the operators themselves, in a fit case, is far from difficult-would that it were more so -for then it would not be so readily undertaken. If it required as much surgical knowledge and skill to make these large and brilliant abdominal incisions, as to tie the subclavian artery or to perform a trying operation of lithotomy, the lives of many women would have been already spared, and fewer would be sacrificed for the future. What would be thought of the feasibility of any other operation involving life in the most imminent hazard, if we discovered that out of 67 cases where it had been attempted, it was, from absolute error of diagnosis, incapable of completion in eighteen; that of the remaining 49 patients, where the extirpation was effected, sixteen died and two were not cured; so that out of the whole number 67, the operation failed in thirty-six and succeeded in thirtyone, less than one-half. Such results are distressing, especially when we hear no greater doubt expressed about the operation itself, but only higher confidence in its value, and greater laudation of the operators. We willingly concede presence of mind and ability to many of the extirpators of ovarian cysts; but we are unable to discover (for the later operations have been quite as unsuccessful from unfitness of the cases as the earlier ones) that any advance has been made in diagnosis. Nor, when the tumors themselves are examined after death, when the malignancy of many of them is recognized, and their firm, almost indivisible adhesions, and their immoveable masses of new and morbid substance are brought to view; it is next to impossible to entertain any sanguine hope, that our means of diagnosis can ever be much improved."

In concluding our still imperfect analysis, we must, in justice to the author, declare our conviction, that his work on female diseases is the most able, and certainly the most standard and practical, we have yet seen. It will, now that it is completed, find its way into the library of every practitioner, and justly confer on its talented author a very high place in the first class of obstetric physicians.

Nor can we close these critical remarks, without congratulating Dr. Ashwell, that even his unfinished book should have received from our utilitarian and clear-sighted brethren in America the high compliment, not merely of republication for sale, but of an extensive reprint for private circulation, amongst the members of the largest Medical Society in the United States: Dr. Hall, the Secretary, remarking, that it may afford Dr. Ashwell some gratification to know, that his labors are appreciated on

66

this side of the Atlantic, and are conferring a special benefit on six or seven hundred physicians in Massachussetts."

ON THE CHANGES INDUCED IN THE SITUATION AND STRUCTURE OF THE INTERNAL ORGANS UNDER VARYING CIRCUMSTANCES OF HEALTH AND DISEASE, AND ON THE NATURE AND EXTERNAL INDICATIONS OF THESE CHANGES. By Francis Sibson. Worcester, 1844. Octavo, pp. 270.

THE present work formed one of the principal contributions to the twelfth volume of the "Transactions of the Provincial Medical and Surgical Association;" and reflects great credit upon its author, Mr. Sibson, resident medical officer at the Nottingham General Hospital. The post of resident at a well-conducted hospital offers to a man of talent and industry excellent opportunities for the pursuit of pathological investigations; but the emolument attached to it is generally so insufficient as to induce gentlemen who accept it, at least those of them whose acquirements would enable them to turn its opportunities to advantage, to retain it only until something better can be found, and consequently for too brief a period to admit of the prolonged pursuit and reiterated examination of any important or novel subject of inquiry. This is much to be regretted; for, the place of ardent, well-educated, inquirers of this description can in no-wise be supplied by the active medical officers, whose time is occupied and attention distracted by the cares of private practice, and who are for the same reason not always so perfectly in possession of a knowledge of the most recent advances in physiological and pathological science, as he who has just quitted the sources of its diffusion; and the consequence is that a most important field of research lies comparatively uncultivated.

We will state the object of Mr. Sibson's publication in his own words.

"It is now some years since I found that my notions of the usual and healthy sites of the various viscera were ill defined. To clear up this obscurity, owing to which I was constantly at fault in examining patients suffering from chest diseases, I took diagrams of the position of the viscera, when making post-mortem examinations of the patients that died in the General Hospital near Nottingham. I first drew a careful outline of the ribs and sternum, and then added the internal viscera, taking care that their bearings to each other, and the ribs, were accurately planned.

"After a time I procured a frame, and stretched strings across and along it, at distances from each other of three inches; the whole frame was thus subdivided into 45 squares. I ruled a piece of paper with squares of a like fashion, but of one-third the size: the frame I laid over the subject to be copied, and with care and accuracy traced the objects that were behind each three-inch square upon the corresponding one-inch square on the paper.

"I showed these diagrams, from time to time, to Dr. Hodgkin: he was interested in them, said they were of value, and gave me many important hints respecting them. Last Winter, Dr. Hodgkin exhibited and explained many of the diagrams at one of the conversaziones at St. Thomas' Hospital, at the time when the medical school of that Institution had the advantage of his services. Some months before these diagrams were thus brought before the profession, Dr. Hodgkin suggested to me a plan for taking them, which I immediately

adopted a plan that placed my inquiry on an entirely new and more solid footing. This method consists in drawing the outlines of the organs on a piece of lace, stretched on a frame and placed over the body; the sketch is transferred by placing the lace over a sheet of paper, a piece of the manifold letter-writer paper being interposed. By pressing firmly with a point on the chalked outlines they are traced in black on the paper beneath. By this plan, employed with care, perfect accuracy is ensured. It has the advantage also of being applicable to the living as well as to the dead.

"To reduce these full-sized diagrams to their present dimensions, I employed a pentagraph that was recommended to me by Dr. Hodgkin.

*

*

"I possess, including those engraved in this paper, 79 diagrams of the internal viscera, taken from the dead, and 85 from the living subject. I have likewise records, in a tabulated form, of the relative position of the various viscera, as ascertained by percussion and auscultation, in 88 persons of both sexes, and of various ages, occupations, and residences, in almost all of whom the heart and lungs were healthy. In 66 of these cases I have minute notices of the form of the surface, as indicative of the viscera underneath; of the respiratory sounds over the larynx, and over different parts of the chest, in tranquil and in forced respiration; of the nature of the heart's sounds over the region of the heart's superficial dulness, the course of the great vessels, and the general surface of the chest; and of the seat of the heart's impulse. The results of the scrutiny of these materials are detailed in the preceding pages."

About forty of these diagrams are here engraved, illustrating the normal situations of the various thoracic and abdominal organs, and the variations these undergo in consequence of the presence of the different diseases of the chest. They form, as the author observes, not merely illustrations of the present essay, but also of the works of Laennec and his successors, and will therefore prove of value to any one engaged in the study of any of these. The Essay itself consists of a detailed description of the position of each organ under the circumstances of health and disease, and of the varieties which occur in this respect during the different acts of the process of respiration. The diseases of the chest are treated of at considerable length under the heads-1st. Of Diseases where the bulk of both lungs is enlarged, as Emphysema and Bronchitis. 2d. Diseases where one organ and one side of the chest are enlarged, as Pneumonia, Pleuritis, and Diffused Tuberculous Consolidation. 3d. Diseases in which the bulk of the affected lung is lessened, as Phthisis. 4th. The Heart and its Diseases.

The work is so completely one of reference for the subject to which it relates, that an analysis of its contents is uncalled for, and would be scarce intelligible condensed into the space we have at command. We will therefore content ourselves by extracting a few passages.

Effects of Respiration on Jugular Pulsation.-" The veins of the neck contain the least blood during a deep inspiration, the expansion of the walls of the chest withdraws the pressure of those walls from the right cavities of the heart, and permits the blood to be sent more freely into those cavities. The venous pulsation is much diminished, in many persons rendered invisible, during a deep inspiration. A forcible and deep expiration has, on the other hand, quite an opposite effect the contracted walls of the chest compress the right cavities of the heart, and prevent the ingress of venous blood. The veins of the neck and of the thyroid body become necessarily distended; these veins indeed become an evervarying reservoir, which adapts itself with perfect flexibility to the expansion or contraction of the heart, so that, when the cavity inside is lessened, the reservoir