THE BRITISH AND FOREIGN MEDICAL REVIEW OR QUARTERLY JOURNAL OF PRACTICAL MEDICINE AND SURGERY EDITED BY JOHN FORBES M.D. F.R.S. F.G.S. VOL. XVIII JULY-OCTOBER 1844 LONDON JOHN CHURCHILL PRINCES STREET SOHO MDCCCXLIV. THE BRITISH AND FOREIGN MEDICAL REVIEW, FOR JULY, 1844. PART FIRST. Analytical and Critical Reviews. ART. I. Clinique Chirurgicale de l'Hôpital de la Pitié. Par J. LISFRANC. Tome troisième.-Paris, 1843. Clinical Surgery of the Hospital of La Pitié. By J. LISFRANC.Paris, 1843. Third Vol. 8vo. pp. 748. THE present volume, which completes M. Lisfranc's work, is-with the exception of two chapters, one on tumours adjacent to but not connected with the female organs of generation, the other on hemorrhoids,-entirely devoted to certain diseases of the uterus and of its appendages. We shall not lay before our readers a detailed analysis of the entire volume, as the greater part of its contents necessarily consist of generally known facts, but we shall endeavour to notice whatever seems valuable either from being more or less novel, or from bearing on important or unsettled points of pathology or practice. Fibrous tumours of the uterus. The first chapter treats of fibrous tumours of the uterus, a disease not yet fully elucidated, notwithstanding the labours of Bayle, Bichat, Roux, Cruveilhier, Dupuytren, Lee, and others. The history given of the pathological anatomy of the affection agrees in the main with that given by the writers whom we have just enumerated, and as anything on that head requiring remark may be more conveniently noticed when considering the chapter on polypus of the uterus, we shall only advert to M. Lisfranc's views respecting the symptoms, diagnosis, and treatment of the malady. The account of the symptoms produced by fibrous tumours, though rather diffuse, is not very accurate. M. Lisfranc does not, for example, mention how materially the symptoms vary according to the situation of the tumour, and it might be readily inferred from his account, that those symptoms are the same, whether the growth projects towards the peritoneum or encroaches on the cavity of the uterus; while it is to the latter form of the disease that the description given is chiefly applicable. On such points, however, we shall not dwell; our object is not to examine XXXV.-XVIII, 1 the history of the affection in detail, but to state M. Lisfranc's doctrines respecting its symptomatology and treatment, which, though scattered through fifty-two pages, are comprised in the three following propositions: First, that there are no signs by which the existence of a fibrous tumour of the uterus, can in any case be positively ascertained during life. Secondly, that, in consequence of the impossibility of forming an accurate diagnosis, every supposed case of fibrous tumour of the uterus should be treated as if it were a curable induration of that organ. And thirdly, that, though the true fibrous tumour is always incurable, its progress may often be arrested for years, by means of such treatment. M. Lisfranc claims those opinions as his own undoubted discoveries, and alleges, as we shall see, that he has sustained no small persecution for having been bold enough to promulgate them. How far this claim is founded, we shall briefly examine, after having stated the facts and reasoning adduced by our author in support of his views, and this we shall do as nearly as possible in his own words. The rational symptoms produced by fibrous tumours of the uterus, merely announce the existence of some disease of that organ, without specially indicating any particular malady; but there are three symptoms, to any of which, where present, M. Lisfranc attaches very considerable importance, viz. the occurrence of expulsive pains at variable periods, but more especially a few days before or after menstruation ; the existence of menorrhagia, usually very obstinate, and, when controlled, extremely liable to return;—and above all, to this, viz. "That the volume of womb may diminish under appropriate treatment, and after a time again augment in size. It is not very unusual to see this diminution and subsequent increase of the hypertrophy of the uterus occur several times in succession. The phenomenon, I think, may be thus satisfactorily explained. The medicines administered disperse, but only for a time, either partially or entirely, the hypertrophy of the tissue of the uterus, caused by the presence of the fibrous tumour. These last-mentioned signs are, in my opinion, very important, they are not, it is true, pathognomonic, but they afford very strong presumptions in favour of the existence of a fibrous tumour." (p. 13.) M. Lisfranc next considers the physical signs, or those ascertainable by the sight and the touch, and maintains that they are equally inconclusive as the rational signs. The uterus may be enlarged in size, we may detect with the finger or speculum, or both, hard tumours more or less circumscribed, but we cannot with any certainty determine whether such tumours are fibrous growths, or indurations consequent on simple inflammation of the womb. "When we discover," says M. Lisfranc, "one or several tumours, more or less rounded and circumscribed, situated on the womb, it is supposed that those tumours are always fibrous. From this grave error it follows that a merely palliative treatment is adopted, and thus the opportunity is frequently lost of curing tumours, whose progress, because of the inertness of the treatment, remains unchecked, and usually terminate in the death of the patient. It is necessary to prove the truth and value of this opinion, and I shall, therefore, here reproduce the evidence so often adduced at my clinique. "As inflammation of the uterus may exclusively affect the neck or the fundus of the organ, why may it not also occupy still more limited portions of the womb and why may it not terminate in indurations more or less rounded and circumscribed? "We know that inflammation, affecting the thigh for example, may disappear almost completely, only leaving here and there isolated indurations more or less rounded and circumscribed. May not inflammation of the uterus terminate in the same way? Reasoning and analogy favour this view, which is also sanctioned by experience. When I was in the habit of exhibiting operations on the dead body, I have opened the bodies of many women who died of chronic metritis or metro-peritonitis, and frequently observed this to be the fact. Do we not also know that true abscesses, sometimes containing very concrete pus, have been found in the parietes of the uterus? I have met with such an abscess in the centre of a hard tumour, perfectly rounded and circumscribed. "I have demonstrated round and circumscribed indurations of the uterus, lobulated or uneven on the surface, like fibrous tumours, which they also perfectly resembled in hardness. "When I commenced practice, I was misled by received opinions, and set down these tumours as fibrous, but I soon discovered that their size in many instances diminished under the influence of antiphlogistics and narcotics, employed with the view of relieving inflammatory and nervous symptoms. I was thence induced to administer discutients when the inflammation had been completely subdued, and thus frequently effected their complete resolution. Need I say, that it is impossible to disperse a fibrous growth? From the foregoing data then I conclude that simple inflammatory indurations of the uterus have often been mistaken for fibrous tumours. I am in possession of numerous cases which bear out this opinion, of which the following are examples." (pp. 17-18.) The cases here referred to are twenty-six in number, and are given at such length, that they occupy twenty-three pages. It would be superfluous to analyse them. Suffice it to say, they afford examples of indurated tumours of the uterus, closely resembling fibrous tumours, but which yielded to the treatment to be presently mentioned. "From these observations," says M. Lisfranc, " to which, I repeat, I could add many others, I conclude that there are no certain signs of the existence of fibrous tumours of the uterus previous to their assuming the form of polypi. For the expulsive pains merely raise a strong presumption of the existence of those tumours, inasmuch as those pains may be caused by clots or other foreign bodies in the cavity of the organ, and are sometimes even occasioned by simple tumefaction of the uterus, a fact which I have ascertained by post-mortem examination; the same, as I have already stated, holds good of obstinate and frequently recurring sanguineous discharges, continuing for a long period, and also of augmentation of the bulk of the womb, after its volume has been reduced by appropriate treatment. "In this uncertainty of diagnosis what course should the practitioner pursue? He should employ the treatment suitable for simple inflammatory induration of the uterus, and by so doing, will frequently succeed in curing the disease. Numerous facts, I cannot too often repeat, sanction this novel opinion, which has proved offensive to many, and has exposed me to numberless attacks. "Furthermore, fibrous tumours usually cause the same symptoms as simple tumours of the uterus, and it is therefore sound surgery to adopt the same treatment in both cases. If, in fact, we have to deal with a fibrous tumour, we mitigate or even remove the symptoms it excites, and may possibly to a certain extent, prevent their recurrence; finally, we may retard or render stationary its dangerous progress, without obstructing its natural cure by the conversion of the tumour into a true polypus; so far indeed, from the treatment interfering with this salutary result, it, on the contrary, favours its occurrence; if, however, the tumour consists of an hypertrophy either simple or indurated, it has been shown that it may be cured." (pp. 41-3.) "In some cases, under the influence of the treatment, the apparently fibrous tumour remains stationary, and the patients may live for years, experiencing generally but little inconvenience, though liable to the supervention of severe |