1817)

Ovarian Cysts.

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coat. It is even not unfrequently situated upon the uterus, or some other of its appendages, besides the ovaries. However some persons believe that, even in these cases, the ovary is the original source of the disease. They suppose that an ovum spontaneously detached under the influence of venereal excitement has fallen into the peritoneum, where it has contracted attachment, and continued to grow.

"This opinion, of which the accuracy cannot be demonstrated, is nevertheless very probable, for cysts within the pelvis are perhaps never met with but in the female. It is therefore natural to refer the production of these tumours to some natural organic condition of the female, and this condition can be no other than the presence of an organ which does not exist in the male."

Without questioning the strong predisposition which exists in the ovary and its vicinity to the production of serous cysts, we cannot unite in the theory here adopted, since cysts having in every respect the anatomical character of those occurring in the ovary are found in various organs and textures of the body, in males as well as in females. That they are not degenerations of the vesicles of De Graaf, is evident from the fact, that the morbid enlargement of these vesicles, when it does occur, gives rise to cysts materially different from those which constitute the ordinary form of ovarian dropsy. It is not, however, improbable that the peculiar microscopic texture of the ovary, which admirably fits it for the production of a succession of Graeffian vesicles, may, by some disturbance of this process, bring about the formation of the cysts in question.

A good description is given of the symptoms, varieties, and terminations of these ovarian cysts. A case observed by Dr. Bonfils, in which the rupture of the cyst was followed by radical cure, is mentioned as a solitary instance. Several instances of the same kind, have, however, been seen and recorded in this country.

With regard to the treatment, our author admits the entire failure of all medical means. The strong support and compression of the abdomen is to be adopted as a palliative. Puncture, generally employed with this view only, has sometimes obtained a radical cure. The puncture, which is generally made through the abdominal parietes, may sometimes be performed through the vagina, which is not only favourable to the escape of the fluid, but also to the introduction of the canula, by which a gradual and continued discharge may be procured; and such evacuation has been known to lead to an entire cure. The operation is only practicable in this mode in some cases, and when practicable is not always safe.

Some persons have ventured to attempt a radical cure by injecting irritating liquids or vapours into the sac after evacuation, and others have incised the cyst after having caused adhesion to the abdominal parietes. All of these plans our author rejects as more or less imprudent, and whatever success may have been related as accompanying them is not sufficient for their justification. On the same grounds he rejects the extirpation of the cyst after merely alluding to the operation, and stating that it has been performed. He, however, recommends a treatment stated to have been successfully performed by Professor August Bérard. It consists of making punctures through the cyst with a long acupuncture needle. He considers that, by this means, the cyst is so modified as to promote a slow but ultimate absorption of the liquid.

Amongst the horny and epidermic productions are noticed horns, which are more often met with in aged females than in males. They are sometimes solitary, more seldom numerous. They are about two centimetres in length, but have been seen upwards of thirty. Malpighi and Raspael thought they were formed by a nervous prolongation from the dermis, but Breschet thinks, with more probability, that they are a morbid secretion. The other forms of corneous production are ichthyosis, pityriasis, lepra, and psoriasis.

After noticing cartilaginous and osseous formations, Dr. Grisolle speaks of Polypi, merely enumerating those which from their position come more particularly under the attention of the surgeon, as for example, in the nose, pharynx, and uterus, but dwelling on those of the stomach and intestines, and of the larynx and bronchi. He states that most of the cases of polypi of the heart which have been published in France and England, are only cases of sanguineous concretion, but that there are some wellauthenticated though rare examples of accidental productions of the same character, or analogous to the fibrous and fungous polypi of the nose and uterus. Their most frequent seat appears to be the left auricle, and in two instances they were attached to the spot at which the foramen ovale had been closed. In two cases, which we have seen, adventitious productions somewhat resembling this character were attached to the margin of this valve, which had remained open to an advanced period of life.

The so-called vegetations of the heart noticed by Corvisart and Laennec, and which the former, erroneously supposed to be of the character of syphilitic warts, are formed in the ventricles, or attached to the valves. Some are regarded as unquestionably the result of endocarditis, whilst others have more the character of coagula.

ACCIDENTAL PRODUCTIONS FOREIGN TO THE SYSTEM.

We shall pass by all the calculi and the parasitical animals which are included by the author in this class, only observing that he inclines to the recent and not improbable opinion, that acephalocysts are merely the envelopes to the echinococcus, and that the vesicular mole or placental hydatid is to our surprise included under the head of hydatids, which is the more remarkable as the author is acquainted with the researches of Madame Boivin.

In the same section, and without any subdivision, the author treats of the whole group of cancerous scrofulous and melanotic productions, these last being separated from the other forms of malignant disease. In noticing the microscopic characters of cancer, as marked by various forms of nucleated cells, he only mention's the observations of Lebert, without alluding to those of Müller, which were, we believe, the first, and which have been followed up by many others.

There is nothing new or remarkable in the description which is given of the various forms of cancer, and which appear to have been drawn from various sources, including several English authorities. The author adopts the opinion of Bérard with regard to the softening process, depending on increased vascularity, which is doubtless a part, though we believe not the whole of the truth. He agrees with those who of late have properly distinguished the colloid or gelatiniform cancer from the encephaloid. The

1847]

Diseases of Particular Organs.

41

distinction is doubtless correct with respect to the most characteristic specimens in which there is no blending of the two diseases, but there are examples in which, judging from external and manifest appearances, they seem to concur and insensibly pass into each other.

Cancer is described not only in its general characters, but in relation to the most important organs liable to be invaded by it, such as the lungs, pleura, stomach, intestines, liver, uterus, &c.

The author treats of tubercle in general as a peculiar deposit, following Laennec and Louis for its manifest characters, and Lebert for the microscopic. He notices the views of Baron, Cruveilhier, Lallemand, Piorry, and Carswell, as to the mode of origin, and those of Broussais, Lombard, Andral, and Louis, as to the mode of development and the influence produced on surrounding parts.

Under the special affections of this group, phthisis pulmonalis is of course the most prominent, and the article on this disease contains a summary of the observations of the best authors, but he does not appear to be aware of the beautiful microscopic observations and researches of our countryman, Mr. Raine.

Tubercular meningitis, which forms another member of this group, is made to include hydropcaphalis internus. Tubercles in the substance of the brain are treated of separately.

Tubercles in the mesenteric glands, constituting mesenteric atrophy. forms another division under the name of Carreau.

The article on scrofula is short, and we regret to observe the absence of any notice of the laborious enquiries of our countryman Benjamin Phillips. We pass over the 9th Class of nervous affections to notice the last, viz., 10th Class, in which are placed affections peculiar to certain organs or tissues. This comprises the following list:

Disorders peculiar to the digestive organs, the first of which are those accompanying the first dentition; secondly, Indigestion; thirdly, Gastric disturbance; fourthly, Intestinal disturbance; fifthly, Constipation; sixthly, Intussusception, or volvulus; seventhly, Diabetes.

Peculiar to the liver-Jaundice or Icterus.

Peculiar to the kidneys-Bright's disease.

Peculiar to the heart-Insufficiency of the valves, viz. of the Sigmoid, of the tricuspid and mitral.

Those peculiar to the air-passages ;-Asyphyxia, divided into three forms-1, by compression of the chest,-2, by strangulation;-3, by submersion.

Disorders peculiar to the genital organs;-Dysmenorrhoea; Irregular menstruation; Amenorrhoea; Cessation of Menstruation, or symptoms attending the change of life.

Disorders peculiar to the fibrous and muscular tissue:-Rheumatism, subdivided by its several seats (one of the most remarkable of which is rheumatism of the uterus during pregnancy and parturition); Acute rheumatism and rheumatic gout; Chronic rheumatism.

Diseases peculiar to the skin :-Prurigo, lichen, urticaria, elephantiasis, lupus, maculæ, lentigo, eplelides.

Were we disposed to criticise the arrangement adopted by the author we should, perhaps, object, in the first instance, to the formation of this

last and miscellaneous class; and secondly, to his having placed in it some affections which might have been arranged in some one of the preceding sections, to which they would seem naturally to belong. Little practical inconvenience can, however, result from the course which the author has adopted, and the practitioner, as well as the student, will find the articles on Bright's disease, on diabetes, and on rheumatism, very worthy of attention. In the short article on deficiency of the valves of the heart, he gives a prominent place to the labours of Corrigan, Hope, and Henderson, as well as to those of his countrymen, but he does not seem to be aware that the affections to which he alludes were known and described before the appearance of the articles to which he refers.

In taking leave of the work we think we are justified in pronouncing it one of the very best and most comprehensive general works on medicine with which we have yet met. The abundant proofs which the author has given of his labour and candour warrant us in anticipating that he will continue to improve the subsequent editions, which the demands of the students in the French schools can scarcely fail to call for.

I. A TREATISE ON THE STRUCTURE, DISEASES, AND INJURIES OF THE BLOODVESSELS. By Edward S. Crisp, M.R.C.S. 8vo. pp. 350. Plates. Churchill, 1847.

II. OBSERVATIONS ON ANEURISM AND ITS TREATMENT BY COMPRESSION. By O'Bryen Bellingham, M.D. 12mo. pp. 180. Churchill, 1847.

MR. CRISP's Treatise is an expansion of the Essay for which the Jacksonian Prize was adjudged in 1844. The institution of this prize has been eminently conducive to the progress of surgical science. Several of the Essays which have gained it have since become standard works upon the subjects to which they respectively relate, and the names of a considerable number of the prize-holders are now European. Mr. Crisp's work, although not admitting of comparison with those of some of his predecessors on the list in originality or novelty of views, is, nevertheless, a very creditable production; and one of which the general practitioners have reason to be proud, as coming from one of their own body, unprovided with any special opportunities in the shape of public appointments, but possessing great zeal and untiring industry in the pursuit of medical science.

After briefly describing the anatomy of the arteries, (assigning to them four separate tunics), and presenting a table of the very varied appearances which those of the chest and abdomen offered in 102 cases of death from different causes, Mr. Crisp goes on to consider the subject of Arteritis.

He observes very truly, that this has been but little investigated, in consequence of the hasty and imperfect manner in which post-mortem examinations are performed. In the case of the Aorta, the signs of its inflam

1847) Crisp on Diseases & Injuries of the Bloodvessels.

43

mation are so various, and its complication with-heart disease so frequent, as generally to defy accurate diagnosis. The only morbid appearances upon which we can depend are more or less permanent reddening, and a pulpy and swollen appearance of the inner and middle tunics-deposits of lymph being also occasionally found in the inner coat. In a few cases the abdominal aorta has been found obliterated by fibrinous coagula. "Although these coagulations are probably in some instances the effects of inflammation, they may, I think, occur from deficiency of the heart's action, combined with a roughened and diseased state of the coats of the aorta. Some of these obstructions may take place a short time before death when the vis a tergo is not sufficient to propel the blood through the diseased tube. John Hunter says that the blood will not coagulate in a healthy artery, an opinion which I believe to be correct." P. 29.

When the inflammation attacks the arteries of the extremities, its diag nosis is less obscure. Burning, shooting, or pricking pain and tenderness in the course of the vessels are often followed by absence of their pulsation, and with a disposition to dry gangrene of the limb affected. In the aged the inflammation is more subacute, but the tendency to gangrene is greater. A common pathological effect is the obstruction, or even obliteration, of the calibre of the vessel by adherent fibrinous deposits-these extending even sometimes to the collateral and terminating branches.

"Some high authorities believe that arteritis is not present in the dry gangrene of old people. I have paid much attention to this complaint for many years and have had the opportunity of inspecting the bodies of several who have died of it, I have invariably found the lining membrane of the artery of a red appearance, the vessel often obstructed by fibrinous coagulum, some distance above the gangrenous part, as well as in the arteries near the seat of the dis

ease.

66

Many who, like Dr. Carswell, believe that dry gangrene is the result of debility and not of inflammation, appear to have forgotten that inflammatory diseases are very common in old persons. According to the researches of MM. Hourman and Dechambre at the Salpêtrière, inflammation is the most frequent cause of death in old persons. How often the aged are affected with cutaneous inflammation of the legs; and reasoning from analogy, why, let me ask, may not the internal coats of the arteries be subject to the same engorgements? We have, I think, abundant evidence to show that ossification alone is not sufficient to produce the disease, as this deposit exists to a great extent in the majority of individuals who have attained advanced age. The most common of the exciting causes of acute arteritis in the aged is, I believe, the detachment of a portion of the bony plate of the artery. The great toe, a part the most exposed to mechanical injury, is often the first affected." P. 34.

In treating arteritis, we must resort to the same measures we employ for combating inflammation of other organs: but in old subjects, in whom the disease attacks vessels already much altered in structure by bony deposition, Mr. Crisp has found most benefit from the employment of large doses of opium, combined with a mild, non-stimulant diet. When gangrene has supervened, a line of demarcation having formed, the patient being young, and the collateral branches sufficiently enlarged, Mr. Crisp believes amputation is indicated.

Several cases, which have occurred, either in the author's own practice or in that of his friends, some of which are of a highly interesting charac