the uterus itself. There are, therefore, two kinds of uterine moles, viz. those which are the product of conception; and those which are independent of pregnancy. Of course the majority of such cases may be traced to conception as their first cause: but it is also certain that there are moles and hydatids which do not thus originate. Moles differ much from each other; sometimes not resembling any animal form, but rounded with an external coating like skin. The author remarks that there are several examples in Guy's Hospital Museum of the mole which has been termed "the false germ," where the embryo is absent, while the membranes are somewhat perfectly formed.

"All pathologists allow the existence of those moles, however differently they may explain the circumstance of their formation, where the embryo having died early, the ovum being retained, has increased in size and solidity, not by a process of growth, as in natural pregnancy, nor even as in a tumour or polypus, but by the effusion of coagulable lymph from inflammation of the lining membrane. This forms successive layers over the surface of the dead ovum, giving it eventually a great degree of consolidation. Some of these masses when cut into, have no cavity; but the chorion and amnion are demonstrable, although the enveloping lymph may be one or two inches in thickness. It seems somewhat surprising, that the coverings of the fœtus, should be carefully constructed when there is no embryo. But the fact is so. Lately, I was present at the expulsion, after much previous flooding, of a firm, fleshy mass, equalling in size a large orange. The small central cavity was lined by a smooth and perfectly formed amnion, with a little fluid; but, although I examined the specimen under water most carefully, I could detect no appearance either of an embryo or umbilical cord. If in such instances the embryo has never been formed, they may be regarded as genuine examples of false conception. Some physiologists, however, have supposed that in these cases, the tender germ may have been accidentally and early deprived of life, and subsequently dissolved in the liquor amnii. However explained, the absence of the embryo is thus certified."

Of Moles which do not owe their existence to Conception.-The author has twice seen fibrous clots, the product of dysmenorrhea, growing into mole, not expelled till they had attained a considerable size, and then only with great pain and serious hæmorrhage. The following case we give in Dr. Ashwell's own words:

"Some years ago, I was asked by Dr. Hodgkin to visit a lady a few miles from town, who was thought to have polypus. On examination, a fleshy and tolerably firm body could be touched just within the cavity of the cervix uteri, there had been considerable bleeding, and the anæmia was distressing. Ergot was given, and in a few days the mass was protruded through the os. A ligature was placed around it, which in twelve hours cut through, bringing away the tumour, but not without considerable hæmorrhage. Ergot was again exhibited, forty minims of the tincture every quarter of an hour, and after the sixth dose, a fibrous mass, as large as a turkey's egg, of firmly coagulated, and partially organized blood, was expelled. In six or seven weeks another mass, only smaller, was got rid of in the same way. This lady had long suffered from dysmenorrhea, and had frequently passed firm concrete clots of lymph and blood. There had been no sexual intercourse for eighteen months prior to this occurrence. She afterwards died; dropsy of the chest and abdomen having supervened."

Vesicular Moles or Hydatids of the Uterus.-We are tempted to inquire why these products are not classed amongst the moles that are dependent on pregnancy. We can scarcely believe, even on Dr. Ashwell's high autho

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 foetal production, and we are therefore constrained to believe, that these vesicular hydatids, invariably found in connection with it, must be fatal, 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 seven months' pregnancy. The abdominal tumour 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 seaside, 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 tumours 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.

"These considerations are entitled to great weight when determining the propriety of extirpation, uncalled for by present and great evils; or where the operation, 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 tumour 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 tumour 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 tumour 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 In such cases, if the diagnosis excludes the belief that there are

one.

serious adhesions, or malignant and solid growths complicating the tumour, 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 tumours. 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 thirtysix and succeeded in thirty-one, 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 tumours themselves are examined after death, when the malignancy of many of them is recognised, and their firm, almost indivisible adhesions, and their immovable 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 labours are appreciated on

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

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's 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