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many aspects, and some of these are such as to deceive an un- practised eye or an impatient finger. There can be no mistakein cases such as have been described, but there may very readilybe in irritable subjects. In such persons, owing to the excite-ment of the examination, or some unusually severe pang at themoment, the pulse, when first felt, may beat with considerableforce and fulness, and so give rise to an impression of fever orplethora ; but this rapidly passes off, and the colour fades, andthe pulse flags and falters. The pulse, indeed, is eminentlychangeable, and any excitement which may be manifested in itis quite momentary, in comparison with the almost constantstate of depression. It must also be borne in mind, as confirmingthe same view, that in fatal cases the spasms of tetanus continue,and often increase, in spite of the progressive failure of the cir-culatory powers-a fact which is only explicable on the supposi-tion that the spasms are dependent upon the very reverse ofvascular activity.The same conclusion arises also out of the consideration of

cadaveric rigidity, for in this case we have a state of tetanoid, crrather cataleptoid contraction, which subsists with stagnation anddeath of the blood, and which endures untiringly until themuscles are broken up by incipient decay.

In spasm, therefore, as in tremulousness and convulsion, thereis abundant evidence of a decided lack of circulatory power. Itwould seem, also, as if that lack were greater in convulsion thaniri tremulousness, and in spasm than in convulsion.

(To be continued.)

ON A CASE OF RUPTURE OF THE UTERUS.BY J. WATSON, M.D., Ashted.

S. L-, aged twenty-eight, a single woman, had been slightlyindisposed for some days. During the last few hours sLe hadcomplained of pain in the abdomen, and sickness. These symp-toms becoming suddenly aggravated, I was sent for on the

evening of February 14, 1853. My assistant returned with themessenger, and found her in nTticulo Tnortis.On post-mortem inspection, (by coroner’s precept,) the exterior

of the body appeared plump, but unusually pallid, and thedeceased was about seven months advanced in pregnancy. On

opening the abdomen, the cavity of the peritonaeum containedfrom two to three quarts of blood, a huge clot covering all the ’,abdominal contents. On removing this, the uterus was seen toreach midway between the umbilicus and ensiform cartilage, andwas found ruptured in its fundus to the extent of four inches, theedges of the wound being an inch and a half asunder. Theplacenta, lying in contact with the fundus, was exposed by therent, and prevented the escape of the uterine contents into theperitonaeum. On carefully examining the texture of the uterus,I found it to be no thicker than a sheet of writing-paper for atleast a distance of two inches around the ruptured part. Theliquor amnii was entire, and the foetus in sitec, the breech pre-senting. Pressing against the thinned portion of the uterus justnoticed lay the head of the fœtus, made additionally prominentby its having the right hand and the feet, side by side, restingupon it. All the other organs in the body were healthy, and thestomach contained chyme.

Ashted, Birmingham, 1853.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.Intestinal Obstruction for Ten Days; Death; Autopsy.

(Under the care of Dr. BABINGTON and Mr. BIRKETT.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morbornm, etdissectionum historias, turn aliorum proprias, collectas habere et inter secomparare.-MORGAGNI. De Sed. et Caus. Morb., lib.i4. Frooeuuum.

WE placed upon record, a short time ago, (THE LANCET,vol. i., 1853, p. 202,) a case of obstruction of the bowels, treatedby Mr. Hancock at Charing-cross Hospital. It was iu this case

thought advisable to explore the abdominal cavity and toopen the colon in the left lumbar region, with the hope thatthe artificial opening, by allowing the escape of the accumu-

lated fsecal matter, might save the patient, in favouring theremoval of the cause producing the obstruction. These hopeswere not realized, but it is plain that in such extreme casesmeasures of a very hazardous nature are justifiable, when itbecomes evident that the patient must, if they be notattempted, inevitably sink. To-day we have to direct atten-tion to a case of an analogous nature, which, however, differsfrom Mr. Hancock’s in several respects-viz., by the appa-rent existence of strangulated hernia, the number of daysduring which the obstruction continued, the seat of thelatter, and the cause of the constriction. These points willbecome apparent by the following details obtained from thenotes of the clinical clerk, Mr. R. B. Marriott:-

George P--, aged fifty-eight, an agricultural labourer, ofrather emaciated appearance, and somewhat unhealthy, sallowcomplexion, residing at Southend, Bromley, was admitted intoJob’s -ti7ard, No. 13, under the care of Dr. Babington, on the16th of February, 1853. The patient is married, of temperatehabits; and has six children, all of whom are healthy. Hisfather and mother died many years since; the cause of deathis unknown to him.The man states that he has for many years suffered from

rupture on the right side, for which he has worn a truss; inspite of this, the bowel has frequently come down, but wasalways returned by himself without any surgical assistance.About twenty years before his present admission, the patienthad an attack of jaundice, and a short time afterwards, one ofinflammation of the bowels. Since that period his health hasbeen extremely good, until a twelvemonth ago, when hesuffered from diarrhœa, accompanied by sickness and painover the abdomen. The looseness of the bowels soon ceased,but the pain and sickness continued, the latter recurringdaily, generally a short time after taking food. The man’sappetite has lately fallen off, and he has lost flesh. Hisbowels have been lately irregular-sometimes loose, at otherscostive. Defecation is not attended with any difficulty, norhas he observed his motions to be compressed or flattened.The painful symptoms became much aggravated about twomonths before the present examination, and obliged him toseek for medical advice, but he derived but little benefit fromthe treatment.When admitted, the patient complained of a dull, aching

pain over the whole surface of the abdomen, most severe inthe right hypochondriac region, and below the umbilicus,where there was some degree of tenderness on pressure, aconstant feeling of nausea and frequent vomiting recurringgenerally within two or three hours after taking food; therewas also a disagreeable taste in his mouth, and entire loss ofappetite. The bowels had not been open for a week, and theabdomen was found slightly distended, although not verytympanitic. On survey ing the abdomen. a swelling’, of the sizeof a hen’s egg, was observed in the right inguinal region,which swelling appeared to contain principally fluid, as thegreater part of its contents could be readily returned into the

, abdomen, although the tumour descended again immediately, the pressure wc.s removed. The right testicle was distin-guishable, but atrophied; and nothing like intestine could be. felt in the scrotum or inguinal canal. There was a slight

tendency to umbilical hernia, for which a compress andbandage were applied. The skin was rather dry, but cool;pulse 90, regular; tongue slightly furred at the base andceiitre; respiration easy; no cough; urine small in quantity,specific gravity 1017, not albuminous; physical signs of chestnormal. A drachm of sulphate of magnesia, in an ounce ofinfusion of roses, to be taken three times a day.

Second (by.-The patient slept pretty well, but he has noappetite; the sickness has not returned since admission;pulse 100; tongue moist, but furred; skin cool; abdomenslightly tender on pressure over the seat of pain, which stillcontinued; bowels not opened. Mr. Cock examined the

t swelling in the inguinal region, but could not detect any in-etestine in the old hernial sac. An enema with soap was

ordered, and calomel and opium, one grain of each, everyfourth hour.

Third day.-The man slept very badly; pain in abdomenmore severe, and there is some tympanitis and fulness on the

,

right side. He has been very sick, and retched a good deal,but did not vomit. As no relief was obtained from tlieinjec-tion and opium, Mr. Cuck and Mr. Birkett thought it justifiable

to explore the hernial sac, deeming it possible that a portione of intestine might be entangled at the internal abdominalring. Accordingly, at two P.u., Mr. Birkett proceeded to° operate in the usual way for oblique inguinal hernia. On·t dividing the external coveriugs, he found the atrophied rightt- testicle immediately below and adherent to the old hernial

267

sac; the latter was much thickened, and on opening it somefluid escaped; the sac was otherwise empty. The internalring was large. Mr. Birkett passed his finger through it, andfelt the small intestine lying against the ring, much distended,but quite free from any constriction. Such being the state ofparts, the edges of the wound were brought together bysutures, lint was applied, and the patient taken to his bed.He bore the operation with remarkable fortitude, took somebrandy and one grain of opium immediately afterwards, andwas ordered a soap enema to be at once administered, one

. grain of opium every fourth hour, and four ounces of brandy.- Nine P.M.: Much in the same state; abdomen rather moretender on pressure, and the tympanitis has increased; pulse115, rather hard; urine small in quantity, high coloured; skinhot and dry; tongue furred; mouth parched. The patientcomplains of thirst and occasional retching, but has notvomited; he passed a little flatus, but the enema has had nofurther effect. Mr. Birkett now made a careful examinationof the rectum, but could find no cause of obstruction therein.This bowel contained only a few scybala, which were readilyremoved by an injection of salt-and-water, thrown through atube introduced nearly twelve inches up the intestine. Noevacuation was, however, produced.Fourth day.-Has passed a very restless night; the pain in

the abdomen is more severe; tympanitis considerable, espe-cially over the cæcum and ascending colon, which latter canbe felt somewhat distended, the transverse and descendingportions being less prominent; tenderness of surface of abdo-men increased; hiccough came on this morning, and is now adistressing symptom. About ten A.M. the poor man vomiteda large quantity of fluid, with a most characteristic faecalodour; and this recurred twice during the morning. Believingthe seat of obstruction to exist at a point somewhere betweenthe superior termination of the ascending colon and the

I

sigmoid flexure, Messrs. Cooper, Cock, and Birkett were nowconsulted by Dr. Babington as to the propriety of opening theascending colon in the right lumbar region. On placing thepatient in the prone posture, and carefully manipulating inthe region of the ascending colon, that intestine could not befelt with sufficient clearness, nor was it distended to thatdegree to justify an operation. The opium was thereforecontinued. The patient took the drug at four P.M., and thevomiting did not recur till eight o’clock, when he broughtup a large quantity of fluid, having all the appearance andodour of fluid fæces.-Nine P.M.: Hiccough continues; abdo-men not so tender as in the morning, but a good deal distended;pulse 120, very feeble; tongue furred; skin cool. Anotherenema was administered, but with no effect; one grain ofopium was now given every second hour, and the brandycontinued.

Fifth day: Sinking; features pinched and contracted; sur-face of body cool, and bedewed with a clammy perspiration;tongue furred; pulse 130, hardly perceptible; hiccough con-stant, vomiting frequent, and abdomen distended. The poorfellow takes his brandy with difficulty. He remained in thisstate till ten P.M., when he died, five days after admission, andten days from the last alvine evacuation.

Post mortem examination, sixteen leours after death -Ex-ternal appearance: Body a good deal emaciated, with marksof the recent operation for inguinal hernia on right side.-Thorax : Right lung healthy; surface of left lung studded withnumerous small black bodies, not larger than small shot;substance of the lung healthy, heart likewise sound.-Ab-domen : Traces of recent peritonitis. The surface of theintestines had a greasy feel and a dull appearance; lymphhad been thrown out, and caused partial adhesions, mostabundant about flexure of colon. Numerous small tubercles,apparently carcinomatous, were found in the great omentum,resembling mesenteric glands in appearance. The smallintestines were greatly distended with fluid faeces, as was alsothe co3cum and ascending colon. The transverse arch anddescending portion of the same bowel, as well as the rectum,contained nothing but a little flatus and a few small scybala.The stricture existed in the right flexure of the colon, exactlywhere the ascending portion joins the transverse, and not inthe sigmoid flexure, as we stated in a former allusion to thiscase (LANCET vol. i. 1853, p. 102). The obstruction was causedby a contraction of the peritonaeal coat and a growth withinthe bowel composed of numerous vascular villi, covered withcolumnar epithelium, having the character of what has beencalled by the German pathologists zottenkrebs," or villouscancer. The ilio-caecal valve was contracted in size, butpatulous its mucous membrane much thickened, and coveredwith points of commencing ulceration. The rest of the intes-tines were healthy, as well as the other abdominal viscera.

It may now be asked, whether an operation similar to thatperformed by Mr. Hancock would have been of service tothis patient ? Probably not. The obstruction was caused by a carcinomatous growth within the ascending colon, and it isplain that the tendency of this tumour would always havebeen to narrow the bowel more and more. So that thereasons given by Messrs. Cooper, Cock, and Birkett, for ab-staining from an operation before they knew of the nature ofthe obstruction, besides their value at the time of the con-sultation, gain considerably in weight by the post-mortemexamination. No fulness or distension could be felt in theascending colon; it might therefore be inferred that theobstruction lay higher up in the canal, the latter circumstancerendering an operation in the right lumbar region useless.We understand that the weak and almost hopeless state ofthe patient was also looked upon as an additional reason torefrain from operating. The presence of a sac distended withfluid in the inguinal canal was certainly calculated to renderthe diagnosis difficult; and no satisfactory view of the casecould have been taken if the operation had not been per-formed. Whether the latter had any influence on theoccurrence of peritonitis cannot be easily determined; themore so as it may readily be supposed that the distension mayhave been the principal cause of the peritonaeal inflammation.It will, however, remain clear that the operation was indis-pensable, whatever may have been its effects upon the ultimateresult of the case.

____

ST. BARTHOLOMEW’S HOSPITAL.

Medullary Cancer of three years and a half duration, extensivelyattached to the Dura Mater, and appearing externally; Ope-ration; Death; Autopsy.

(Under the care of Mr. LAWRENCE.)AMONCt the various painful duties which the surgeon has to

perform, there is one which is certainly calculated to fill hismind with regret-viz., when he is obliged to tell a patientwho applies for relief that the control of the affection is beyondsurgical art. Now, it is a matter of no small importance todecide whether this answer should be given in cases of medul-lary growth springing from the dura mater. Opinions willcertainly differ very little on this point when the tumour hasreached a large size, and non-interference will be the rulewith every one. When, on the other hand growth issmall, when its presence causes intense pain’ and there isever so small a prospect of permanent relief, the surgeon may,perhaps, pause and consider whether he should refuse to ope-rate, or accede to the patient’s request.

It appears from the history of the subjoined case, that sur-geons are not agreed as to the line of practice to be pursuedin instances of this kind; for the patient was advisedin somehospitals not to seek for a third operation upon the tumour,and was told in others that temporary relief might be obtainedby the excision of the tumour. Mr. Lawrence belongs to thelatter category, and was probably actuated by the desire ofsaving the woman a great deal of pain, and by the hope thatthe tumour might not be so extensively connected with thedura mater as it eventually proved to be.Under whatever point of view the operation and the result

be viewed, they afford an unusual amount of practical instrue-tion. We first learn that the apprehensions as to hsemorrhagein ablation of scalp-tumours (whether these be connected withthe dura mater or not) are not groundless, for the loss of bloodwas here extremely alarming. We also perceive that therecurrence of medullary growths in this locality, takes placethe more rapidly as the operations have been multiplied. Itthus becomes a question whether it would not be advisable,when we are first consulted respecting such tumours, to usepressure rather than excision.We alluded just now to the propriety of not operating when

a tumour of the dura mater is of very large size: such an in-stance occurred a short time ago in this hospital, in an oldwoman under the care of Mr. Lloyd, in Treasurer’s ward. Thetumours had in this case grown to an enormous, and it mightreally be said to a frightful size, as the three principal ones,situated at the top, sides, and back of the cranium, were largerthan an adult’s head. The huge mass had only taken threeyears to reach this very large bulk, and the poor woman soon

sank under the effects of this distressing malady. The tumourswere, on a post-mortem examination, found to consist of me-dullary matter.But growths of this kind are not confined to patients of an

advanced age, the young are also liable to them; exampleswere afforded in this hospital by the present case, and another,ome time ago under the care of Mr. Stanley, (THE LANCET,