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the weight of its contents broke it up in several parts, thefluid, which was very acid, escaping through the rent thusformed. On opening the organ, the whole of the cardiacextremity was seen denuded of its mucous membrane; thegreat curvature was in the same state, but the mucous liningwas not destroyed along the lesser and pyloric extremities.The kidneys were slightly granular on the surface; the liverrather fatty, but otherwise healthy, as far as the unaided eyecould discern..

It is stated in the relation of this case (see above) that "overthe left nipple, and towards the epigastrium, a to and frocardiac friction-sound is heard, which is stronger on pressure."To the latter circumstance we would direct especial attention,as by slight pressure with the stethoscope, and the interventionof a card between the skin and the instrument, the bruit, which-ever it may be, is rendered very clear. Dr. Sibson was kindenough to point out this peculiarity to us in the wards of thishospital. ____

KING’S COLLEGE HOSPITAL.

HÆMORRHAGE FROM THE JEJUNUM; DEATH; AUTOPSY.

(Under the care of Dr. TODD.)THOUGH the theory of haemorrhage by exhalation is some-

what surrounded by obscurity, we now and then meet with ’,oases which afford striking proofs that the blood cannot haveescaped by any other way than exudation; and among theseinstances a perfectly unbroken intestinal mucous membrane I,after death from melæna, is one of the most unanswerable.When this form of passive hæmorrhage takes place in a patientdebilitated by want and mental distress, we are naturallyled to establish a comparison between the intestinal haemorrhageand purpura. For it is plain that both pathological phenomenaare originally the same, the difference being simply that theepithelium offers less resistance to the passage of blood thanthe epidermis. No doubt but the fluid of perspiration finds itsway through the cuticle, but we may suppose that in dia-phoresis there is more force acting from within, and more re-laxation of the vascular network.To return to haemorrhage from the bowels, it may be stated

that cases of this kind are of a very distressing nature, both asregards the patient and the physician, since it is extremelypainful to the latter to see the life-blood oozing from thesystem, and to observe the inadequacy of the means adoptedfor the control of the hæmorrhage. And the task becomesdoubly difficult in cases where bad nourishment and depressionof mind have been principally conducive to the haemorrhage,for it may be supposed that in such cases two powerful causesare acting at the same time-viz., increased fluidity of theblood, and want of tone in the vessels. It is evident that as-tringents, topically used, can only act upon the vessels of theaffected mucous membrane; and the aqueous condition of theblood remaining the same, it cannot excite surprise to see thebest directed means for arresting haemorrhage proving useless.It is here that prevention should be thought of, for by propermedicines and diet the condition of the circulating fluid maybe greatly improved, and this favourable result might in manyinstances altogether prevent, or render but very trifling, anattack of intestinal hæmorrhage.

It is to be regretted that in the following case the state ofthe portal circulation was not described, because passive in-testinal haemorrhage depending on this cause in a weak subjectis known to be almost certainly fatal, and the inefficacy of theremedies would thus be in some degree doubly explained. Itwill be seen below that the patient refused the enema of icedwater, which, if taken, might perhaps have turned the scale inhis favour; but he was a medical man, and hence a littletimorous. We would finally call attention to a circumstanceof the case which should not pass unnoticed : the patient hadsuffered from an attack of fever some months before being seizedwith the haemorrhage from the bowels, and one is naturallyinclined to inquire whether the fever left on the intestinalmucous membrane an impression which might be looked uponas a predisposing cause of the haemorrhagic attack. The

following brief details were obtained from the notes of Mr.Holderton, one of Dr. Todd’s clinical clerks :-Anthony de G-, aged forty-five years, a native of Poland,

and belonging to the medical profession, was admitted May 19th,1854, under the care of Dr. Todd.The patient states that last year he was an inmate of Guy’s

Hospital from November to January, suffering from feverbrought on by mental and bodily distress. Since that periodhe had enjoyed tolerable health until about a week beforeadmission, when he was attacked by dysentery, the evacuations

being principally composed of blood. The abdominal complaintwas accompanied by frequent fits of vomiting, and the patientcannot assign any cause for the severe symptoms under whichhe laboured. The motions from the bowels have been as manyas fourteen or fifteen per diem.

Dr. Todd ordered one grain of calomel and one of opium tobe taken every third hour. The evacuations remained, how-ever, as numerous and of the same nature as before, so that astarch enema was administered, and ordered to be repeated iffound inefficient.On the next day, at eleven in the morning, it was found

that the patient had had a quiet night; he was free from pain,and had not had any return of the purging. But towards twoo’clock in the afternoon the alvine discharges began again, themotions consisting almost entirely of blood, and the pulse beingvery weak. Brandy was given at short intervals until Dr. Toddsaw the patient, when one grain of acetate of lead, with half a.

grain of opium, were ordered to be taken every third hour, asalso iced water injections; the latter, however, the patientrefused. The purging continued incessantly until ten o’clockat night, when delirium, gaping, and hiccough came on, thepoor man tossing himself from side to side, and seeming ingreat distress. He died in a state of extreme exhaustion atfour o’clock in the morning.

Po8t-morte-m examination, eighty-four hours after death.-Atolerably well-made, muscular man, of medium height, pre-senting nothing externally worthy of notice. The brain andthoracic viscera were found healthy, the vessels of the formerorgan being rather full of blood than otherwise. On openingthe abdomen and turning up the omentum, the first ten ortwelve inches of the jejunum appeared of a dark, damaskcolour, which was gradually lost below that point. Theexternal surface of the bowel was smooth and glistening, andthere was no appearance of peritonitis. Above and below, theintestines appeared healthy, both internally and externally.Peyer’s patches were normal, and there was no evidence any-where of abrasion of surface. The bowels contained a consider.able quantity of highly offensive blood, of the same dark hueas noticed in the jejunum. The livid portion of the latter.presented much the same colour internally as on the outersurface; it was much thickened and gorged with blood, butthere was no ulceration, and the mucous membrane was easilydetached. Under the microscope, the vessels were seen muchdistended with blood, but the mucous membrane was entire.Kidneys healthy,; spleen enlarged; rectum perfectly healthy.

LONDON HOSPITAL.

ANEURISM OF THE OPHTHALMIC ARTERY; DELIGATION OF THECAROTID.

(Performed by Mr. CURLING.)DELIGATION. of the carotid artery, though pretty often per-

formed, is nevertheless an operation of much importance, andshould never pass unnoticed. Indeed, the results of thisoperative measure are of so hazardous a kind that every casein which it is resorted to should be carefully noted, were itmerely for the sake of facilitating the framing of statisticaltables. But if the deligation of the carotid is worthy of fixingour attention, the fact of its being undertaken to promote theconsolidation of an ophthalmic aneurism makes it still moreimperative upon us to direct the attention of our readers to thecase. Aneurisms of the ophthalmic artery are avowedly rare,and when we heard of the present case we felt greatly in.terested, as just at the same time another case of aneurism ofa vessel very seldom attacked-viz., the glutæal, had for sometime past been the subject of conversation in surgical circles.But those who thought that a case of the latter kind hadactually been seen at King’s College, under the care of Mr.Fergusson, were misinformed, as there had been but a suspicionthat a pulsating tumour, situated over the left sacro-iliacsynchondrosis, of a thin and debilitated patient, was connectedwith the glutseal artery. Various circumstances have sincemade it clear that the swelling is owing to other causes, thenature of which we shall state when we come to report thecase, which has certainly excited more than common interest.Being on the subject of aneurisms of vessels seldom so

attacked, we may say that a patient presented himself a fewdays ago to Mr. de Méric, at the German Hospital, Dalston,who had a flattened tumour on the right temple, pulsatingstrongly, and yielding to the ear a very distinct bruit; the eyeon the corresponding side was much pushed forwards, and thesight very dim. The case is under observation.As to Mr. Curling’s case, it would seem that it is of a

traumatic kind, for the patient, who is about forty-nine years

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of age, was admitted March 24, 1854, for concussion of thebrain and fracture of the clavicle, produced by a fall on theshoulder and side of the head. This man had lost the lefteye from cataract ten years before this accident, and wasreceived in the hospital immediately after the fall, but it wasonly about five weeks after admission that the eye began toswell, protrude, and pulsate, the sight becoming at the sametime weak. The stethoscope applied to the temple gave proofsof a distinct bruit, and ophthalmic aneurism having beendiagnosed, Mr. Curling tied the carotid artery on June 2nd,1854. Immediately after the operation the sight of the eyewas suddenly lost, but it has since gradually returned, andthe patient is doing well.

Another case has lately occurred in this hospital, in whichthe deligation of the carotid artery has been performed by Mr.Critchett. We shall soon refer to the particulars.In the case of operation for artificial pupil by Mr. Critchett,

published in a late "Mirror," (THE LANCET, vol. i. 1854, p.597,) a misprint should be corrected. About the middle of thecolumn and beginning of a paragraph, instead of "limited tocornea," read "limited to capsule. "

CLINICAL AND CRITICAL CONTRIBUTIONS TOOBSTETRIC SCIENCE AND PRACTICE.

BY ROBERT BARNES, M.D. Lond.,MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN-ACCOUCHEUR

TO THE WESTERN GENERAL DISPENSARY, PHYSICIAN TO THE METRO-POLITAN FREE HOSPITAL, LECTURER ON MIDWIFERY, ETC.

ON UTERINE POLYPUS; ITS NATURE; EARLYDETECTION AND TREATMENT.

(Continued from p. 614.)

NATURE OF POLYPUS, AND CLASSIFICATION.

POLYPUS has come to be admitted as a general term, including’every tumour connected with the inner walls of the uterus orthe cervix, and projecting into the cavity. That tumours foundin this position may be of very different characters is wellknown. Simple projections of a portion of hypertrophied mu-cous membrane and cancerous tumours have been alike designatedas polypi. It is obvious then that the prognosis and treatmentof polypus must be governed by the view taken of the patho-logical nature of the individual tumour under consideration.The pathology, therefore, of the various growths of the uteruswhich may project into the cavity and assume a polypoid form,is a subject of great practical importance. The subject in myopinion admits of being usefully simplified by eliminating fromthe definition of polypus all cancerous tumours, and also thecauliflower excrescence. These tumours seldom assume a truepolypoid form; they seldom project into the cavity of theuterus or cervix, preserving only an attachment by means of apedicle; still less frequently is the diseased structure defined byany accurate limits. It extends for the most part beyond thebase or point of attachment, and therefore seldom admits ofbeing entirely removed by a ligature as a polypus does.

Dr. Montgomery has referred to another form of organic dis-ease of the cervix, which sometimes assumes some of the ap-pearances of polypus so as to be mistaken for it. Extensiveulceration of the cervix uteri, with hypertrophy of the anteriorlip, the mass projecting so as to form a defined tumour, with aneck at the base, may, to the touch alone, convey the idea of apolypus. An examination by means of the speculum will atonce reveal the true nature of the disease, and perhaps obviatethe application of a ligature. I would here remark that it hasbeen strenuously contended that the speculum is of no usewhatever in the diagnosis or treatment of polypus. Experience,however, must satisfy every one that the eye is frequently ofuse in correcting the impressions conveyed by the touch; andit does not seem reasonable to discard a means of informationupon which we are accustomed to rely as the foundation of ourmost certain knowledge. By means of sight the mistake indiagnosis, which may lead to a mistake in treatment which Dr.Montgomery has pointed out, may be avoided; and I may referto the second case I have narrated as an example of the use ofthe speculum in treatment. Not only was I enabled to applythe ligature more accurately so as to escape injuring the cervix,but also when the larger tumour was thus removed, I wasenabled to observe a second minute polypus, which must almostcertainly have escaped detection by the finger.

I propose to exclude this form of disease of the cervix alsofrom the definition of polypus.

The classification of polypi admits of more precision than Ithink has hitherto been observed. On an analysis of casesoccurring in practice it will be found that polypi take their risefrom three sources: from the bloodvessels lying under themucous membrane, or from the mucous membrane, or sub-mucous fibro-cellular tissue. I believe that a division thusfounded upon the origin is at once the most scientific and themost practical.

I.—ON POLYPI SPRINGING FROM THE MUSCULAR ’WALLOF THE UTERUS. t

The polypi which take their rise in the muscular walls of theuterus have been commonly called I I fibrous." Recent inves-tigations have, however, proved that they really consist in anabnormal development of muscular fibre, their structure essen-tially resembling that of the muscular wall of the uterus itself.This muscular character of the so-called " fibrous tumours" and" fibrous polypi" of the uterus, both in the unimpregnated andin the gravid womb, was first, I believe, distinctly proved, byVogel, and figured in his admirable work.* Cruveilhier had,however, previously observed that there were " hard polypi,"I which consisted in hypertrophy of the tissue of the uterus-such is the one figured pl. vi. liv. xie - and others consist-ing of fibrous bodies developed under the uterine mucous mem-brane." The celebrated French pathologist thus describes thestructure of the polypus referred to: " The figure represents anantero-posterior section of the polypus and of the fundus of theuterus. The tissue of the polypus is seen to be continuous,without any line of demarcation, with the proper tissue of theuterus; it is a prolongation of this proper tissue, and not afibrous body developed in the thickness of the uterus, capableof being separated by enucleation. The identity between thetissue of the uterus and the tissue of the polypus is such thatthe closest examination does not reveal the slightest difference."

Cruveilhier does not appear to have suspected that the ordi-nary fibroid tumour, distinctly defined from the proper uterinetissue, and capable of enucleation, might also consist of mus-cular fibre in every respect resembling the muscular fibre of theuterus.As this discovery is of especial interest in relation to the

pathology of uterine tumours and polypi, I think it of import-ance to translate Professor Vogel’s account at some length.In describing Fig. 5 of Plate IX., he says, " It represents theprimigenous cells of a fibrous tumour arising in the uterus.These cells are doubtless the rudiments of organic muscularfibres, which but rarely come under observation. The historyof the disease is as follows :-A single woman, aged forty-four,was admitted into the hospital, after having suffered for severalyears from a fluctuating swelling in the right side of the abdo-men, which hitherto had caused no pain, a dragging sensation,as if the patient were about to bring forth, only excepted.Suddenly violent pains came on in the abdomen, increased bypressure. These continued, notwithstanding energetic treat-ment by bleeding and emollients. The patient died after threedays.The autopsy gave the following results :-The omentum

was considerably thickened on the right side, and adherentboth to the abdominal walls and to a hard tumour, whichreached below into the pelvis, and was of the size of two fists.The tumour was knobby on the surface, of a white colour, andhard to the feel; it was intimately connected with the fundusof the uterus, from which it seemed to spring. The inner sur-face of the uterus appeared natural; the mucous membrane un-altered. In its cavity, however, was a round tumour, the sizeof a billiard-ball, hard, of a bluish-white colour, and coveredwith a yellowish purulent matter. It lay free in the cavity ofthe womb, without any attachment to the walls. The sub-stance of the uterus was much thickened; the thickness wasnot uniform, but in many places it was three inches. In thesubstance were many round tumours, of the size of a pea, abean, of a walnut, up to that of a billiard-ball. These tumourswere for the most part free, or at least could be easily de.tached from the surrounding substance of the uterus; theywere of a white colour, and very firm texture. They were ingeneral bullet-shaped, but most of them were knobby. Onsection, they showed interiorly the same hard, glisteningtissue as the outside; but a fibrillation or distinct texturecould not be distinguished by the naked eye. The large tumourfirst described, arising from the fundus uteri, was softened inparts; it exhibited irregular, eroded excavations, traversed bybands, which were soft at the surface, but hard in the interior.These cavities were, some empty, some filled with a soft blood-coagulum, or a greasy, purulent gray matter. The softened

* Erlauterungstafeln znr PathologTsehen Histologie. Leipzig, 1843.