is worse than useless. This question brings us face to face with the operation of colotomy in the lumbar region (Amussat's operation). In the management of cases of cancer of the rectum colotomy is a resource of the greatest value; this operation it is our duty to propose to the patient if there be no obviously contraindicating circumstances. The archives of surgery contain sufficiently numerous examples of lives temporarily saved, and comfort afforded, to render it imperative, where communication exists between the bowel and bladder, or between the bowel and vagina, and where constant distress renders life an insupportable burden, that the surgeon should firmly recommend colotomy. When complete obstruction exists, delay tends so much to diminish the chances of a favorable result, that the expediency of the operation before inflammation has been set up and the intestines have been damaged by over-distension must be authoritatively declared.

The danger attending the operation of colotomy, Mr. Curling says, is much less than is commonly supposed (p. 169, op. cit.). Mr. Pollock (article on "Diseases of the Alimentary Canal," Holmes, p. 180, vol. iv) thus describes the operation:

"The incision should commence in front of the ongissimus dorsi, and be carried forward to the extent of about six inches. The integuments having been divided, the muscles are to be carefully cut through until the intestine is exposed. This is not a difficult or troublesome proceeding. . . . The bowel should be at once hooked up by a curved needle; two or more points should then be secured by threads to the margin of the wound, and the gut opened."

Mr. Allingham (p. 224) has found, from numerous dissections, that the descending colon is always normally situated half an inch posterior to the centre of the crest of the ilium, and he before operating is in the habit of marking this spot either by a piece of adhesive plaster or a touch of strong iodine paint; he says (p. 225)

"A cut not less then four inches should be made midway between the last rib and the crest of the ilium. . . . . It is of the utmost importance that the deeper incisions be kept the same length as the cut through the skin..... I am quite convinced that this is the secret of overcoming the difficulties of the operation. If the colou be fairly exposed as I have directed, there is usually but little difficulty in recognising it, even when it is quite undistended, and picking it up from the bottom of the wound.'

We have before us a letter from a confrère, whom we assisted, some time since, in the operation for colotomy, the case being

one of cancer of the rectum in reply to our inquiry as to the termination of the case, he writes:

"The patient lived a few days over six months after the operation. I may mention that, after we got rid of the hardened fæces which were lodged between the opening and the rectum, the patient suffered very little pain and inconvenience, and he recovered his appetite. My impression is, that if I had operated much earlier, and so prevented the irritation of the ulcerated surface by the daily fæcal evacuations, he might have gone on much longer. I should also endeavour, in another case, to so manage the opening in the colon that no fæces could pass into the lower part of the bowel, for if by accident any did do so, we were sure to have acute suffering for two or three days."

Mr. Smith convinced of the advantages of palliative colotomy says (p. 72):

"I shall not hesitate, in the first suitable case which comes under my care, attempting to give the relief which most certainly may be better afforded by Amussat's operation than by any other means."

Mr. Allingham (p. 172), in dealing with the subject of "Ulceration of the Rectum," observes:

"In the most advanced stages of ulceration and stricture, where there are several fistula and the whole rectum disorganized, as it frequently is, nothing short of lumbar colotomy offers to the patient any chance of life. My experience is that these are really the cases in which colotomy is especially to be recommended. I have now three patients alive who were operated upon years ago; I saw a woman lately upon whom I performed colotomy in the year 1867, and she continues perfectly well. Three of my cases are published in the St. Thomas's Hospital Reports' for 1870. It is unfortunate that it is not often one can persuade these patients to submit to colotomy until they are almost in 'articulo mortis;' they have a natural repugnance to the idea of an opening in their loins for the rest of their lives, and so they postpone the operation, often until it is too late. My own opinion is that the operation may be considered, not merely palliative, but curative; in time, I am sure, from the cases I have watched, the rectum will in a great measure return to a healthy condition. When no fæces pass through it the ulceration will heal and the stricture may be dilated; fistula will also close, spontaneously in some cases. If we could assure these patients that, should the rectum again become pervious, and the ulceration heal, we could close the opening in the loin, many, no doubt, would willingly undergo the operation, but I feel that this is just what I cannot honestly guarantee. I have recently attempted to close the lumbar aperture in an hospital patient, and at present it has not succeeded. In this case the patient's rectum has become fairly sound; there is no ulceration and no stricture, and

some time since I slit up a fistulous sinus, and that has quite healed. She has often passed some motion per anum, but usually it all comes through the loin.

We seem, therefore, to be in a fair way to have colotomy established as a common operation. We need not despair that improvements in the treatment of the lumbar opening, when no longer the necessity for that opening exists, will make its obliteration as certain as the cure of vesico-vaginal fistula; for but a comparatively short time has elapsed since a severe vesicovaginal fistula was looked upon as incurable.

The term polypus of rectum appears to be applied to several distinct affections. Van Buren thinks "polypus of the rectum is an uncommon disease, occurring in the majority of instances in children."

We believe that polypus in children is a congenital condition of the mucous membrane, exactly represented by the pendulous tumour of the skin, ecphyma mollusciforme of Erasmus Wilson.

Mr. Hulke (Path. Soc. Trans.,' vol. xxii) has described the structure of a polypus, removed by him from a young woman, as consisting of a "central mass of a delicate, finely fibrillated, and nucleated stroma, pervaded by large and numerous bloodvessels, the walls of which were very thin. Externally, the stroma became closer and less vascular, and at its outer surface it bore a distinctly papillated layer." The pathological parallelism above suggested is, therefore, more than probable. "There are glandular polypi which may be regarded," Mr. Hulke says, "as local over-growths and out-growths of the normal elements of the mucous membrane, fibrous polypi and fibrocellular polypi."

Mr. Allingham admits that fibroid polypus is quite rare, but his assertion that such growths resemble in structure almost precisely a uterine fibroid, we are disposed to question. It is, we assume, with reference to small polypoid thickenings to be met with at the upper angle of old starting fissure of the anus that Mr. Smith declares (p. 82) that he has "come to the conclusion that perhaps next to hæmorrhoidal disease polypoid excrescences, in some shape or another, are as frequently met with in the rectum as any other morbid condition of this part."

Villous tumour of the rectum, or as Mr. Quain first described the lesion "a peculiar bleeding tumour of the rectum," holds, in relation to polypus and to cancer, a doubtful position. This disease may truly be termed rare. Amongst the 4000 cases tabulated by Mr. Allingham we do not observe a single example of villous tumour noted. With regard to the nature of villous tumour, Mr. Quain willingly acknowledging the great assistance microscopical observation affords in skilful and expe

rienced hands, does not think it too much to say that the clinical history of a case is indispensable in order to affirm the cancerous nature of any rare morbid growth, and he accordingly inclines to the belief that villous tumour is nonmalignant. Mr. Sibley (Path. Soc. Trans.,' vol. viii), describing a villous growth (from the dura mater of a woman who died of uterine cancer), classes villous along with colloid disease as non-malignant.

If villous tumour of the rectum be really non-malignant it may claim to be classed as a polypus, and thus to constitute a fourth species of polypoid disease.

Dr. van Buren's last lecture contains some valuable remarks in his customary straightforward and impressive style on the means and appliances to be employed in order to form a prompt and accurate diagnosis in affections of the rectum. Any proposed addition to our apparatus for physical exploration is worthy of attentive consideration. Dr. Bodenhamer figures a Recto-colonic Endoscope, it consists of a cylinder fourteen inches long and seven-eighths of an inch in diameter, partly flexible and highly polished, furnished with an internal reflecting mirror mounted upon a rod; but he adds that "this instrument was gotten up with considerable haste, and may upon further trial be found to need some improvements."

It may be observed in the preceding pages we have quoted in several instances, the opinions of writers who have already become standard authorities; we have done this in order to let our readers determine to what degree advance has been made within the past decennium. We think that the frank acknowledgments by both the American and English authors whose names stand at the head of this article, of what they owe to their immediate predecessors cannot but be gratifying to these gentlemen.

III.-Sir J. Simpson on Diseases of Women.1

THE third and concluding volume of Simpson's obstetric works is, in many respects, the most valuable part of the recent re-publication, since it contains the record of the author's vast clinical experience, not previously published in a readily acces

1 Clinical Lectures on the Diseases of Women. By Sir JAMES Y. SIMPSON, Bart., M.D., D.C.L. Edited by ALEXANDER R. SIMPSON, M.D. Edinburgh,

sible form. The substance of this volume was familiar to all who were privileged to be Simpson's pupils, and parts of his lectures had appeared in the Medical Times,' but they had not been collected into a volume, and to the bulk of the profession they will be entirely new.

Gynecology is year by year advancing with such rapid strides that, short as is the time since these lectures were delivered, they cannot be considered to be quite up to the most recent knowledge on the topics they discuss. Still the volume, as a whole, stands unrivalled as embodying the records of that wonderful knowledge and fertility of resource for which Simpson was so remarkable, and which found their greatest development in the subjects here treated of, since they formed so large a portion of his daily work.

To attempt anything like a critical or exhaustive review of the contents of a volume extending over 700 pages would be far too ambitious a task, and one which could not be attempted in the short space of one paper. We shall, therefore, content ourselves by referring to a few of the most prominent articles, which are specially interesting either on account of their own intrinsic value, or from the discussions and differences of opinion to which they have given rise.

The first essay on the "Diagnosis of the Diseases of Women" is, perhaps, more widely known than others, since it is a reprint from the first collected edition of his works published by Priestley and Storer. It is peculiarly worthy of study by all who wish to master the subject, dwelling forcibly as it does on the importance of cultivating our powers of accurate diagnosis to the utmost, and pointing out the fact, too often not sufficiently remembered by gynæcologists, that there is nothing special or peculiar about diseases of the uterus; that that organ is liable to the same varieties of ailment as other parts of the body, and that it is a fatal mistake to fix our attention too exclusively on any one class of symptoms, or to refer them, as so many are apt to do, to one class of causes. Were these facts sufficiently remembered we should not so often meet with obstetricians who can examine no woman without finding inflammations and engorgements of the womb, and others who discover that every woman has her womb twisted out of its normal shape. Special stress is laid upon the sympathetic derangements which so commonly attend upon uterine disease, and a knowledge of which will guard us from overlooking the true cause of disturbances apparently unconnected with the uterus; untractable to all treatment that does not trace the symptoms to their true source, and readily cured when their real nature has been ascertained. Cases of this kind must be familiar