directed to the removal of the textural changes of the uterus usually present. If the flexion be of recent date, and dependent on simple relaxation of the uterus, the cold douche, cold hip-baths, and vaginal injections consisting of infusion of ergot, twice or thrice a week, are recommended; and when very profuse cervical blennorrhoea is present, cauterization of the cervical canal by nitrate of silver. Leeches are to be applied to the cervix every eight or fourteen days in cases in which there is abundant hæmorrhage, the venous stasis being thereby much diminished, and the tendency to serous infiltration of the body of the uterus mitigated. Scanzoni finds the obstinate constipation often attendant on cases of this kind very easily and simply obviated, by directing the patient to wear a bandage round the pelvis, between which and the hypogastric region of the abdomen is placed a pad or cushion. The pressure of the pad is said to prevent accumulation of fæces in the lower part of the intestinal canal, and to be moreover occasionally effectual in removing the flexion itself.

Of 114 cases of prolapsus and procidentia uteri treated by Scanzoni, 99 occurred in women who had given birth to children. For the relief of simple cases of this kind he recommends the sponge pessary, alum, tannic and muriate of iron injections. The pessary of Zwanck, consisting of two oval flat perforated pieces, connected by a hinge-joint, which, after being introduced into the vagina, are separated and maintained in this position by a simple contrivance, he finds useful in many cases. The instrument is simple, easily removed and introduced, and we think its more extended introduction into this country might be attended with advantage. Another form of uterine support, the air-pessary of Jariel, is favourably spoken of in cases where the vaginal walls are much relaxed and extended.

Respecting the operative procedures for the cure of this condition, Scanzoni has performed that of removal of a portion of the mucous membrane of the vagina, in order to produce narrowing of this canal, in 13 cases; and that of narrowing the vaginal orifice in 5 cases. He expresses himself, however, as "by no means satisfied with the results obtained."

Of the "chronic infarctus," or "chronic parenchymatous inflammation of the uterus," we receive a very complete account. The uterus so affected is enlarged, the uterine wall at the fundus sometimes measuring as much as an inch in thickness. The whole organ is also remarkably hard and firm, its tissue very resistant, dry, and anæmic; but in parts the vessels are much enlarged and full of blood, the latter hyperemic condition being more often present in cases of fibrous tumour or polypi of the uterus. The anatomical change which takes place in the uterine tissue is said to be a great increase in the amount of connective tissue. The complications of this condition of the uterus are-varicose enlargements of the veins in the neighbouring organs; chronic catarrh of the vagina, bladder, and rectum; peritoneal adhesions of the uterus, and chronic hyperæmia; and formation of cysts in the ovaries. The effect produced on the menstrual function is generally to diminish the quantity of the discharge, and in many cases to give rise to

dysmenorrhoea. The chronic hyperemia of the uterine mucous membrane often leads to the formation of an exudation on its surface, which is discharged at intervals and with great pain in the shape of small membranous shreds. The chief causes of chronic infarctus are, according to the author, acute metritis; any circumstance leading to irritation and congestion of the uterus; displacements of the organ, &c. Its origin is frequently to be traced to deficient puerperal involution of the uterus, abortion, and excessive sexual intercourse. The unfruitfulness of prostitutes he considers to be connected with the existence of this uterine hypertrophy.

On the subject of Diagnosis, Scanzoni's observations are always good. There is occasionally, he remarks, a difficulty in diagnosticating between chronic infarctus and fibroid tumours or polypi. The state of the catamenial function will afford useful information, for in chronic infarctus the discharge is,

"As a rule, small in quantity, but in cases of sub-mucous fibroid and polypi nearly always very profuse, and occurring unusually often. Larger, sub-peritoneal fibroid tumours of the uterus are recognised by palpation, as more or less clearly limited, round, uneven elevations; and, in the case of an intra-uterine polypus, or a sub-mucous fibroid tumour which has attained a volume somewhat more considerable, the length of the cervix is markedly diminished, the cervix has sometimes actually disappeared, in consequence of the spreading out of the cervical cavity; whilst in simple infarctus the cervix is found nearly always unusually enlarged, and its walls thickened."

The treatment found most successful in cases of chronic infarctus is the following:-At first, leeches to the cervix every five or six days, warm hip-baths, and injections, consisting of water alone, or of solutions of salts of iodine and bromine. Internally, the use of the mineral waters of Marienbad, Kissingen, Karlsbad, Ems, &c.; and in cases where they are indicated, the preparations of iron.

The "fibrous tumours" of the uterus are classed according as they are situated within the tissue of the uterus (" round fibroid tumour"), or in the cavity of the organ (" uterine polypi").

The "round fibroid" tumours vary in size, from a barleycorn to twice the size of a man's head, and they are chiefly situated at or near the fundus. For practical reasons, Scanzoni distinguishes them into "sub-peritoneal," "interstitial," and "sub-mucous." The diagnosis of each of these forms is given with great precision. The interstitial variety, inasmuch as it generally attains a larger size than the others, and gives rise to more profuse hæmorrhage, is regarded as the most unfavourable to the patient. Iodine taken internally, and applied externally, Scanzoni appears to have most faith in as a remedial agent; but he speaks rather discouragingly of the results obtainable, so far as a complete cure of the disease is concerned. He does "not remember a single instance in which, by the use of these or any other means, a perfect removal of the fibroid tumours was effected." The symptoms produced may be very much relieved, and even removed, by treatment, but the improvement is to be attributed to the removal, or diminution of the intensity of, the secondary alteration

produced by the tumour, hypertrophy of the uterus in particular. He speaks favourably of the effect of an ointment introduced into the uterine cavity, composed of iodide of potassium and mercurial ointment, a combination recommended first by our countryman, Dr. Rigby. After a description of "fibrous polypus" of the uterus, follows an inquiry into the comparative merits of the three methods of treatment usually recommended for the removal of these bodies-by the ligature, excision, and torsion. The same operation is considered not to be admissible in all cases. Scanzoni rejects the ligature in most cases, owing to the unfavourable and occasionally dangerous symptoms liable to be produced. Of 31 cases operated on by him, he had only used the ligature three times, and in these three cases either torsion was impracticable, owing to the thickness of the pedicle, or excision impossible, owing to the high attachment of the polypus. Torsion was adopted in 10 cases: in these cases it was not possible to introduce the scissors sufficiently far to cut across the pedicle, and the fact that the diameter of the pedicle was small enough to allow of the tumour being twisted off had been ascertained. Scanzoni arrives at the knowledge of the fact in question by seizing the polypus and endeavouring to impart to it a rotatory motion; if the rotation is easily effected, the neck of the polypus is considered to be so thin as to allow of its removal by the method of torsion. The long narrowbladed scissors are the instruments recommended for the excision of these uterine polypi.

Passing over the disorders of menstruation, a subject discussed in a very philosophical manner, we come to the affections of the ovaries.

Ovarian tumours are divided into two classes, consisting of hollow and solid tumours. In the first are included, simple cyst-formations, compound or multilocular cysts, cystic sarcoma, colloid tumours, and cysto-carcinoma. The solid tumours of the ovaries include fibroid tumours, of which Scanzoni has observed 4 cases; enchondroma, and cancer, the latter being, as a rule, a secondary affection.

Of 1823 women observed by our author in his gynecological practice, 97 were affected with ovarian disease. Of 41 cases in which the nature of the disease was established by post-mortem investigation, simple follicular dropsy was found in 14 cases; compound cystic disease in 12; colloid tumours in 9; cystic sarcoma in 5; and cysto. carcinoma in 2 cases. In 14 cases the right, in 13 the left, and in 14 cases both ovaries were affected. Lee's, Chéreau's, and Scanzoni's cases together are 349 in number, and in these the right ovary was the seat of the disease 173 times, the left 126, and both ovaries 50 times.

The general conclusions as to the etiology of ovarian diseases are thus expressed :-They, with few exceptions, only become developed during that period of life in which the generative organs are in a state of activity. Abstinence from sexual intercourse, especially when combined with menstrual irregularity, and long-continued and intense hyperemia of the ovaries, from whatever cause, are the most frequent causes of these affections.

The important and much-debated question as to the proper treat

ment of ovarian dropsy, the reader will find comprehensively and judiciously handled. The "operations" for the cure or relief of this affection are the following:-Puncture of ovarian cysts through the anterior wall of the abdomen; puncture through the wall of the vagina; injections of irritating fluids into the cavity of the cyst; excision of a portion of the cyst wall; extirpation of the whole tumour. Scanzoni regards the first of these operations to be generally unsuccessful as a curative method, while it is not always free from danger. The second, that of puncture of the cyst through the wall of the vagina, is spoken much more favourably of, as affording a chance of permanent relief, Of 14 cases operated on by the latter method, 8 were cured. In 2 cases the cyst began to fill again a few weeks after. In 3 cases the result was unknown, the patients having escaped observation, and 1 died subsequently of typhus. In this operation, the results of which are thus so encouraging, and which is of course only admissible in those cases in which the cyst has not risen from the cavity of the pelvis, the cyst is punctured, and the fluid afterwards allowed to drain off through a tube which is retained in the cyst for some few days. Injection of the cyst, Scanzoni considers to be hazardous, on the ground that it is always impossible to predicate the amount of inflammation which may be excited thereby; and excision of a portion of the cyst wall as still more so, from the severe hæmorrhages and inflammations likely to occur. The operation of extirpation of the tumour he characterizes as simply a surgical venture (chirurgisches Wagestück). Of 11 cases operated on by Kiwisch and Langenbeck, he reports 9 as having terminated fatally.

In conclusion, we have only to say that we have derived much instruction from the perusal of the work, and we can confidently recommend it to those engaged in the investigation and treatment of the diseases of the female generative organs, as a sound, practical, and useful treatise.

REVIEW X.

Report of the Commissioners appointed to inquire into the Regulations affecting the Sanitary Condition of the Army, the Organization of Military Hospitals, and the Treatment of the Sick and Wounded; with Evidence and Appendix. Presented to both Houses of Parliament by command of her Majesty.-London, 1858. Folio. In the spring of 1856, after the tale of the sufferings of our gallant troops in the Crimea had been substantiated by undoubted evidence, the House of Commons, on the motion of the late Mr. A. Stafford, appointed a Select Committee on the Medical Department of the Army. The object of this Committee was apparently (for, as there were no instructions given to it, this can only be conjectured from the general tenor of its examinations) to trace out the causes of those practical defects in the working of the department which had become manifest in the early part of the Crimean war; to inquire into the

acknowledged and alleged grievances of the medical officers; to suggest such alterations in the mode of their admission, promotion, and retirement, and in the system of government of the department, as should seem best calculated to raise it to a high state of efficiency; and to make such recommendations on the organization of military hospitals as would be likely to prevent a recurrence of the disastrous mismanagement which had unfortunately been the characteristic of the general hospitals at Scutari in the winter of 1854-5. In due time the Committee made its Report, which, with the evidence and Appendix, was printed in the form of a Blue Book. Rumours were then current of a Royal warrant, founded on its recommendations, which was greatly to ameliorate the condition of the medical department; but no such document appeared. On the re-assembling of Parliament in 1857, in reply to a question by Mr. Stafford, whose exertions on behalf of the sick soldier merit the highest praise, Mr. F. Peel stated that it was the intention of her Majesty's Government to appoint a Royal Commission to inquire into the subject. This decision was probably come to from the feeling that a Committee of the House of Commons, on which there was not a single medical officer, nor indeed any member practically acquainted with the subjects under inquiry, was likely enough to commit some serious mistake, or to make some impracticable recommendation. The members were, certainly, much at the mercy of private advisers, who were not unlikely to direct attention to points personally interesting to themselves, and to neglect the weightier interests of the sick soldier and of the medical department generally.

In announcing the intention of the Government, the Under-Secretary of State for War

army

"Would not deny that the advantages offered in other services had the effect of preventing the most able men from competing for employment in the Army Medical Department; and he was anxious that the medical officers of the should possess at least equal advantages with those enjoyed by the same class of persons in other services. He confidently believed that the recommendations of that Commission, coupled with the resolutions of the Committee of last session, would enable the Government to deal with this question in a manner which would be satisfactory to the medical officers and beneficial to the service."

Accordingly, in May last a Royal Commission was issued to the Right Honourable Sidney Herbert, who had formerly been Secretary at War; Mr. Augustus Stafford, who had personal experience of the hospitals in the East, and had obtained during the previous inquiry much knowledge of the state of the department, and the feeling of its members; Colonel Sir H. Storks, the military commandant of the hospital at Smyrna, and subsequently at those of Scutari, and now holding an appointment as military secretary in the war department; Dr. A. Smith, director-general of the army medical department; Mr. Alexander, inspector-general of hospitals, who had served through the whole of the late war, both in Bulgaria and the Crimea; Sir T. Phillips,

* Hansard's Debates, vol. cxliv.