3. Or it may be of an hysterical or neuralgic character.

4. It occurs in connexion with some inflammatory action of the uterus, usually the os and cervix; and,

5. It arises from ovarian irritation.

The presence of one or other of these causes must of course influence the treatment in each particular case, and general principles must be our guide. The symptoms attending that particular form of dysmenorrhoea in which the ovary is the chief seat of pain, are well described in the following extract:

"The organ becomes highly congested or actually inflamed; it swells considerably, and becomes intensely sensitive. The pain is of the most agonizing character, and is frequently attended with severe nausea, or obstinate and most distressing vomiting. The patient describes it as being different to any other pain she ever experienced, and dreads a return of the attack; its peculiarly unbearable, sickening character apparently resembling the sufferings from orchitis, or from any injury to the testicle in the male. This is decidedly the severest form of dysmenorrhoea, and, moreover, is remarkable for another peculiarity-viz., the formation of fibrinous exudations from the uterus.”

The author further remarks:

"That a slight amount of ovarian irritation, although it will be accompanied by ovarian pain at the menstrual period, may not be of sufficient duration to produce the uterine exudations; hence, although we may have ovarian pain without exudations, we cannot have exudations without ovarian pain.”

The chapter On Menorrhagia occupies thirty-two pages of wellwritten, practical matter, but we search in vain for anything that is not already familiar to the experienced accoucheur. The various causes of menorrhagia are usefully commented upon; and in cases where the hæmorrhage is very profuse, we are glad to find the means we have on several occasions practised and recommended, approved also by so good an authority as Dr. Rigby-viz., plugging the vagina with a sponge dipped in vinegar or alum-water, and throwing up a large enema of cold water. This, he says,

"Acts beneficially in many ways. By thus applying cold immediately along the posterior wall of the uterus, we not only produce a considerable check upon the activity of its circulation, but stimulate the organ to a firmer state of contraction, which will exert a powerful control on the profuseness of the discharge; and though last, not least, it will effectually clear the rectum of any fæcal accumulations which may have existed, and necessarily tend to aggravate and keep up the discharge.'

With respect to the concluding remark about fæcal accumulations, we would strongly impress upon all students and practitioners who may be called upon to deal with functional or even organic diseases of the uterus, the absolute necessity of removing daily the solid contents of the large intestines. Of the functional disorders, fæcal accumulations are perhaps the most fruitful source, and they never fail to aggravate those which depend upon organic change; the enormous quantity of solid material which lies packed up in the colon in some of these cases is almost incredible, and the removal of it often alone effects a cure. This, however, is not to be accomplished by means of strong purgatives, but by the daily exhibition of some mild aperient

for a length of time. Dr. Rigby recommends sulphate of iron and sulphate of magnesia, but we have found nothing answer better than a dinner-pill composed of one or two grains of watery extract of aloes, and the same quantity of extract of rhubarb; or this failing, a combination of compound colocynth pill and extract of henbane, followed, if necessary, by an occasional enema of warm water or gruel.

As an astringent in leucorrhoea, Dr. Rigby highly extols the infusion of red bark (Cinchona oblongifolia) with nitro-muriatic or sulphuric acid.

"I know of no astringent tonic so powerful as the recent infusion of this species of bark; and if the liver have been previously well roused to active secretion, and the bowels effectually cleared, a rapid improvement, not only of her general health, but also as regards the diminished leucorrhoea, will soon be evident."

On the subjects of inflammation and ulceration of the os uteri, the constitutional origin of these affections, in a majority of instances, is strongly, and we think justly, insisted upon; and ulceration unconnected with malignant disease of the uterus is stated to be a rare affection.

"Its presence can doubtless produce much irritation and corresponding local symptoms; but to assert that it is a cause of general derangement in the system, and to propound the postulate (for I can call it nothing else), that it is a most frequent primary cause of impaired health in women, argues either a singular ignorance of the fundamental laws of pathology, or great indifference to truth in the attempt to propagate and maintain certain doctrines in justification of an improper and dishonest mode of treatment."

Our own experience is strictly in accordance with the statement that many appearances denominated ulcerations were simply abrasions or excoriations, and that such cases can be speedily and effectually cured by general restoratives and such simple local means as will ensure entire cleanliness.

In reference to displacements of the uterus, a good description is given of one of the most troublesome we meet with; and it would be a great boon to those who suffer from it, and to the profession, to discover a more effectual and painless mode of cure than the introduction of an instrument into the cavity of the uterus.

"In examining a case of retroversion of the unimpregnated uterus during life, the finger can frequently reach a firm, globular mass, like a walnut, situated behind the cervix uteri, and evidently posterior to the vagina. At the first touch, or to one unacquainted with this condition of the womb, it seems like a lump of seybalous matter in the rectum, for in many-perhaps in most instances the finger cannot reach sufficiently high up to distinguish the conti nuity of this mass with the cervix, the point of flexion being usually in the body of the uterus, close above its junction with the cervix. In other cases, where the fundus is low down, being either on a level with, or even lower than the os uteri, the curve in the posterior wall can easily be felt and traced by the finger from the cervix to the fundus. On examining per rectum, we feel the same hard lump through the anterior wall of the intestine; and by being able to reach higher up in this direction than with the finger per vaginam, we can frequently verify or correct our first impression."

In speaking of uterine polypi, they are said to

Vary as to their size, structure, and the part of the organ from which they grow. The large polypi, which are usually of a fibrous tissue, arise from the sides or fundus of the uterus, while the soft polypi, which consist chiefly of fibro-cellular tissue, more or less condensed, and covered with mucous membrane, arise from the os and cervix.

"These larger polypi are usually solitary, but the smaller ones, which have been commonly called mucous polypi, and which have their attachment to the edge of the os uteri, or just within the canal of the cervix, generally occur two or more together, or sometimes like a fringe around the greater part of the os uteri." (pp. 163-4.)

In corroboration of the opinion of the late talented Dr. Gooch, that it is advisable to remove portions of malignant disease when it assumes a shape fitted for the application of a ligature, we quote the following paragraph, being strongly convinced that such a course is often extremely desirable, and, owing to the uncertainty of diagnosis, sometimes entirely successful :

"A polypoid mass of malignant growth is generally considered as unfitted for the ligature; but having treated many cases of malignant disease in this manner with good effect, I can affirm that it is not only safe, but capable of producing great relief to the patient. I deny that this relief being necessarily only of a temporary character, is a contra-indication to the use of the ligature; and in many inveterate cases of fungoid uterine disease I have had reason to be thankful that such a means was in my power for lessening the constant discharge, the frequent hæmorrhages, and severe sufferings of the patient (although I was well aware that it was but for a while), and that she has thus gained a few weeks more of ease and comparatively improved health. Hence, I have never hesitated, in every case of malignant uterine disease, to apply a ligature, if the shape of the tumour rendered it possible."

The following observations on the treatment of cancer of the uterus are particularly deserving of the attention of practitioners:

"I find considerable difficulty in stating what ought to be the treatment in its early stage, or stage of induration, not only on account of its incurable character, but also because its commencement is so insidious, that we can rarely have an opportunity of investigating the case until extensive mischief already exists. Even when examined at an early period, the practitioner, it is true, easily recognises the solid feel and alteration of the part, and the darting pains and cachectic looks of the patient probably confirm his suspicions; but he dreads to decide the point at this early stage, and hopes on, naturally wishing to give the patient the benefit of every doubt. I have felt the cervix uteri in other and apparently similar cases, as hard, or even more so, and probably more tender; and yet when I had removed the source of irritation, or allayed the inflammatory action of the part, it has assumed its natural characters. I cannot but think that this would be the reasoning of most practitioners in examining a suspicious os and cervix uteri at this stage. In those cases where the suspicious part consists merely of a little isolated tubercle, not bigger than a small pea, and which is probably an indurated muciparous gland, but which is becoming tender and irritable, and the patient complains of lancinating pains, which she distinctly refers to this point, we can successfully obliterate it by holding a piece of lunar caustic against it for about a minute: the darting pains cease henceforth, and on examination two or three weeks afterwards, the tubercle will have nearly, if not entirely, disappeared. With this exception, I have no hesitation in declaring, that the application of caustic in either stage of the disease is mischievous; if applied during the first, or stage of induration, ulceration is liable to be brought on,

where, but for this cause, the disease might have continued in abeyance even for years. In the second stage-viz,, of ulceration, I have repeatedly seen the process greatly accelerated by caustic; the sore quickly assumes a corroding character, and spreads with a destructive rapidity which soon exhausts the patient." (pp. 214215.)

The diagnosis between cancerous ulceration and the corroding ulcer of the os uteri is well described:

"1. The patient does not suffer the acute darting pains which are commonly so remarkable a character in cancer of the uterus.

"2. Nor does the touch of the finger produce the severe pain which is frequently the case in cancer, but a sensation of soreness.

"3. There is no induration of the surrounding parts, as in cancer; on the contrary, they are soft and natural to the touch.

"4. The uterus is quite moveable.

"5. The disease, commonly, does not extend beyond the uterus." (pp. 242-3.)

And, in the present day, when the application of caustic to almost every variety of uterine ulceration is so fashionable, we cannot but think the following remarks especially appropriate :

"The more I consider the causes and characters of phagedenic ulceration in other parts, the more do I feel convinced that it is in general, and not local, treatment that we must chiefly put our trust. It must be by the appropriate use of alterative, laxative, and tonic medicines that we hope to produce such salutary changes in the unhealthy circulation as shall be incompatible with the morbid action which has been set up in a part; and that so far from irritating the slumbering mischief into rapidly destructive action by the senseless use of escharotics locally applied, our endeavour should be to retard its progress, as far as possible, by such applications as shall soothe its irritability, and, at any rate, keep it in a dormant state. By far the worst cases which have come under my notice have been those where caustic has been applied. The ulcer, till then, had been advancing slowly; but, immediately after its application, it seemed to assume a new character. It had spread as much in two or three days as it had done before in a month. The hemorrhages became more frequent and profuse, and soon exhausted the patient." (pp. 243-4.)

The three concluding chapters, On Ovarian Affections, contain much useful information, and well deserve a careful perusal ; but we cannot help expressing regret that Dr. Rigby has given us so little of his own personal experience, and quoted so largely from other authors. That which he has published is instructive and good, and so far not to be found fault with; but there is not much that we can fairly call original; and this, considering the high position and large practice of the writer, disappoints the expectations we had formed on first seeing a new work from such experienced hands. Before concluding our remarks, we feel it right to notice two circumstances, with respect to which we differ; they are not, however, stated on Dr. Rigby's authority, although he appears to sanction them. The first is the statement that the multilocular ovarian tumour must be placed as colloid disease by the side of goitre (p. 285), and that there is a close relation existing between it and bronchocele. That it is connected with the stru

mous constitution we have no shadow of a doubt; but its analogy with bronchocele is surely disproved by the almost certain curability

of the latter, and the constant fatality of the former. The second is the statement quoted from Mr. Safford Lee, that

"Whatever may be the appearance of the complicated structure of ovarian tumours, we never have them producing the effects of malignant disease; nor can they be recognised by their symptoms. There is not a case on record where the colloid-looking portions of the cyst have spread to, or communicated disease to, neighbouring tissues." (p. 291.)

We are acquainted with a case in which the abdomen was occupied by a very large cyst, connected with the right ovary by a thick fleshy pedicle, and adherent over its whole anterior and upper surface to the peritoneum, particularly at and around the umbilicus. The intestines were pressed into a very small space on the left side, in the situation of the spleen. The cyst contained almost a pailful of dark chocolatecoloured fluid, which in the lower part of the sac was thicker, of the consistence of paste, or even putty, and adhered in masses to the lining of the sac. The walls of the sac were of various degrees of thickness; thinner anteriorly, but posteriorly to about the size and shape of a placenta, very thick, and covered with glistening fibres like the expansion of tendinous structure. These thicker portions, when cut into, were found to contain numerous smaller cysts, in various degrees of development, containing gelatinous fluid. Behind the sac on the right side, adherent to it, but not forming an integral part of it, was a mass of cerebriform tumour, soft, and easily broken up with the finger, situated in front of the right kidney. The subject of this disease was a young woman, twenty-two years of age. Her complaint began with pain in the right side, about a year before her death, quickly followed by dropsy. Her body was greatly emaciated. Before death the abdomen was very much distended with fluid; fluctuation was everywhere remarkably distinct. On the right side a hardness could be felt through the parietes of the abdomen. Her aspect was unhealthy, similar to what is observed in malignant disease, and she died in the unusually short period of a year from the commencement of her attack.

Although we have expressed a desire for more originality, we are quite satisfied of the practical utility of the work before us; we strongly recommend it to those who are studying the diseases of which it treats, and shall look forward with much interest to a second edition, in which we hope to be supplied with a greater amount of the personal practical experience of one so qualified in all respects to communicate it, on the subject of ovarian disease.