A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. By T. GAILLARD THOMAS, M.D., Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Surgeons. Third edition. Philadelphia: Henry C. Lea. 1872. pp. 784.

SINCE the new era introduced into gynecological practice by Sims, Emmet, Thomas, and other prominent surgeons of this country, whose ideas have been followed and enlarged upon in the old world, and since the appearance of Sims' " Uterine Surgery," no book has been published which, like the one in question, combines all the new inventions and appliances in gynæcology with a scientific and practical account of the various disorders. The favor which the work has found is plainly shown by the fact that this is the third edition within the short space of four years. Coming from the pen of a well-known American gynæcologist, whose large practice entitles him to write from personal experience on most of the subjects under discussion, it has filled a vacancy in the field of gynecological literature which was felt even more keenly in Europe than in this country.

After giving a historical sketch of uterine pathology from the earliest period of our knowledge--which is divided into three eras, by three men, Récamier, who improved our power of diagnosis in exposing the cervix uteri; Simpson, who opened the investigation of the body of the uterus; and Sims, who rendered both investigations more simple, complete, and satisfactory; and touching lightly on the efforts now being made to place gynæcology and obstetrics as much as possible under the management of female practitioners, on which subject a very just position is assumed, and the allowing them a fair opportunity in the field of medicine approved of, although the history of the past has shown their failure "to advance or even maintain the integrity of the art intrusted to their hands"-the author proceeds to discuss the etiology of uterine diseases. Those influences which, growing out of civilization and refinement, tend most decidedly to produce uterine disorders, may be thus enumerated:-Want of fresh air and exercise; excessive development of the nervous system; improprieties of dress; imprudence during menstruation; imprudence after parturition; prevention of conception, and induction of abortion; marriage with existing uterine disease. "The indolent habits of a great portion of American_ladies; the prevailing style of dress; their imprudence in regard to their sexual functions, which causes the act of sexual intercourse, which in one whose organs maintain a normal position, is a physiological process devoid of pathological results, to become an

absolute and positive source of disease;" and the frequency of intentional abortion, which appears to be tacitly allowed by law, are severely and justly criticised.

The chapter on Physical Diagnosis contains much which is useful to a beginner, such as hints on the introduction of specula, tents, etc. Of the specula recommended, Sims', Cusco's and Ferguson's are the most prominent. Thomas' " telescopic speculum," which can be shortened and lengthened at will, appears to be a practical instrument. The uterine probe used by Sims is advised for first examinations, in preference to the unyielding instrument of Kiwisch or Simpson. The various modes of physical diagnosis are given, as follows: anesthesia, vaginal touch, conjoined manipulation, abdominal palpation, rectal touch, vesico-rectal exploration, speculum, uterine probe, tents, endoscope, exploring needle, microscope, auscultation and percussion. The diseases of the external organs of generation are very fully and practically treated; the articles on rupture of the bulbs of the vestibule (pudendal hemorrhage and hematocele) and on coccyodynia, are not usually found discussed to such a length. In the chapter on rupture of the perinæum, we miss the mention of the operation practised by Prof. Simon, which was first published in 1868, and an account of the successful cases which has lately been given by Simon's assistant, Dr. Hirschberg. For vaginismus, Sims and Burns' operations, and the non-operative treatment of Scanzoni and Tilt, are given at length. The author appears to think both procedures applicable to individual cases. As far as we are aware, the generality of German pathologists and gynecologists now concede granular vaginitis to be due (simply) to a hypertrophical or swelled condition of the papillæ of the vagina; a few pretend to have discovered muciparous follicles in the vagina, and attribute the disease to inflammation of these follicles; but these latter stand very much isolated, and their opinion seems hardly to warrant Dr. Thomas giving it the preference. The chapter on "Fistula of the Female Genital Organs" contains a very good historical account of the operation, and describes the method of Sims, Bozeman, Simon, and others very clearly and satisfactorily. The numerous excellent diagrams in which, moreover, the book abounds, of course greatly facilitate the comprehension of the various manipulations. In speaking of the treatment by sutures of recto-vaginal fistulæ, no mention is made of the method lately used by Simon to dilate the sphincter ani as much as

* A translation of Dr. Hirschberg's paper, by Dr. Paul Munde, of this city, will appear in a future number of the Journal.

possible with duck-bill specula, and operate the fistulæ through the rectum, a procedure which was found to succeed in cases where the attempt had been made in vain by the vagina.

For his treatment of the chapters on "Uterine Pathology and Therapeutics, and the Inflammatory Disorders of the Womb," the particular thanks of the profession are due to the author, for by simplifying and cutting down the host of conflicting and undefined terms and expressions with which the disease hitherto known as "chronic parenchymatous metritis" was encumbered and rendered unintelligible, he has done science a real service. The terms "areolar hyperplasia," or " diffused interstitial hypertrophy," adopted by Professor Thomas, express clearly and concisely the changes in the uterine tissue and the nature of the disease, viz., an increase in number and size of the fibres of the connective tissue of the uterus, a condition also expressed more at length by Klob, as "diffuse proliferation of connective tissue due to hyperæmia." "It is a disorder of nutrition, which very frequently affects the uterus, and is characterized by congestion, hypergenesis of the connective tissue of the organ, and hyperæsthesia of its nerves. It may affect either the entire uterus, or the neck, or the body and fundus; that form affecting the cervix is the most common. The old idea that the chronic enlargement of the uterus was due to inflammation and the deposit of lymph, has been obliged to give way to the evidence obtained by the microscope, and more careful obser vation, which shows that the disease originates in a chronic congestion of the uterus, by means of which gradually the connective tissue becomes hypertrophied and increased in quantity. The causes of this congestion are so various, numerous, and often difficult to determine, that even a short survey of them would take up more space than we could afford. In opposition to Klob, who does not admit any great increase in the muscular fibres, Dr. Finn, of St. Petersburg, reports the result of his observations, which show that the number of muscular fibres is always increased, their length and breadth is extended, and in the latter stages the amount of connective tissue is always relatively diminished, although absolutely enlarged, and that the increase of bulk of the uterus is mainly caused by hyperplasia of the muscular fibres. Opinions are still at variance, as we thus see, and further investigations will have to determine the truth. The author does not incline to the idea that areolar hyperplasia has any direct connection with carcinoma, as cause and effect. The prognosis is unfavorable as regards a cure, favorable as regards danger to life. The treatment of this af fection is very inanifold: rest, both local and general; change

of air, habits, associations; hydropathic treatment, local depletion (less employed by Dr. Thomas from year to year), vaginal injections, suppositories, cauterization, alteratives, tonics, etc. The principle upon which Braun, in Vienna, acts when he attempts to cure prolapsus uteri, by cutting off the portio-vaginalis, in order to produce a retrograde metamorphosis of the bulk of the womb, is also acknowledged by Thomas, and the operation recommended for some unmanageable cases of areolar hyperplasia.

In the treatment of acute endometritis and metritis the author advises the mild emollient treatment, with rest, warm injections and poultices, in preference to the more energetic antiphlogistics. For chronic cervical endometritis the general treatment is placed almost superior to the local; of the latter, medicated tents of sponges, and the removal of enlarged Nabothian follicles by Sims's curette are recommended, among many other applications. These medicated sponge-tents, made very long and slim, are likewise strongly advised in chronic corporeal endometritis, the pressure of the expanding sponge proving actually beneficial. After a detailed discussion of the pros and cons of intra-uterine injections, Prof. Thomas comes to the conclusion, that although comparatively safe in the hands of skilled specialists, they will always remain a hazardous method for the general practitioner lacking such skill, etc. Intrauterine scarification and the curette are also mentioned in the treatment of corporeal endometritis. As regards the significance of versions and flexions, Thomas adopts the view, that occasionally displacements of the uterus, if not attended by any other disease of the organ or its surroundings, are neither painful nor dangerous, but they are always important, and require treatment on account of the impediments to conception and regular menstruation; if complicated with other disorders, they become a source of great pain and discomfort second to no one class of uterine diseases. In the chapter on "Descent of the Uterus" we find nothing new, with the exception of the description of the author's method of narrowing the vagina, which consists, in substance, in tearing loose the anterior vaginal wall from the bladder, uniting it in a longitudinal fold by sutures, and cutting off the loose flap of vaginal wall over a clamp. In three out of five cases the uterus remained in situ. For a more detailed account of the operation, we must refer to the author's description. We miss, again, any mention of Simon's colporrhapphia posterior, which has been resorted to by him with great success in some twelve cases or more.

In ante- and retro-version the mechanical treatment is principally employed; pessaries recommended are Graily Hewitt's.

the author's, Cutter's modified, for anteversion, Albert Smith's, Thomas', Cutter's modified, Hewitt's, and Meig's ring pessary for retroversion. In cases which cannot endure a pessary, the medicated tampon should be employed until the instrument can be borne. In flexions, IIurd's hard rubber pessary, with a canal running through its centre to receive the cervix uteri, will be found of service in many cases. Stem-pessaries require the greatest caution.

In the chapter on "Inversion of the Uterus," the author relates at length his celebrated case of reduction of an old inversion, by means of abdominal section, and dilatation of the cervical ring from above, and also a second and similar case, which, however, terminated fatally.

In order to avoid the confusion which results from the classing of all inflammation of the areolar tissue in the pelvis under the head of "pelvic cellulitis," the author has confined himself to that which chiefly concerns the gynæcologist, viz., the inflammation of the cellular tissue immediately about the uterus, and gives it the term of "peri-uterine cellulitis." Pelvic cellulitis and pelvic peritonitis are not considered synonymous, and are therefore treated separately, there being as much difference between them as there is between pleuritis and pneumiona or endo- and peri-carditis. Pelvic peritonitis is very common, and often overlooked or mistaken for cellulitis. In enumerating the causes of pelvic peritonitis, Prof. Thomas speaks, under "imprudence during menstruation," of the rupture of the peritoneum during evolution. He was apparently not aware (although at page 625, discussing the Anatomy of the Ovaries, he quotes from Schrone, Heule, and Lappeg, and says, "the surface of the ovary is not covered by peritoneum") of the late discoveries of Waldeyer in Breslau (Eierstock und Ei., 1870), who has ascertained beyond a doubt that the surface of the ovary is not covered with a peritoneal coat, but possesses distinct cylindrical epithelium, the boundary-line between which and the tessellated peritoneal epithelium can be distinguished by the naked eye, and is easily seen under the microscope.

Pelvic abscesses should not be opened too early, and never unless the pus can be certainly, easily, and safely reached. In the chapter of "Pelvic hæmatocele" we find almost all the credit of the description of this effusion awarded to France, although the able essays of Schroeder, Freund, Heyar, Crede, and others would have entitled Germany to an honorable mention. Surgical interference, i. e., the puncture of the tumor, is allowable only when great and prolonged pain threaten to exhaust the patient, if the tumor is still fluid, if rupture of a subperitoneal