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The limited space which the JOURNAL can afford renders impossible any satisfactory digest of such a book. Every general practitioner will be well repaid for a careful perusal: the operator for its manifold practical suggestions; and the general practitioner for the knowledge which he will get of the protean forms which disease assumes in the female organization, which may all be due solely to local causes, and the treatment of which, if these causes be ignored, becomes merely empirical. Most of us are familiar with cases of metrorrhagia, dyspepsia, cardiac irregularities, neuralgia, and general nervous derangement, which, after being treated for years unsuccessfully by those wbo "disapprove of local treatment," are finally discovered to be dependent on functional or organic pelvic disorder, admitting of easy and prompt solution when properly diagnosticated.
The book opens with a discussion of the influence of climate, education, and social conditions upon general development, and especially that of the female nervous system. Our author believes that the physique of women in this country is deteriorating, an opinion held in common with many others, but one in which we are unable to coincide. That an unhealthy development of the nervous system, due to the causes which he enumerates, is often manifest is unfortunately and undeniably true; but that on the whole the women of this country are physically better than fifty years ago is a belief which we think might easily be verified. Possibly the large experience of the author in the class of cases which he describes has unfavorably influenced his judgment. It has been a pleasure to feel that we are fast outgrowing the thin, skinny, nervous type formerly reckoned a national characteristic, and that the fuller type of fat and blood is becoming sufficiently common, owing to the more luiurious living incident to the increased wealth of the country. When the rage for coeducation and education in unfeminine directions gets its inevitable check, and women receive a fuller and more physiological feminine culture, there is no reason to apprehend a greater nervous development than such as is unavoidably incident to our climate, and which is perhaps not undesirable as the foundation of the energy and "go-aheađativeness” of the American people in contrast with the more stolid, lymphatic temperament of our European neighbors. With this protest, however, we readily admit that the defects in physical training during the transition period of ten or twelve years in young women of the so-called higher classes are very great. Whether the capacity, in that special class, to produce large families is diminished thereby is somewhat doubtful. Is it not often a question of ethics rather than physiology? Is it not that women will not, rather than that they cannot ?
The ensuing chapters on the principles of treatment, and especially that portion treating of the pelvic circulation, should be carefully considered as of elementary importance by every one who attends to his own uterine cases, all experience proving that success is closely dependent upon it. The articles on ovulation and menstruation are reinforced by, if not based upon, the analysis of nearly twenty-five hundred cases occurring in the author's own service. The question of the, complete denudation of the mucous membrane, or its mere thickening, during each monthly period is merely glanced at, as not coming within the scope of the work; but we confess to disappointment that such a
large field of observation should not have afforded some elements towards the solution of this vexed question. The author's large experience in atresia of the vagina gives to his remarks original value, and the same also of treatment of retained menses from imperforate hymen. Unlike many high authorities, he contends for a free opening in cases of menstrual accumulation, with rapid evacuation and washing out of the uterine cavity.
To the ordinary practitioner perhaps no part of the book will be of more use than that relating to the ætiology and treatment of uterine displacements. He does not admit that anteversion per se is a malposition, it becoming so only when in addition the uterus is prolapsed. This is probably true, and accounts in a measure for the utter want of success in devising any effectual anteversion pessary which does not support the whole organ at its proper plane in the pelvis, the restoration of the prolapse being all that can be accomplished by such means.
For the restoration of a retroversion he relies upon the finger alone. In many cases, doubtless, this —or, what is perhaps better, the “ genu-pectoral position " - is quite sufficient, but the less experienced will often sadly miss our author's sleight of hand, and find the sound to accomplish the object more easily and effectually. Unfortunately, these are the very ones in whose hands the sound may become a two-edged sword, and we recommend to them first a trial of Dr. Campbell's method before resorting to an instrument which may leave the latter end of their patient in a worse state than they found it.
With regard to pessaries, we think he has struck the key-note in the following sentences : “ It is not so much the position [of the uterus] which is to be corrected, as it is the removal of the obstruction to the circulation."
When the instrument fits properly, and has corrected the prolapse, the patient will be unconscious of its presence.” And as to outside fixtures, “ If there were no other objection, the fact that the patient has to be manipulating it constantly would be sufficient to condemn it, and no better plan can be devised for rendering a woman a confirmed invalid. His views upon flexures, the use of the stem pessary,
and the operative measures of Simpson and Sims are worthy of careful attention, if only for their bearing upon dysmenorrhea and sterility.
The author's method of restoring a completely lacerated perinæum has now become tolerably well known, and is founded upon careful, long-continued study of the failures by the old method. It is difficult to see how one can fail to appreciate his way of catching up the straightened-out ends of the torn circular fibres and restoring them to their circular position, though any description is unsatisfactory until the process has been witnessed. We regret to see no allusion to the method devised by Dr. Jenks, of Detroit, for denuding the mucous surfaces, which for rapidity in execution, cleanliness, and freedom from hæmorrhage is a great advance upon the old methods. To the author, with his skillful and experienced manipulation, this denudation with hook or forceps, scissors or knife, is an easy matter, but he is writing for the use of those who are rarely gifted with his dexterity.
Inversion of the uterus, the comparative rarity of which may be estimated by West's statement that it was not once met with in a total of one hundred and forty thousand cases occurring in the Dublin Lying-In and the London
Maternity hospitals, has attracted much attention in this country of late years from the considerable number of cases reported. Dr. Emmet does not believe in the professional tradition that inversion is generally owing to undue traction on the cord. In this he agrees with Schroëder. It must be confessed, however, that West's statement is rather confirmatory of the old belief. The skill which governed the one hundred and forty thousand labors, presumably without any undue traction, it would seem, could have had no influence in preventing an occasional occurrence of the displacement in so large a number of deliveries, if irregular muscular contractions and atrophy from fatty degeneration be, as supposed by Schroëder, the chief cause of inversion. On the other hand, that traction is a less common factor than has hitherto been supposed may well be admitted in view of the force that is often used with impunity both by traction and by expression from above the pubis, and that such forces only become dangerous in an organ diseased or atrophied in certain parts.
The importance and difficulty of the diagnosis are strongly emphasized by the statement of instances which have occurred in New York, " where the mistake has been made of removing the whole organ for supposed polypus, and he gives two instances in which he was himself nearly led into a similar
A good résumé of the various methods of reduction, with the principles involved, is within a compass which admits of easy reference by any one who may meet with such a case.
The subject of lacerations of the cervix uteri may be fairly said to be original with Dr. Emmet. The great frequency of the lesion, its causes, its effects, especially in relation to neuralgia, epithelioma, and hypertrophy, so called, and its surgical treatment were neither known, nor hardly suspected, until demonstrated by him; and though received with great incredulity at first, it has now become well recognized, and the operation as well established as any other in surgery. Its importance in a medico-legal point of view, in reference to abortion, the use of the forceps, etc., is evident to all. He believes that the intelligent “ recognition of this lesion under its different forms ” will afford to the observer “ a new explanation of all his cases of elongated or hypertrophied cervix,” and therefore that cauterization or ablation, except for malignant disease, is malpractice. Cases of apparently elongated cervix, found in the virgin uterus, are, in his opinion, really due to atrophy and prolapsus of the whole organ, the deformity disappearing when examined in the knee-elbow position, the uterus shutting up and falling together as would an old wordout spy-glass if held upright.” Should this view prove to be correct, we shall hear less hereafter of the electro-cautery and resulting stenosis of the os.
In discussing vesico-vaginal fistula he pays a just and generous tribute to one from whom in many things he has been compelled to differ. He says, “ From Dr. Sims's hand the operation [for closure of the opening) was accepted by the profession; it was immediately put into successful practice, and to the present day it has not been materially modified for the better, either in its principles or in its mode of execution.” To the obstetrician this chapter is perhaps of more practical importance than any of which the book treats. The possibility of spontaneous closure of many of these injuries under the use of hot-water injections shows the urgent necessity of their early recognition before such changes have occurred in the tissues as may render anything short of operative interference nugatory. He controverts the common idea that the opening is due to instrumental interference, asserting, on the contrary, that it is owing to neglect of the catheter, and to delayed delivery, for which the forceps should have been sooner applied. As the result of the experience of one who has operated for fistulæ into bladder or rectum on considerably over two hundred cases, the following sentences deserve attention: “I do not hesitate to make the statement that I have never met with a case of vesicovaginal fistula which, without doubt, could be shown to have resulted from instrumental delivery.” “I have claimed that any one who is familiar with the mechanism of labor, although wanting in practical experience, would do less damage in applying the forceps in such a case than would result if the delivery were left unaided.” “ While it may be true that instruments are often resorted to without urgent necessity, we must not ignore the consequence of allowing labor to be protracted. Vesico-vaginal fistula cannot occur as the consequence of a slough if delivery is always brought about as soon as the head fails to recede after each pain.”
With the exception of the subjects of cystitis and cystotomy, for which, as is well known, the author has done so much, but for which we have no space, the remainder of the volume is devoted to diseases of the ovaries. We could have wished for something more encouraging as to the treatment of those cases of irritable and neuralgic ovary which are now the opprobrium of the profession, - cases in which one resorts, in a sort of blind despair, to every possible and impossible mode of relief; in which the “fat-and-blood” treatment, now so popular, proves too often a delusion, even the removal of both ovaries à la Battey being not always a success; and we are forced to the conclusion that it is indeed " difficult to afford any marked relief during the menstrual life of the woman." The ovariotomist will peruse with interest the chapters devoted to that subject, which give, besides the valuable experience of the author, a concise view of diagnosis and the various operative procedures of the best recognized authorities.
The above is but a meagre summary of the important points, the valuable practical suggestions, with which the book abounds. Many of the subjects, as cellulitis, hæmatocele, uterine fibroids, etc., we have not even alluded to. Every practitioner should own the book, and we can promise that he will find embodied in it an experience which will be of daily service to him.
The statistical tables so freely interspersed are made to bear so directly upon the text as to lose for the reader much of their usual dry aspect.
The illustrations, between eight and nine hundred in number, are almost exclusively from original sketches of the author. It would seem almost hypercritical to notice the defects in style in a work of such magnitude, written amidst the cares and pressure of extensive professional duties. Such as they are they will doubtless receive correction in subsequent editions.
G. H. L.
GODLEE'S ATLAS OF ANATOMY." This work consists of a series of plates to be issued at intervals, each fasciculus being accompanied with an installment of description and comment. The plates will form a large folio volume, the text one in octavo. Part First is before us. The four plates which it contains are devoted to the anatomy of the neck, and deserve the highest praise, both for the judgment and skill shown in the dissections, and for the beauty with which they are represented. Our only criticism is that some of the numerals and letters indicating the parts are not sufficiently clear. In the text the plates are described, and there are many practical surgical remarks which are of much value. The author shows himself better read in recent German anatomical literature than most English teachers of this branch appear to be. We hope in future numbers to see sections as well as dissectious, for the work is so good that we shall be disappointed if it is not brought up to the latest requirements.
GEGENBAUER'S COMPARATIVE ANATOMY.? Both teachers and students of comparative anatomy will be glad to find a translation of this valuable manual. It is made from the second German edition (that of 1877), which has several advantages over the first. The few remarks we shall make apply solely to the section on vertebrate animals. We are often inclined to regret the absence of more details, especially with regard to man and the higher apes, but on reflection we see that they do not fall within the plan of the work, which is to give a strong outline of the subject, leaving the details to the knowledge of the teacher and to the private research of the student. Gegenbauer's work is characterized by clearness and good
As an instance of the latter, especially, we would quote from his remarks on the foot of mammals: “In addition to its primitive function as an organ of support and of movement, the foot may be developed into a grasping organ; when this happens the foot comes to resemble in 'many points the end of the fore limb or hand. But in all essential points of structure it is still a foot so long as we hold to the anatomical conception of what hand and foot are, and do not put functional relations into the foreground; and if we do. then the proboscis of the elephant is a “hand' also.” Our author's opinions on the vertebral theory of the skull strike us as very valuable. The crude notions of the older transcendental anatomists that the segments of the skull are modified vertebræ may be considered exploded. On the other hand, there is no doubt that the notochord does extend into the base of the skull, and we must admit a strong resemblance between the branchial and the visceral arches.
1 An Atlas of Human Anatomy. Illustrating most of the Ordinary Dissections and many not usually practiced by the Student, with an Explanatory Text. By RickmaX JOHN GODLEE, M. S., F. R. C. S. Philadelphia : Lindsay and Blakiston. 1878.
2 Elements of Comparative Anatomy. By Carl GEGENBAUER. Translated by F. Jer. FREY BELL, B. A. The translation revised and a preface written by E. Ray LANKESTER, M. A., F. R. S. London: Macmillan & Co. 1878.