tion very obscure: that is, in cases in which there is a diffuse, slightly movable mass felt at the side of the uterus, without any fluctuation. I have removed several such enlarged Fallopian tubes with enormously hypertrophied muscular walls, but without dilatation of the canal, which was even constricted. Prof. Kaltenbach, formerly of Freiburg, is, so far as I know, the only operator who has recently spoken of this muscular hypertrophy of the tube, which he believes to be produced by atresia or stenosis of the tube, the obliteration occurring chiefly at the abdominal orifice. Bimanual palpation revealed a diffuse tender swelling to the side of the uterus, which formerly would have been taken for a pelvic cellulitis in cases of doubtful diagnosis. Some of these patients complain of constant pain, and require to be operated upon. This is the only way of curing them. Others have pain only during menstruation, and not during the interval. In these latter cases we should first try other measures than operative, and I have succeeded in relieving some such cases by persistent counter-irritation and galvanism. While I feel that nothing will cure any of these cases but laparotomy, I still think we should choose our operative cases more carefully than the teachings of Mr. Tait would lead us to do."

THE PRESIDENT, DR. A. VANDER VEER, of Albany, N. Y., wished to make one or two explanations; one in his own behalf. Some time after the meeting of the Society last winter, while looking over his manuscript as it came from the printers, he was somewhat startled at that very statement which Mr. Tait caught up so quickly. He said to himself, "It is possible I have made a mistake. It may be that Mr. Tait had examined these patients previously to my seeing them with him, or previous to the time of operating, and that I erred. I felt in that state of mind for some time. It occurred to me to write to Mr. Tait for a paper, and I find now that I had not erred entirely; that he does not take so much time for his examinations as other surgeons. Now, I believe with him that the reason why he does not make fatal blunders in diagnosis, and the reason why he is so successful is the fact of his experience. He devotes his entire time to this particular subject of abdominal surgery. I occupy the ground as a general surgeon with a strong tendency to abdominal surgery. Whether I shall remain in that field, I do not know. I like it much. But we do not get the cases which Mr. Tait does. He receives cases every day from all regions. Physicians send their cases to him. He has a larger range, perhaps, than any other man in the world. He has but one competitor in Birmingham, Dr. Savage, who is a good man, doing clean work. While Mr. Tait may make use of strong expressions, at the same time I do not think they are rash expressions. I believe that he has authority to back him up in the experience which has accumulated in his hands.

I do not believe that the profession in this country, nor in England, fully appreciate yet what the Tait operation is. I have a case in mind to illustrate that. Mr. Tait believes that if the ovary or any portion of the tube is diseased, the entire appendages should be removed. If there be a pyo-salpinx, or a hydro-salpinx, or an inflammation of any portion of the tube, remove the entire appendage.

I have now under treatment a patient operated upon by Dr. Thomas some ten years ago, reported in the New York Medical Journal as a case of ovariosomy. The patient was relieved for

some time, but for four or five years she has been suffering from well marked pyo-salpinx, the discharge of pus now taking place oocasionally through the uterus into the vagina. Now if in this

case there had been removal of every portion of the tube, I am inclined to think there would not have been this return of the trouble.

It seems to me that Dr. Mundé is quite right in his criticism of Mr. Tait regarding the position for examination. I do not believe one can make as good and thorough an examination with the patient lying upon her side as upon her back. Dr. Mundé's statements in regard to Dr. Wylie's views concerning cellulitis, salpingitis, etc., it seems to me are very much in the right direction. In looking over my notes of cases and autopsies made some years ago, I can recall two cases of well-marked pyo-salpinx and one of hydro-salpinx, in which death took place from discharge into the peritoneal cavity, and in the light of the present day I cannot help thinking that they were cases proper for an operation, and in the hands of Mr. Tait, life might have been saved.

Dr. Wylie's very valuable suggestions show that he has gone over this field thoroughly. How utterly useless for a patient to wear a pessary when there is associated salpingitis! The case in which Dr. Wylie thought of operating in the midst of an attack of peritonitis, but did not reach the patient in time, belonged to that class of cases which Mr. Tait lays a great deal of stress upon. I really think he would operate upon a patient with acute peritonitis, even if she were almost dead, his faith is so great.

With regard to sponging out the abdominal cavity, Mr. Tait lays a great deal of stress upon this point. He takes warm water and sponges out the peritoneal cavity thoroughly. His success must be acknowledged, for look at his one hundred and thirteen consecutive cases of ovariotomy without a death. This must be due to cleanliness, to the care he takes, to the fact that he operates in a special hospital. I am inclined to think that we general surgeons must, if we work in this field, take hold of it as a special work. i cannot believe that doing ovariotomy around at different houses will ever meet with much success.

Mr. Tait operates in his own hospital, keeps his patients under his own observation, under his own hands, watching them with much care, and exercising the greatest cleanliness. Under these circumstances, and with his experience, he is entitled to credit.

DR. WILLIAM HAILES, JR., of Albany, said he recently made a post-mortem examination and found a condition which he would like to have some of the gentlemen present throw some light upon. The body was that of a woman 28 years of age, well nourished, weighing in the neighborhood of two hundred pounds. The abdominal walls were very thick, and their contour gave no evidence at all of any tumor within. But when the pelvic viscera were examined it was found that there was ovarian disease on both sides. The left ovary had a multilocular cyst about the size of a lemon. The right ovary had undergone cystic degeneration, one of the cysts being much larger than the rest, with transparent and exceedingly thin walls, which burst when the hand was passed gently over it in an attempt to reach the pedicle. He felt quite sure that, if this woman had during life met with any injury, as a light fall, this cyst would have burst, and he would like to ask what would have been the result of such an accident.

DR. WYLIE, in closing the discussion, said: I am sorry that some

of the general surgeons present did not speak, for we are in need of their experience to help us. I will leave my paper to answer most of the remarks made upon it. I think that any one who is operating or expects to operate should make a careful study of the anatomy of these parts. With the exception of three or four, all of the cases I have related gave a history of peritonitis, and evidence of the same was found at the operation, yet not in a single instance did I fail to get both ovaries and tubes. So I am not in fear of adhesions which have formed in that way. If you go about the operation as I have stated, unfolding the tubes, you can overcome the adhesions. This is the reason why I find it necessary to make only a small opening, and I believe that a small abdominal opening is one cause of Mr. Tait's success.

As to pelvic abscess, in three of these cases there was pelvic abscess as distinctly as could be, for they were as low down in the pelvis as possible without going through the vagina. In one case the symptoms were so slight that the patient was going about constantly, yet I believe that, if the operation had been postponed until after the next menstruation, she would have died of general peritonitis.

Dr. Hailes has mentioned an autopsy at which he found an ovarian cyst with transparent and exceedingly thin walls, and expresses the opinion that a slight jar would have caused it to burst during life. I am confident that it would have so burst, for I have known a cyst to rupture in more than one case from pressure through the vagina. The result was not injurious. Only a slight local peritonitis is caused, and with such thin fluid it is hardly worth while to wash out the peritoneal cavity.

DR. W. B. CHASE, of Brooklyn, asked concerning the connection there might be between gonorrhea and disease of the Fallopian tubes.

DR. WYLIE replied that this was a very broad question, and could not be fully discussed here, but he would say that he thought many cases of pyo-salpinx were undoubtedly due to a septic endometritis especially liable to follow abortions; but that gonorrhea is sometimes a cause there is no doubt. He did not think, however, that it is so frequently the cause as has been claimed by Dr. Noeggerath, of New York."

REVIEW.

PUERPERAL CONVALESCENCE AND THE DISEASES OF THE PUERPERAL PERIOD. BY JOSEPH KUCHER, M.D. New York: J. H. Vail & Co., 1886. Pp. 311.

To many readers this unassuming little volume will possess a significance greater than would be inferred from its modest title-page. It will be specially interesting to those who are personally acquainted with the author, and know him to be a foreigner who has adapted himself to our American ways with a grace and rapidity seldom exhibited by his professional countrymen who cast in their lot with us. We are glad to welcome Dr. Kucher's book as an exposition of that school of midwifery that has exerted such a deep and invaluable impression upon the rising generation of obstetricians. In turning over its pages, visions of the old

familiar "Kreisesaal" rise before us, the row of students zealously scrubbing their fingers at the mandate, "desinficiren, meine Herren!" the eager group clustering around some interesting case, the anxious look of the embryonic obstetrician as he reaches the object of his ambition and grasps the forceps for the first time, overwhelmed by the mighty responsibility of introducing the proper blade first and sparing the perineum. Restraining our errant imagination and confining ourselves to the sober facts, we are struck with a certain unique feature in the work before us. It is thoroughly German, and yet it is not German. The author is firmly imbued with the idea that Vienna midwifery is "hard to beat" (and he is right), while at the same time he has not fallen into the error so common to German physicians, of stubbornly refusing to adapt themselves to their American environment. If, as a class, they would only recognize and appreciate the fact that they are themselves to blame for our apparently cold reception of many of their ideas, because of the ungracious manner in which they seek to force them upon us, their influence upon our profession would be far more decided than it is. The Germans cannot accuse us of undervaluing their intellectual power; the only trouble is, that the average American objects to being told bluntly that he is a fool (even when he knows it). Administer that truth in a sugar-coated form and he will swallow it readily enough. This digression may be allowed when we state that it is explanatory of our opening sentence that Dr. Kucher's book is significant in that it presents German ideas in such an American form, that it goes far to disprove the wide-spread belief that no German can ever become Americanized. One fact is apparent at a glance, even if the author had not called attention to it in a rather lengthy preface. The book is written by a practical man for practical men. Familiar as most of the subject-matter is, it is not the compilation of a beginner. Any one with but a tithe of the writer's experience might have written the same volume, but the reader would not have failed to recognize the absence of that personal knowledge which alone entitles an author's words to respect. With a rare self-restraint in one of his nation, Dr. Kucher has avoided those long and rambling discussions which mar so many otherwise excellent German treatises, and has omitted the copious references to foreign literature that so appall the general reader. What he says, he knows; what he describes, he has seen. His pictures of disease are not those of the novelist; he has, to use a vulgar but expressive phrase, “been there." Uneven and condensed as many chapters appear, the general impression conveyed by a reading of the book is that the author had material enough for a work far more ambitious, but wisely preferred to say too little rather than too much, keeping back a large amount of reserve force for another occasion. Having acknowledged frankly our approval of the purpose and general scope of the book, we feel at liberty to be equally frank in our criticisin of some of its weak points.

Before examining each chapter in detail, we cannot escape the impression that the arrangement of the subject-matter is not pleasing. Not that it is wanting in system, but the system is faulty. From the title we assume that the volume consists of two main divisions, the first being devoted to the normal puerperal state, the second to the abnormal. It would have been well, in the interests of the general reader, to make this distinction more clear by stating that the second portion begins with chapter V.

And then the term "diseases"--what is included under it? From the table of contents we see that the list begins with simple abscess of the breast, goes on to post-partum hemorrhage, skips back to thrombus of the vagina and vulva, then advances to those formidable complications, rupture and inversion of the uterus; then succeed albuminuria, eclampsia and phlegmasia alba. We are next, by a sudden transition, introduced to the subject of relaxation of the symphysis pubis, followed by tetanus, puerperal mania, sensory motor disturbances, embolism, and, as a grande finale, puerperal fever the last, we may add, being practically a separate monograph. Now, we leave it to the impartial reader if this order is not a singularly original one, and the sequence rather difficult to trace. Every author has a right to designate the order in which his chapters shall come, but the general effect in the present instance would certainly be more effective if the "diseases' and "accidents" (for is rupture of the uterus properly a "disease?") were grouped together. The transitions would certainly be less abrupt than they are under the present arrangement.

As before stated, the first four chapters, or rather the second, third, and fourth, treat of normal childbed and its management. Chapter I. contains some sensible remarks on antiseptics, which are distinguished by an absence of those extravagant statements that are so frequently made by enthusiastic supporters of this or that germicide. There are not a few homely aphorisms which will bear quotation. "To dip the fingers or instruments in some antiseptic fluid is not sufficient, if a thorough cleansing with soap and water has not preceded the use of antiseptic lotions" (page 21). "Long finger-nails are as useful for an obstetrician as sand in the shoes; the sooner we get rid of both, the better” (page 22). Chapter II., on "Normal Childbed," is divided into a number of sub-headings, under which the author discusses briefly the condition of the uterus immediately after labor, retention of urine, the pulse and temperature, after-pains, the lochia, diet and the care of the bowels. It is unnecessary to refer to these sections in detail, since the reader will not find in them much that is new. The remarks on the contraction of the uterus after delivery are essentially the tenets of the Vienna school. "The main reliance,' says the author, "is placed on external manipulations." Ergot is unreliable. We commend the views concerning the doubtful value of the binder after delivery. "Good involution of the abdominal walls by the recumbent position and good nourishment," in Dr. Kucher's opinion, contribute more to the preservation of figure than a binder can ” (page 23). He rightly believes that the only service rendered by this traditional appliance is to support the lax abdomen, while it very often does positive harm to the patient by crowding her uterus into the hollow of the sacrum.

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In the chapter on "Lactation " there is a brief discussion of the subject of milk-fever, a febrile condition which is characterized as a bug-bear," that has "lost all its terrors now." The elevation of temperature is readily explained, the writer thinks, by septic absorption from the genital tract, intestinal disorders, or mental excitement. Chapter V., on Mastitis," is excellent. The author's remarks on treatment are marked by that prompt, decisive tone which show that when he believes that the knife is necessary he does not use it with a timid hand. Conservative up to a certain point, his teaching with regard to surgical interférence is not wavering.