It certainly seems marvellous that the ovaries, or tubes, or both, are, in the opinion of some operators, so frequently and so gravely diseased that extirpation is the only cure. Nature is sadly at fault if she gives woman organs essential for her sexual life that are thus subject to grave maladies that often before she reaches even the meridian of that life, those organs must be taken away; or else medicine is sadly deficient in curative means. There are too many hapless victims of this bold surgery, women who have lost their ovaries, for example, no better of pains and aches and nervous disorders than they were before being operated upon -in some instances, not only the ovaries removed, but a second operation done for the removal of the stump of the pedicle-to permit one to think oophorectomy has so large a field as some of its friends have given it. Many of the profession can remember when division of the cervix was, under the inspiration of Sir James Simpson, a frequent operation, but now it is rarely per formed. So, too, they well remember when extirpation of the clitoris was regarded by one of the ablest men in the London profession, and one of the most brilliant operators, the late Baker Brown, as a certain cure for various nervous disorders, but swift and terrible punishment from the profession fell upon him, and the operation by which he was so fascinated is now rarely done. I do not believe that removal of the uterine appendages will go the way of splitting the cervix or of clitoridectomy, yet the indications for it will be more distinctly defined, and more limited, than at present; some indications now accepted will be entirely rejected. The student of this work will adopt the conservative teaching of its author, and endeavor by medical means to cure some maladies of organs which, according to others, demand instant extirpation of the diseased structures, only resorting to radical treatment when these means fail and life or health is seriously imperilled; as cannon are spoken of as the ultima ratio regum, so ought removal of ovaries or tubes to be held by conservative men in the profession as the final resource.

The many illustrations, all of them new, and most of them remarkably good, add to the value of the work. Many diseases of the genital organs, not mentioned in our English text-books at least, are here described, and the classification given greatly facili

tates the study of all. While the author has omitted an account of genito-urinary fistula in the female, and the operations these lesions require, the omission is more than compensated by the chapters upon diseases of the mammæ, instruction thus given that will meet a more general want than that pertaining to the former.

No one can read and thoroughly study this volume without deriving not only much important practical information, but also finding his views of gynecology growing larger, and the superstructure resting upon a broader and firmer foundation,

As Americans, we may be justly proud of what our countrymen have done in promoting a knowledge of diseases of women. The four names, however, which, in virtue of original work, adding to therapeutical resources in the treatment of diseases of women, will probably shine with the most enduring lustre, are those of McDowell, Sims, Emmet and Battey. In 1809, McDowell, living in an obscure Kentucky village, first demonstrated the practicabilily of removing ovaries that had undergone cystic degeneration, and thus was the author of the greatest surgical beneficence of the century, and one of the grandest achievements of all the centuries. Nearly fifty years passed before Marion Sims, as the fruit of his brilliant genius and patient perseverance, demonstrated the curability of genito-urinary fistulæ in the female, and became the founder of the American school of gynecology. His work, too, was at least begun in a comparatively obscure part of the country, and distant from any of the great centres of population. Professor Winckel, as will be seen in a moment, gives him ample praise for his great accomplishment, and for the wide influence he exerted upon the progress of gynecology.

Emmet and Battey have made important additions to gynecological surgical therapeutics, but I refrain from special consideration of these additions.

Professor Winckel, in the introduction to his work, attributes the remarkable development of gynecology which has taken place in scarcely more than a generation, to a gradually growing surgical tendency, and in this connection makes the following statement: We are indebted to the American, Marion

Sims, more than to any one else, for a large part of our knowledge of, and progress in the treatment of diseases of women." He further says that, "it is worthy of remark that vesico-vaginal fistula excited the ambition of two such men as Sims and Simon, causing them to devote all their energies to the cure of these lesions which hitherto had been considered almost incurable. This operation demanded not only great patience and perseverance but, from the very nature of the case, led to improved methods of exposing the internal genital organs, drawing down the uterus, and the application of sutures to it, to the vagina and the bladder."

He finds other causes for its progress in the increased number of successful ovariotomies in England and Germany occurring soon after the advance by Sims and Simon, and in the value of the bimanual method of examination as pointed out by Holst. About this time the remarkable work of Sims, Clinical Notes on Uterine Surgery, appeared, a work which immediately acquired great popularity. In considering the causes of this remarkable popularity, he attributes it, apart from the many new facts which were described in the most original manner, to the very attractive history of the development of his ideas, the mistakes which he at first made, the means by which he reached the goal, and the many accidents which led him on to the accomplishment of his purposes. "Some, however, were so impressed by the various cases presented, the greatness of the material, and by his success, that they doubted the truth of his statements. But, whoever tested those statements, results and methods-and certainly all so did who had the opportunity-soon saw that nothing but the plain truth had been told, and were astonished at the numerous and careful observations and practical remarks made by Sims; the clearness with which he saw what was to be accomplished, and his certainty of method."

"Great men stamp upon their generation the impress of their minds. It does not, therefore, appear remarkable that two such eminent men as Sims and Simon, who, in fact, were surgeons giving special attention to diseases of the female sexual organs, exerted such an influence upon gynecological practice that the then prevalent conservative methods were replaced by a remark

able surgical tendency which rapidly became popular. The progress would, however, have been much less rapid had not Lister shown the value of antiseptics in surgery."

After referring to Battey's and Hegar's oöphorectomies, and to Freund's and Czerny's hysterectomies, Winckel remarks: "It now seemed that a safe and justifiable operation had been devised for all diseases of the female. Accounts of laparotomies and castrations appeared by the hundred, though in former years these operations had scarcely been attempted. But where there is much light there are also many dark shadows. The general adoption of Listerism in surgical gynecology caused laparotomy to be thought a panacea for all disorders of the female sex, and large ovarian tumors and uterine myomata are no longer the sole indications, but the operation has been proposed and done for ovaralgia, pelvic adhesions, and even for displacement of the uterus as retroflexion, prolapse and inversion. It may be further stated that whenever a woman has suffered for a considerable time from pelvic disorder, recourse is had to laparotomy if the ordinary gynecological treatment fails to give prompt relief. This statement is sustained by the report of operations performed by Tait, and presented to the London International Congress in London, in 1881. It is, in fact, performing experiments usually restricted to the lower animals upon a woman, and it is not strange that Tait so energetically opposes vivisection."

"The readiness with which laparotomy is now resorted to leads to errors in diagnosis. The careful and thorough examinations essential to a differential diagnosis becomes tiresome when one is able to have the tumor in hand and examine it after an abdominal incision."

Other judicious remarks follow, and then there is given a case which almost parallels that quoted from Wells: "What if one gynecologist examines a young girl, and declares that she has no abdominal tumor, but afterwards another makes an incision into the abdomen, and, though finding no tumor, proceeds to extirpate the ovaries because he sees a few small cysts upon them, and she is castrated? This is not a hypothetical case, for such operations have been frequently performed." He also states that so many are doing oophorectomies the mortality cannot

be known, because many unsuccessful cases are not reported; nor do we know the general therapeutic results, for like reason. There might be added to this source of error in arriving at the value of the operation, that which arises from the fact that some of the patients that have had their ovaries removed, do not continue to report their condition to the operators, who, honestly believing these patients cured, contribute the cases to statistics. The woman who has undergone oophorectomy and finds herself some mouths afterward as miserable as she was before the ovaries were removed, is not half so likely to consult the surgeon who operated upon her as she is some other practitioner. I feel confident that there may be errors resulting from this cause, in some statistics.

That which Winckel terms the operative tendency characteristic of recent gynecology, has, in this country, especially been manifested in the frequent performance of Emmet's operation for lacerated cervix. A Dublin gynecologist not long ago remarked that," the Americans had gone wild" in regard to it. This is doubtless an extravagant assertion; but it must be confessed that cervico-plasty has been frequently done when there was no necessity for it, and that many women have escaped the operation only by consulting another physician after examination by one of the blind enthusiasts who readily find in nine out of ten, if not nineteen out of twenty parous women, one or more tears of the cervix, and at once declare an operation should be done. There never was more need than at present, both in regard to these lesions of the cervix in women who have borne children, lesions which in almost all cases are physiological, not pathological, and in regard to certain affections of the tubes and ovaries, of the injunction, Take care, or you will find what you are looking for!

Professor Winckel confidently asserts that conservatism is gaining, and that there is reason to hope that extirpation will no longer be considered the only curative means for anomalies of important organs. "It is a mistake, arising from a failure to comprehend the essential nature of the disease, to perform operations upon the female genital organs not indicated by any local condition, for the cure of hysteria; castration, amputation of the clito