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for digestive purposes, and tonic remedies such as iron, strychnia, and arsenic.

On the other hand, if the congestive troubles can be checked, and a temporary hydraulic equilibrium has been attained, the time has come to train up the heart, and to encourage development of cardiac power by carefully graduated exercise. The chief precautions to be observed are these :-(1) not to attempt it until circulatory equilibrium has been established for the patient in a state of rest; (2) to be moderate in the first instance; (3) to be increased gradually and with care; and (4) always to stop short of fatigue; moderate palpitation and oppression of breathing on beginning the treatment need not be seriously regarded; but any tendency to syncope or cardiac irregularity constitute distinct contra-indication.

CORRECTION.

[Dr. Stacey Wilson desires to correct a statement in his paper on " Dilution of the Blood" in the September issue of the Review. He is informed that the method of treating diarrhoea in children by means of iced water enemata was in use in the out-patient practice of the General Hospital for several years prior to the date of its introduction as mentioned in the paper, having been adopted by Dr. Saundby shortly after its origination by Professor C. A. Ewald of Berlin.]

REVIEWS.

ON GONORRHOEAL INFECTION IN WOMEN.* THIS is a most able and interesting book, eminently readable and conveying in concise and well-chosen manner, an exhaustive account of all the chief modern work on the subject of gonorrhoea.

* On Gonorrhoeal Infection in Women. By William Japp Sinclair, M.A., M.D. London: H. K. Lewis, 136, Gower Street, W.C. 1888.

While the author plainly avows himself a disciple of Noeggerrath and Neisser, accepting in the main the theory of the former as regards latent gonorrhoea, and the conclusions of the latter regarding the gonococcus, the book is written in no partisan spirit. The whole modern literature of the subject is fairly taken into consideration and, with commendable scientific impartiality, not a little has been reviewed which may tell against some of the conclusions to which the author arrives. These are not definitely tabulated, but we think the reader may be justified in assuming that the following propositions contain the main doctrines accepted by the author.

I. That gonorrhoea arises from the gonococcus-" without the gonococcus-no gonorrhoea; without gonorrhoea-no gonococcus." (p. 69).

2. That gonorrhoea in the female is exceedingly apt to cause pelvic inflammation of a special type, "recurrent perimetritis."

3. That in most men, after an attack of gonorrhoea, a latent form persists, due to imperfect cure, although no gonococci may be found. (According to Noeggerrath, who is the author of this view, gonorrhoea is a life-disease and is never cured.*)

4. That a chronic or creeping form of gonorrhoea exists in women, due to infection from a "latent" gonorrhoeal sourcethat the symptoms of this are leucorrhoea, dysmenorrhoea, menorrhagia, and vague pelvic pains and indurations, varying from doubtfully abnormal conditions up to chronic pyo-salpinx.

Now it will be evident to anyone who candidly examines these propositions that the questions involved in 3 and 4 have. no special bearing on those in 1 and 2. Not only so, but the acceptance of all may most naturally and reasonably be held to involve a contradiction or inconsistency. For if there is no gonorrhoea without the gonococcus, how can there be the grave danger involved in latent forms where no gonococcus can be found? We consequently find the author and those writers who agree with him reduced to the necessity of forming the *This opinion is stated to have undergone some modification and change. (p. 41.)

following hypotheses to account for the reasonableness of such a dual belief.

(a) That a few rare and "decrepid" gonococci are started into vigour by post-nuptial excess (p. 95).

(6) That though the gonococcus has gone and can nowhere be found, some spores, as granules or débris, are left as permanent causes of contagion (p. 98).

Probably everyone will assent to the actively contagious nature of gonorrhoea, and, in women, to the damage it involves of acute endometritis, acute pyosalpinx, and recurrent peritonitis, with chronic inflammatory disease of the uterine appendages. But it is by no means certain that the sources of contagion (whether "gonococcus" or not) has not a life and death history in the human organism, and that although the adhesions consequent on repeated attacks of limited peritonitis may possibly persist throughout life, the infective gonorrhoea may after a time become perfectly cured.

Both the arguments and evidence in favour of this view are quite as strong at present as those which can be brought forward in favour of the opposite view. The cases cited by Dr. Sinclair and others as examples of chronic and creeping and persistent forms of gonorrhoea are by no means conclusive, and much more investigation is needed before these later developments of doctrine can be generally accepted. That in the study of so widespread a disease as gonorrhoea there may be a decided danger of forming hasty and extravagant conclusions, is occasionally shown in some passages from the work before us. On page 79 we read :-"The question arises whether the cases of isolated tubal tuberculosis are not due to an old tubal gonorrhoea." Tubal tuberculosis has been found in the virgin, as also pyosalpinx The inflammatory condition of the uterine appendages have been found as a consequence of the infective diseases of scarlatina and smallpox, and it would be grossly unjust if patients of these classes were indiscriminately set down as the victims of some form of gonorrhoeal disease.

It must not, however, be supposed that the intention of the

present writer is to minimise the dangers of gonorrhoea in women. If the Fallopian tubes are thoroughly attacked by the disease there can be no doubt that the prognosis is grave, and the results of the disease in many cases incurable except by operation. But in these cases, if the facts were fully known, there is probably always a clear and indubitable history of direct contagion. One possible source of fallacy in the investigation of the subject of gonorrhoea lies in the assumption that after marriage the husband and wife have lived a strictly moral life whatever their antecedents may have been.

Unfortunately this is far from being correct. A man who has had repeated attacks of gonorrhoea may, subsequent to marriage, expose himself to contagion and, at the close of a very transient attack of three or four days duration, may infect his wife. Is he questioned on the subject? He may confess to an acute attack a year or so before his marriage, but not to his recent transgression. On the other hand, there is abundant evidence similar to that collected by Dr. Thorburn (and referred to on page 45), that a man may contract a gonorrhoea, may recover from this, and, provided he leads a virtuous life, his subsequent marriage may be healthy, happy, and fruitful.

If this be true, the cure of gonorrhoea becomes of the more rather than of the less importance. Instead of the vague and hopeless ideas involved in the belief of its latency and incurability—ideas which tend to paralyse all but operative action-earnest enquiries will be made into the relative value of the gonococcus and the "débris," into overlooked sources of contagion, into best methods of treatment, and into the several indications of recovery.

These are likely to be fruitful in good results. The author's views on the subject of treatment are given in chap. vi., and his method of uterine injection or irrigation may be worthy of trial in suitable cases. As he recognises (on p. 157), it is dangerous in cases where the disease has spread beyond the

uterus.

Considering the exhaustive character of the work it is rather surprising that the only reference to gonorrheal rheumatism is on page 53.

A thorough investigation of the phenomena involved in this complaint and the character of the fluid effused into the joints would probably be more likely than anything else to clear up the doubtful points regarding latency and chronicity.

ON THE TREATMENT OF RUPTURE OF THE
FEMALE PERINEUM.*

DR. Bantock has published a second edition of his work on the treatment of rupture of the perineum. The main substance of the book having been written ten years ago is rather out of touch with modern thought. The scientific world moves apace, and to read of the "quilled suture" from a controversial point of view is almost like listening to an argument for steam locomotion or Free Trade. In the description of the " remote operation, which is supposed to be fully brought up to date, we cannot but think that Dr. Bantock would have done better to have had totally fresh illustrations. Anyone following religiously the directions according to fig. 9 might perhaps succeed in making a linear bridge between the rectum and vagina, but could hardly hope to effect the restoration of anything like a normal perineum. Dr. Bantock describes in his text a flapsplitting operation; his illustrations are for a denuding operation. The result is not quite satisfactory. And if, as appears from recent correspondence, the merit of the idea of flap-splitting belongs to the late Mr. Maurice H. Collis, and its adaptation to perineal operations to Mr. Tait, some recognition of these things might naturally have been expected.

There is a vast amount of literature, both European and American, on the subject of perineal laceration and its cure. We are afraid that the whole of it is not of very great value. The operative treatment cannot be satisfactorily taught either by text or illustration; at all events no one up to the present has succeeded in making the subject clear and intelligible for all

*On the Treatment of Rupture of the Female Perineum. By George Granville Bantock, M.D., F.R.C.S., Edin. Second edition. London: .H. K. Lewis, 136, Gower Street, W.C., 1888.

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