hours. Patients who pass habitually a greatly diminished quantity of urinary solids daily, say, for example, 30 to 50 per cent., are patients who are suffering from veritable uræmic poisoning. It is simply astonishing to see how common renal insufficiency is in most gynecological cases. When patients are passing only about 400 grains of urinary solids a day we will find them presenting various degrees of nervous irritability. When the amount is lessened, say to about 300 grains per day, we find this nervous irritability manifested in various urgent ways. When the solids are diminished still further, say to 200 grains per day, we find the invasion of the nervous system so grave as to demand our most solicitous attention. And with the amount still further diminished, say to 100 grains per day, we will find our patients dangerously near to the verge of uræmic convulsions or coma, the condition which we often find in the last stages of gestation.

I never consider a gynecological patient thoroughly examined unless I estimate the amount of urinary solids that she voids daily. I think the determining of the possible presence of renal insufficiency is oftentimes of more importance than that of metritis or of menstrual derangement, for the simple reason that many pelvic derangements run back in this causation, or at least in their perpetuation, to renal insufficiency.

It is a very easy matter to calculate the amount of solids passed daily. The simplest formula is to multiply the last two figures of the specific gravity of the voided urine by the number of ounces of urine passed in twenty-four hours and that product by 1. We can thus calculate the number of grains of urinary solids passed in twenty-four hours. Women will weigh anywhere from 90 to 180 pounds, and they will pass from 500 to 1100 grains of urinary solids per day. A woman falling below 20 per cent. of what she ought to pass of urinary solids may be said to be suffering from renal insufficiency. In gynecological work the patients suffering from renal insufficiency are wonderfully benefited by the stimulating diuretics. I have learned to connect, in many cases, amenorrhoea in girls and young women with renal insufficiency. I have seen cases in which the use of stimulating diuretics were the only remedies used to relieve this form of amenorrhoea. One patient may serve as an illustration of this class. An unmarried woman of twenty, who had menstruated five times the previous year, presented the condition of renal insufficiency, with a diminished amount of about 50 per cent. of urinary solids. She suffered also from impacted colon. Colonic flushings were repeated several times, and the stimulating diuretic in the course of thirty days increased her urinary solids to 1300 grains. She ought to have passed 900 grains normally; she was passing only 428 when I first saw her. The diuretic was continued for a period of three months. She menstruated regularly for the next nine months, when the renal insufficiency supervened again and the lapsed menstrua

tion again came on. For the last three years she has been able to watch the condition of the kidneys, and when she has increased the amount of urinary solids her menses have appeared with great regularity.

It is a well-known fact that the kidneys, ovaries, and tubes spring from the same source embryologically. It is also a well-known fact that patients who suffer from organic disease of the kidneys suffer from irregular menstruation. The article on the relation between the kidney and menstruation is yet to be written. The remedies best suited to the treatment of this disorder are few, comparatively. The foremost remedy that I know of is the old-fashioned combination of digitalis and acetate of potassium. The salts of lithia are also extremely useful.

In the foregoing examination of subjects for the consideration of gynecologists, one can but be impressed with the paucity of suggestions. I have been impelled to the consideration of this subject by the fact that so little attention is paid to the subject of general medical treatment of this class of patients. It is a lamentable fact that so many young physicians, upon graduating, are too much inclined to drift into specialties; and the gynecologist who is unable to get outside of the pelvis in the consideration of the disorders of women is greatly to be pitied.

REVIEW S.

A MANUAL OF OPERATIVE SURGERY. BY FREDERICK TREVES, F.R.C.S., Surgeon to and Lecturer on Anatomy at the London Hospital. Two octavo volumes containing 1550 pages, with 422 engravings. Cloth, $9; leather, $11. Philadelphia: Lea Brothers & Co., 1891.

MR. TREVES has produced a book which will assuredly add to his well-established reputation, and cannot fail to be of great assistance to operating surgeons. It is written entirely from the standpoint of the operator, but little space being given to historical detail or to the varying indications in particular cases for or against operative interference. Statistical matter, which is now undergoing such rapid changes, has been largely omitted. The measures which appear to the author to be the best having been selected, such methods as are especially advocated by individual surgeons, or which have been largely or exclusively employed by them, have been described so far as possible in the language of these surgeons themselves.

The author remarks in the preface that the majority of the descriptions are founded upon personal experience in the operating-theatre and upon repeated operations upon the dead, and a careful perusal of the book shows that this statement is amply justified.

The first part, on the General Principles or Elements of Operative Surgery, is an excellent example of the evident care with which the book has been written. Attention is called at the start to the fact that no operation is without risk, and that it is the duty of the surgeon to estimate the proportion between the danger incurred by the operation, on the one hand, and by the disease if left untreated, on the other.

His remarks apply to all those operations for the removal of trifling blemishes, real or imaginary, in regard to which surgeons are so frequently consulted, especially by young women. The writer has known of one instance in which the operation for removal of a small exostosis of the lower end of the femur, after having been declined by two surgeons-the growth having produced absolutely no symptoms-was undertaken by a third with a fatal result. Mr. Treves mentions a similar case in which the operation for removal of such an exostosis led to suppuration of the knee and final ankylosis of the joint. There are also local risks in these operations de complaisance which are taken into consideration.

In endeavoring to estimate the risks involved by operation so far as the patient is concerned, Mr. Treves considers the following factors: 1. Age. 2. Sex. 3. Strength. 4. Obesity and plethora. 5. Alcoholism. 6. Serofula and tuberculosis. 7. Other constitutional conditions. He believes that the results of all operations are more powerfully influenced by disease of the kidneys than by corresponding disease of any other

organ.

The preparation of the patient is described with great care, and a chapter is devoted to what might have been called the "Preparation of the Operator." This occupies only a few pages, but is admirable in the sound common sense of its teachings, and in the terse, concise, almost epigrammatic language in which they are conveyed: "A shakiness of the hand may be some bar to an operation, but he of a shaky mind is hopeless." "In the handling of a sharp instrument in connection with the human body a confusion of the intellect is worse than chorea." Mr. Treves insists that as the full use of the larger muscles as developed by vigorous athletic exercise adds distinctly to the steadiness of the hand, "an operator should be most careful of his general muscular development."

The operating-room, the instruments, and all the details of making a wound, of the arrest of bleeding, and of closing and draining the wound, meet with the fullest attention.

The circumstances in which drainage is necessary and those in which it may be dispensed with are described in a number of concise paragraphs, as are also those relating to the local conditions which influence primary healing. The dressing which Mr. Treves prefers consists of sponges dusted with iodoform and held in place by absorbent wool and a bandage applied so as to make firm pressure upon the wound.

He also uses Tillman's dressing-linen, which he considers admirable on account of its softness, compressibility, and power of absorption, and of the quality of not sticking to the wound. He advises that, whenever possible, the wounded part should be kept in the open air. This applies particularly to operations upon the lower limbs, as he believes that the atmosphere under bed-clothes, which is hot, moist, and frequently foul, is, on antiseptic principles, the worst possible for the wound if it accidentally gains access to it. It is proper to add that the writer has seen a series of cases in Mr. Treves's wards in the London Hospital treated by his methods in which the results certainly justified his confidence in them, union by first intention being the almost invariable rule.

In the section on the Ligature of Arteries, to which about 100 pages are devoted, it is apparent in every sentence that the teaching is the result of long experience, and that the descriptions have been done at the side of the body. The surgical anatomy is, as might have been expected, exceedingly good. The diagrams are well chosen, and the descriptions are concise and clear. Particular attention has been paid to the attitude of the operator, the side of the patient's body upon which he should stand, etc., and the after-treatment is given in more detail than in most articles upon this subject. The operation for ligation of the lingual artery affords an excellent example of the care and attention to minutia which characterize all this part of the work. We note as of peculiar value the direction to pass a small blunt hook around the digastric tendon where it is nearest to the hyoid bone and to have it drawn forward and toward the surface by an assistant. This obviously simplifies the whole operation, which is usually one of the bugbears of students in the operating room and not infrequently of the surgeon himself. A single trial of this method is convincing of the fact that the area of operation is thus brought into better view and increased in extent, the parts well fixed, and the hyoglossus muscle easily recognized and attacked.

Ligature of the common iliac artery is recommended by the intraperitoneal method through a median abdominal incision, after the plan

which has been already employed by several operators in securing the internal iliac. The great objection that some few years ago would have been urged against the procedure-namely, the risk of acute peritonitis -may now be almost disregarded.

In the chapter on Nerves we note that in the removal of Meckel's ganglion Mr. Treves employs a chisel and mallet to cut away the anterior wall of the antrum, believing that, as compared with the trephine, the chisel is the more convenient and precise instrument and inflicts a less degree of injury upon the surrounding tissues. The operation of Mr. Rose for removal of the Gasserian ganglion is fully described, together with two cases in which that operation has been performed. As the latter of the two was not published until February, 1891, it af fords evidence of the care with which the book has been brought to date. The section on Amputations begins with a concise history of the operation of amputation, which is followed by a long account of the treatment of the stump. As the success of any amputation is to be measured, not by the rapidity or proficiency with which the operation is performed, but rather by the mortality attending the procedure and by the qualities of the resulting stump, it is evident that the importance of this subject has not been over-estimated by Mr. Treves. The future of the stump after each amputation also receives careful consideration, and the section which treats of it is among the most useful portions of the book. The subjects of the position of the scar, the securing of a good blood-supply, the providing of a reliable and permanent covering for the bone, the least sacrifice of healthy tissues, etc., are all considered preliminary to the description of special methods, as are also general points, such as handling the knife, the temporary and permanent arrest of hemorrhage, etc. The plan which has been followed by the author includes a description of all the best methods of each amputation, followed by indications for choice among them. He is opposed to transfixion at all times.

Among special amputations the section devoted to the amputation of fingers, with the surgical anatomy thereof, that of amputation of the metacarpus, and those on amputation of the toes and foot may be specially mentioned, although the descriptions are all so excellently done that there is but little room for choice. In the forearm the circular method is recommended for the lower third of the limb and that by equal antero-posterior flaps for the upper two-thirds. At the elbowjoint the operation by anterior ellipse (Farabeuf) is very properly preferred, provided, of course, that the tissues upon the flexor side of the limb are sound. In amputation of the arm the general surgical rule that the least possible amount of the limb should always be removed in all amputations is especially emphasized. Even the short stump left after the bone is sawn through at the surgical neck is better than that remaining after disarticulation at the shoulder joint.

The osteoplastic resection of the foot is thought to be still on trial, the author believing that its supporters probably lay too much stress on the importance of preserving every possible scrap of the foot. In the lower third of the leg the large posterior flap is to be preferred, and at the middle of the leg a similar flap made by one of two different methods is recommended.

The section on Diseases of the Bones and Joints includes all the most important excisions, those involving the superior maxilla being very fully treated, while the descriptions of the various methods for removal