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quent occurrence. Then Bernutz and Goupil turned the tide for some time by their able work, where they classed almost all pelvic inflammatory affections as peritonitic. They, however, greatly underrated the amount of connective tissue surrounding the cervix, just as Guerin has more recently written in the same strain as to the connective tissue of the generic endep broad liga- ments ; and Le Bee, too, has endeavored to buy cheap endep support the opinions of the latter by his observations on the lymphatic distribution of the broad liga- ment. There is now little doubt that Bernutz and Goupil pushed their views too far; so that in America, Germany, and Britain gynascologists now consider pelvic inflammation as either peritonitic or cellulitic. Clini- cal, anatomical, and pathological facts are each day putting this view on a firmer basis. The fact, however, that these diseases are not rapidly fatal> and that generally we get post-mortems only of advanced or resolved cases, along with the admitted difficulty of exact clinical differentiation, endep 25 mg renders our knowledge at present much less complete and exact than could be wished. Finally, we must note that both diseases are always combined. Thus, in a endep 10mg marked pelvic peritonitis there is always some pelvic cellulitis, and in a marked pelvic cellulitis always some pelvic peritonitis. This is quite analogous to what is found in pleurisy and pneumonia." The authors state that they have seen some cases that seem to bear out Dr. Noeggerath's views as endep 25 to the part played by "latent gonorrhoea" in the etiology of pelvic peritonitis. Regarding the frequency of the chronic form, they remark that it often remains as a sequel to the acute form, but may develop slowly of itself. Wc should say, order endep online rather, that in the vast ma- gQO REVIEWS AND LITERARY NOTES. jority of cases it arose in the latter way. It is indeed the insidious mode of onset of this affection that so often blinds the physician to its existence. Except when they cause purchase endep trouble by pressure, encysted serous collections occurring in the course of the disease should, endep tablets the authors think, be left to be absorbed, and, when adhesions are extensive, " the case is better left alone." The first of these precepts seems to us unquestionably sound ; the second might have been put in a form somewhat less absolute — it is not all treatment that is contra-indicated in such cases, but only harsh manipula- tion. The authors do not exaggerate the frequency of pelvic inflammation when they remark that "it is the rare exception to examine a female pelvis without finding some traces of a previous cellulitis or peritonitis." In re- gard to cellulitis, they do not believe that mere traumatism, " apart from septicity and tension," can cause an inflammatory attack. In the short but excellent chapter on hsematocele, the authors criticise the common statement that the effused blood naturally gravitates into endep 10 mg Douglas's pouch, maintaining that it lies there only because it has been effused near by, and does not make the pouch bulge downward, unless it has been poured endep 50mg out below adhesions that hem it in above. They point- edly add: "Blood has a speciflc gravity of 1'055, and remains where it has been effused ; yet effused blood is often spoken of as if it were lead, sinking down whenever it got out of the blood-vessels." Whatever its specific gravity may be, effused blood does sink, as can readily be seen by watching the course of a subcutaneous extravasation. It is stated endep 10 tablets that catarrhal salpingitis can not be diagnosticated during life. This we consider erroneous, at least as concerns cases in which the tube is distended. The following conclusions in regard to oophorectomy seem to us very judicious : " This operation is as yet on its trial. Gynaecologists have not buy endep yet settled the exact indications for it, nor the question as to whether it is always worth the risk. The mortality is high; . . . part of this is, of course, due to the worn-out state of many of the cases [? patients] operated on, and to the extensive adhesions present. Probably the mortality will diminish, although it must be kept in mind that operators have had the benefit of the previous advice and endep tablets 10mg experience of ovariotomists as to its results. We have already seen that its most brilliant successes have been got in fibroids ; its success in other cases has been moderate. When many adhesions exist, it is probably better not to attempt it. Some interesting physiological points have been brought out by it : removal of the ovaries does not bring on the menopause, sexual appetite is not diminished, and no womanly attributes arc in any way removed. The outcry that it un- sexes a woman is absurd. The ovaries removed were probably useless for procreation ; and, when their presence is causing serious bodily illness, they are better removed." Passing to the chapter on affections of the uterus, under the head of REVIEWS AND LITERARY NOTES. gQl amputation of the cervix, we find endep 10 buy endep online the ingenious hint to use a rubber um- brella-ring as a cervical tourniquet. We quote the following purchase endep online considerations in regard to the results of cervical lacerations : " Lacerations of the cervix in themselves produce no symptoms. Haemorrhage may arise at the time of production, but is not a order endep symptom of the persistence of the laceration." " Other pathological conditions arise secondarily as the result of the lacera- ' tion, of which the most important is cervical catarrh ; cicatricial tissue in the cleft may produce reflex nervous symptoms." " Pathological condi- tions are frequently present along with the laceration, as cellulitis and sub- involution. These have each their own train of symptoms. We are not endep 25mg yet in a position to say how these are endep 50 related to lacerations." The authors consider subinvolution of the uterus to be a form of chronic metritis. The term subinvolution, they remark, is etiological, and simply expresses one mode in which chronic metritis is produced ; adding that, apart from the history, it is impossible to diagnosticate between sub- involution and enlargement from chronic inflammation. To those who still cling to the stenosis theory of dysmenorrhoea we commend the following : " The flushing of any diseased tissue with blood causes an aggravation of pain, which is increased if the tissue be of a dense structure. The cause of the intense pain in periostitis as the affected limb becomes warm in bed is thus explained. Now, the tissues of the uterus are frequently in a state of chronic inflammation, and there is sometimes in- crease of connective tissue, making it of a less yielding structure ; this occurs in retroflexion complicated with subinvolution. The monthly flush-

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