to the student an aid towards correct diagnosis of the conditions with which he will most frequently be brought in contact. EGBERT H. GRANDIN. BERICHTE UND ARBEITEN, ETC.-CONTRIBUTIONS AND RESEARCHES FROM THE OBSTETRICAL AND GYNECOLOGICAL CLINIC AT GIESSEN, 1881-1882. By F. AHLFELD, with Contributions by F. MARCHAND. Leipzig: Fr. Wilh. Grunow, 1883. The custom of this indefatigable writer of reporting within a single volume the nature and amount of the clinical material which passes under his observation, together with critical commentaries, of greater or less length, on rare cases and methods of management, is one which might well be emulated by those of us in America, who, being in charge of obstetrical and gynecological services, necessarily possess a vast material from which to deduce points of value to the less fortunate majority of medical men. As it is, largely as a result of the haste which is typical of life here, many a rare case goes to waste, and many an observation of value is never committed to paper. Even a casual glance suffices to prove the worth of the present volume, the material of which is drawn from a close study of three hundred and fifty-two obstetrical cases, and five hundred and ninety-three gynecological. The mortality in the obstetrical clinic during the period considered was only four cases, and in two of these cases there was infection before labor. This is an excellent showing for a maternity clinic which is utilized, as ali such should be, for purposes of instruction. Of the special obstetrical topics treated of in this volume we would note: An article on the Diagnosis of Pregnancy-especially with reference to the value of Palpation in the determination of the Fetal Attitude. A contribution to the Physiology and Management of Normal Labor; a contribution to the Pathology of the Puerperium, in which are outlined Ahlfeld's views in regard to sepsis and its treatment-views to which we have, in connection with another volume by this author, referred at length. Articles by Professor Marchand, relating to certain congenital defects in the fetus, defect in ventricular septum, transposition of aorta and pulmonary artery without septum defect, etc. The gynecological clinic was rich in operative material. We instance only a laparotomy for removal of a sarcomatous tumor, laparotomy for cancer of uterine body, two vaginal hysterectomies for cancer; extirpation of a carcinoma clitoridis. In connection with the treatment of cancer of the uterus, we find that once the attempt was made to diminish the size of the uterus through ligature of its lateral arteries. The attempt failed, the patient dying of peritonitis. Ahlfeld expresses his belief in the justifiability of vaginal hysterectomy for carcinoma. As a concise record of clinical observations emanating from skilful observers, this volume must commend itself to all. EGBERT H. GRANDIN. BERICHTE UND ARBEITEN AUS DER GEBURTSHILFLICH-GYNÆKOLOGISCHEN KLINIK ZU MARBURG.--REPORTS AND CONTRIBUTIONS FROM THE OBSTETRICAL AND GYNECOLOGICAL CLINIC AT MARBURG. By F. AHLFELD. Second Volume. Leipzig: Fr. Wilh. Grunow, 1885. The contents of this volume consist in an analysis of the material admitted into the Marburg hospital from April, 1883, to De 99 66 66 cember, 1884, followed by special contributions on The Anatomy and Physiology of Pregnancy," "The Physiology and Management of Normal Labor," "The Pathology of Pregnancy and Labor," "The Pathology of the Puerperium, The Pathology of the Ovum and the New-born," all from the pen of Ahlfeld, and two contributions by Schrader, the one on "The Dangers following too early resort to Veit's method of delivering the after-coming Head," the other on The Pathology of Menstruation." It would carry us too far, and be hardly profitable, to give an outline sketch of each of the above contributions. We much prefer to devote our space to a statement of Ahlfeld's views in regard to the management of the third stage of labor, and to describe an experiment whereby he proves, as clearly as may be, the possibility of autoinfection. The question of the proper management of the third stage of labor we believe to be well-nigh settled in the minds of the majority of obstetricians. Each one may differ in minor detail, but the broad rule is to wait for uterine contraction, and, on its occurrence, to resort to Credé's method of manual expression. Ahlfeld, or the contrary, is opposed to this method, his belief being that the mother's interests are best subserved when the expulsion of the placenta is left to the efforts of nature. In support of his views he quotes, in particular, the results obtained by Dohrn from an analysis of two thousand cases, one-half of which were subjected to manual expression, and the remaining half treated expectantly. Dohrn's conclusions, briefly stated, are: In one thousand cases where the expuision of the placenta was left to nature, the results were far superior to those reached in an equal number of cases subjected to Crede's method. In the first instance there was less hemorrhage, and fewer cases of puerperal fever and of retained shreds of membranes than in the second. Particularly was a difference noted in those cases where manual expression was resorted to within five minutes from the birth of the fetus. Ahlfeld's experience places him in perfect accord with these conclusions. He lays special stress on the fact that, where the expectant plan is pursued, there is less liability to post-partum hemorrhage than after resort to Credé's method. The percentage of cases of post-partum hemorrhage reported from Winckel's clinic from 1876 to 1878 is as high as 11.9%, and that from Olshausen's clinic from 1879 to 1883 is 1.67%. Both of the gentlemen are advocates of manual expression. At Marburg, on the other hand, there was not a single case of post-partum hemorrhage in 385 labors. Wherefore Ahlfeld's belief that the expectant plan of dealing with the placenta is in every respect better for the patient, especially on the score of lessened loss of blood. The fallacy underlying Ahlfeld's argument is that he jumps at the conclusion that the cause of the large proportion of cases of post-partum hemorrhage, etc., occurring at Winckel's clinic was due solely to the method employed for tre delivery of the placenta, and that his own immunity is due to the fact that he followed another method. Now, the causes of post-partum hemorrhage are as variable 28 is the amount of blood which may be lost in each individual case. A priori, we should expect less hemorrhage after the use of that method which best promotes firm uterine contraction, and this Credé's method aims at, and, in our experience, generally accomplishes without injury to the patient. We believe that where fault is found with this method it is due to the fact that efforts at expression are made too early. A pause of variable duration is physiological after the completion of the second stage of labor. The uterus cannot be expected to recover its tone at once and contract efficiently. Efforts at expression, therefore, are contra-indicated until the uterus is felt to distinctly contract under the expectant hand, and, during the interval of waiting, an opportunity is given the placenta to loosen its connection with the uterus, so that, when the act of expression becomes indicated, the afterbirth is more likely to be expelled intact, than if the uterus, through untimely efforts, be spurred into what, likely, enough, are but partial and insufficient contractions. However well Ahlfeld's expectant method may have answered for him, and in the face of Dohrn's positive assertions, we should fear to trust to a method in private practice which entails leaving within the uterus, for a period dependent on Nature's whims, that which, having subserved its purpose, has become a foreign body. Just so long as the placenta remains in the uterus, just so long should the physician remain by his patient; for there is no safety in an alternately dilating and contracting uterus. Let the placenta be carefully and judiciously expressed, and the uterus contracts firmly and efficiently. Then the physician may leave his patient with clear conscience, and, if the uterus relaxes and the patient bleeds, we do not think he can blame Credé's method, but rather must seek for a cause, mental or physical, which, in its effect on the uterus, is relaxing. A second contribution, to which we would refer very briefly, is Ahlfeld's experimental attempt to prove the possibility of autoinfection as a cause of puerperal fever. He chose for this purpose fifteen patients who, he ascertained, had not been examined previous to admission into the hospital. These patients were allowed to pass through the course of labor without any interference whatsoever, no vaginal examination being made, no douche being given, the external genitals being simply washed before labor and after delivery with a solution of sublimate. In nine of these patients there occurred a rise of temperature above 38 C., beginning at the second or third day, and generally preceded by a marked chill. Whilst the cases are few in number, it cannot be denied that they speak strongly for auto-infection, since every possible precaution was taken to prevent infection from without. In Ahlfeld's opinion they settle forever the question as to the possibility of a fever developing during the puerperium solely dependent on auto-infection. To such cases we should prefer to apply the term putrid intoxication as opposed to true puerperal septicemia, where bacteria are the pathogenetic factors. In conclusion, we would simply note that the various contributions to this volume were prepared with evident care, and will be found generally interesting. EGBERT H. GRANDIN. OBSTÉTRIQUE ET GYNÉCOLOGIE, RECHERCHES CLINIQUES ET EXPÉRIMENTALES.-CLINICAL AND EXPERIMENTAL RESEARCHES IN OBSTETRICS AND GYNECOLOGY. BY PIERRE BUDIN, Adjunct Professor at the Faculté de Médecine, Paris, etc., etc. Paris: Octave Doin, 1886, pp. 722. Dr. Budin has herein collected the numerous contributions to obstetrics and gynecology, which have made his name such a familiar one on this side of the Atlantic. The volume proves him an earnest and exact student in these specialties, a busy and zeal ous worker, and no words are needed from us in witness of the value of the contents, for every reader of current literature during the past ten years must needs be perfectly versed in Dr. Budin's contributions. Our task, therefore, is limited to a résumé of the prominent topics treated of in this volume. These include papers on: At what moment should the umbilical cord be preferably tied? Clinical and experimental study of the fetal head from an obstetrical standpoint. A study of the fetal heart-beat. A study of the hymen and the orifice of the vagina. Remarks on the physiological contraction of the levator ani in women. Remarks on diagnosis of, and labor in cases of retained dead fetus. Remarks on a catheter for use in washing out the uterus and other cavities. Description of the Budin and Pinard manikin. Cases: Of extreme distensibility of fetal membranes; sub-mucous fibroid of the uterus complicating pregnancy and labor; persistence of fetal heart-beat after destruction of the medulla; cancer of the cervix delaying labor for days (followed by forceps delivery of a living fetus), etc., etc. The above brief and incomplete synopsis of the contents of the volume can serve but to call attention to the variety of topics awaiting those who are sufficiently familiar with the French to be able to follow the accomplished author through his clinical and experimental studies. We are amply satisfied that the verdict will be in their favor. EGBERT H. GRANDIN. A SYSTEM OF OBSTETRIC MEDICINE AND SURGERY, THEORETICAL AND PRACTICAL. For the Student and Practitioner. By ROBERT BARNES, M.D., Obstetric Physician to St. George's Hospital, etc., and FANCOURT BARNES, M.D., Physician to the Royal Maternity, Charity, and to the British Lying-in Hospitals, etc. Two hundred and thirty-one woodcuts. Philadelphia: Lea Brothers & Co., 1885, pp. 884. The need of a new treatise on obstetrics is scarcely, at first glance, apparent. Lusk's excellent work, in our own country, and Playfair's, in England, ought to supply the wants of the student and practitioner to such an extent as to leave no void to be filled. We believe, nevertheless, that this system will be eagerly sought for, not only on account of its intrinsic merit, but also because the reputation which the elder Barnes, in particular, has secured, carries with it the conviction that any book emanating, in part, from him is necessarily sound in teaching and conservative in practice. It is, indeed, eminently fitting that a man who has done so much towards systematizing the obstetric art, in particular its operative side, who for so many years has been widely known as a capable teacher and trusted accoucheur, should embody within a single treatise the system which he has taught and in practice tested, and which is the outcome of a lifetime of earnest labor, careful observation, and deep study. This system, therefore, has a raison d'étre, and that it might be in all respects thorough and accurate, as well as comprehensive, the father has associated with himself in its production the son and pupil, whose name is also favorably known on this side of the Atlantic. From such a conjunction a truly classical treatise might reasonably be expected; but so anxious were the authors to fail in no respect that, with rare modesty, they assigned to other gentlemen the elaboration of certain departments of the science which they themselves felt incompetent to treat efficiently. The result of this arrangement is the produc tion of a work which rises above criticism, and which in no respect need yield the palm to any obstetrical treatise hitherto published. Whilst the work is a joint production-we are told that "neither could have done it alone"-that portion which treats of the history of gestation, of puerpery, of the mechanism of labor, and of hemorrhage, is mainly contributed by Robert Barnes, whilst the prophylaxis of puerperal diseases, and the description of the operations is largely the production of Fancourt Barnes. The department of Embryology was entrusted to Professor Milnes Marshall, and that of Teratology to Mr. Noble Smith. The completeness of this work forbids a close analytical review. We content ourselves with a brief specification of the contents of each chapter, dwelling more or less at length on the views expressed by the authors in regard to disputed points of theory or of practice. In chapter I. is traced the development of the ova in the ovaries from their earliest recognizable state up to maturity. In regard to the corpus luteum, we notice the statement "that there is no infallible sign or character by which the corpus lutem of pregnancy can be distinguished from that of the non-fertilized ovum. The terms true and false, as applied to the two kinds of corpora lutea, appear, indeed, to be altogether erroneous, as the two structures are essentially similar, and, in many cases, undistinguishable from one another." It may be taken, therefore, as definitively settled that the corpus luteum is no evidence that pregnancy has occurred, and the old, yet occasionally resuscitated doctrine to the contrary effect should now be consigned to oblivion. In chapter II. we find a sufficiently concise description of the anatomy of the female generative organs, and a statement of the menstrual process and its attendant phenomena. Chapters III., IV., and V., are devoted to the changes wrought in the ovum by impregnation, to the development of the human embryo and fetus, the formation of the fetal membranes and their purposes, and to the physiology of the fetus. In chapter VI., the anatomy of the female pelvis is given in detail, including a study of the comparative anatomy of the pelvis, the physics of the abdomen and pelvis, and concluding with a description of the gross and minute anatomy of the breasts. We would note that on page 152, Fig. 61, the word conjugate should read transverse, and vice versa. The following five chapters concern gestation, normal and abnormal, the effect of the process on the maternal organism, the phenomena accompanying it, and the effect of supplementary disease of one or another kind of organ. In no work with which we are acquainted are these subjects treated so exhaustively. Witness the fact that nearly eighty pages are devoted to the important subject of the diseases of the gravida, which are subdivided into: 1. The pathological exaggerations of the physiological conditions of gestation. 2. Pathological processes continued from the pre-gravid state, or grafted upon the gravid state. In connection with these chapters there are one or two points we desire to notice. On page 244, in speaking of tubal gestation, the authors state that there are two theories to account for the fact that gestation occasionally takes place in the tube opposite to the ovary in which the corpus luteum is found-the one, the extrauterine transmigration of the ovum; the other, the intrauterine transmigration. We would suggest a third possibility, assumed by a number of writers and certainly as tenable as the two above mentioned-the twisting of the fimbriated |