applications. He thought, however, that there were very few men nowadays who considered leucorrhea anything more than a symptom. We should always endeavor to determine whether endometritis is primary or secondary before resorting to treatment.

DR. W. GILL WYLIE said that he was not in the habit of making intrauterine applications frequently, but that he did advocate their proper use in suitable cases. He first made a clear diagnosis always. In acute cases he did not use them, nor where the uterus was fixed. In case of dysmenorrhea, after dilatation, he made an application to the internal os. In any event he was always careful to have the cervical canal open, and he made application through the silver tube. He thus secured drainage and antisepsis. The uterine sound he rarely resorted to, and he always watched his cases a long time before employing the applicator.

DR. T. A. EMMET asked Dr. Wylie what he proposed to accomplish by applications.

DR. WYLIE stated, in reply, that in dysmenorrhea he aimed at treating the hyperesthesia at the internal os, which he believed. to be the source of the symptoms. After curetting, he resorted to applications for purposes of antisepsis.

DR. B. EMMET, in closing, said he was sorry the discussion had turned on dysmenorrhea and divulsion. His paper aimed at warning the profession at large against the abuse of intrauterine applications.

DR. J. DUNCAN EMMET then read a paper on:

IMPRESSIONS OF GERMAN AND ENGLISH GYNECOLOGY, BY AN ALUMNUS OF THE WOMAN'S HOSPITAL.

The reader gave an interesting sketch of the methods of various operators, referring, in particular, to their neglect of American procedures, and to the small esteem in which American gynecology was held. His impression was that in the plastic surgery of women the Germans were far behind the Americans, whilst in laparotomy they were most at home. Gynecology, pure and simple, was not a specialty in Germany. The obstetricians largely performed the plastic operations, whilst to the general surgeon fell the laparotomies. In England, gynecology was beginning to emancipate itself from obstetrics. The reader then referred to the good results obtained at the Samaritan Hospital by Bantock and Thornton, notwithstanding the one was a strong advocate of Listerism in all its details, whilst the other would have nothing to do with it. At Birmingham, he had had ample opportunity to witness Mr. Tait's operative methods, and came away impressed, as all are, by his skill in diagnosis and operation, and by his little short of wonderful results. In conclusion, the reader stated that he would account for the better results obtained by laparotomists in Europe on the grounds that, first, they could choose their patients and time for operating; second, the females operated on were, as a class, stronger than here; third, assistants are dispensed with as far as possible; fourth, strict cleanliness is aimed at.

REVIEWS.

THE THEORY AND PRACTICE OF OBSTETRICS. By P. CAZEAUX. With additions and revisions by S. TARNIER, Professor of Obstetrics and Diseases of Women and Children in the Faculty of Medicine, Paris. Eighth American Edition. Edited and Revised by ROBERT J. HESS, M.D., Physician to Northern Dispensary, Philadelphia. With an Appendix by PAUL F. MUNDÉ, M.D., Master in Obstetrics of the University of Vienna, Professor of Gynecology at the New York Polyclinic and at Dartmouth College, etc., etc. Philadelphia: P. Blakiston & Co., 1886, pp. 1,202. Vols. 2.

The popularity of this classical treatise is sufficiently attested by the fact that an eighth American edition has been called for. No obstetrician, be he young or old, needs to be reminded of the great value of Cazeaux's labors, and of the deep impress on all obstetric literature, native and foreign, exercised by this mastermind through his encyclopedic work. Professor Tarnier, to whom, at Cazeaux's death, was intrusted the revision of the work, aimed to keep it thoroughly in accord with the progress of the art, and the edition under review has been judiciously revised by Dr. Hess, of Philadelphia. In the laudable desire to make the book fully in sympathy with the state of obstetric practice and progress to-day, the publishers requested Dr. Paul F. Mundé to prepare an appendix, wherein subjects might be amplified which did not receive sufficient consideration in the body of the work, and wherein questions of prime importance to every practitioner might be discussed, by a capable American authority, in the light of the most recent knowledge and opinion. The body of the work, needing no introduction, and calling for no special criticism, will not detain us. Our concern is with the appendix, on the worth of which hinges the question as to whether Cazeaux and Tarnier's conjoined labors have been made more useful, and a classical treatise more complete.

In the preparation of this appendix, Dr. Mundé associated with himself his assistant, Dr. Brooks H. Wells, assigning to him the preparation of the chapters on Hygiene and Dietetics, Anesthetics and Narcotics, Antisepsis, and Obstetric and Gynecic Jurisprudence. To bring these subjects up to date required careful research and judicious selection, and Wells has evidently spared neither in his effort to make these topics valuable and complete. The chapters on Posture in Obstetrics, External Obstetric Manipulation, Puerperal Fever, Puerperal Cellulitis and Peritonitis. Lacerations of the Genital Organs, Primary Perineorrhaphy, The Diagnosis and Treatment of Extrauterine Pregnancy were specially prepared by Mundé. A glance at the above chapter headings shows the eminently practical nature of this appendix, certain of the subjects, furthermore, being such as rarely find sufficient, if any, space in treatises on obstetrics, to the detriment, we believe, of both the general practitioner and of his patients.

The first chapter considers the hygiene and therapeutics of

pregnancy, labor, and the puerperium, the subject of placental expression, the value of electricity in the gravid and post-gravid state. Credé's method of placental expression is strongly advocated, the more so because, in the body of the work, the barbarous and irrational method of placental delivery by traction on the cord is recommended. We are satisfied that Credé's method fails, in the hands of many attempting it, for the reason that they lack specific information in regard to the manner of making expression. They resort to expression too soon. In this appendix, the directions are concise, and the capital point in the method is brought out, that expression is only indicated and of value when the uterine sphere is felt to contract. In one respect we disagree with the author in his management of the third stage of labor, and this is the direction to administer ergot after the birth of the child, and before the delivery of the placenta. This advice, whilst in accord with the practice of the majority of, at least, the older general practitioners, is in disaccord with the dictum of most authorities. We, personally, can find no excuse for this premature administration of this drug. Further on in this chapter the graphic words in which Barnes describes the action of the drug, and the possible tetanoid contractions of the uterus which may follow its administration, are quoted with approval, only, however, in so far as the remarks apply to the second stage of labor, for, in the next paragraph, the statement is made that in the third stage of labor, "My routine practice is always to give ergot immediately after the birth of the child; and in an extensive experience, I have yet to note any ill result from its use in this manner." The experience of one man, however, differs from that of another, and we have heard of cases where, through the premature administration of ergot, the placenta has been locked up, not to the radical detriment of the mother, it is true, but causing much concern both to her and her friends, so anxiously is the advent of the after-birth awaited by all in the lying-in chamber. And what is to be gained by the administration of ergot before the delivery of the placenta? Nothing, except where there exists a great degree of uterine inertia, and here there are other means and agents at our disposal for spurring the uterus without running the possible risk of evoking, to quote Barnes, "a brutal power like that given to Frankenstein." Ergot is administered to secure tonic contraction of the uterus. We do not seek for this tonic contraction till after the placenta has been delivered. We need not fear post-partum hemorrhage until after the placenta has been delivered, for, in such an event, being on the spot, we may remove the placenta manually, and at once give ergot hypodermically. We seek in vain, therefore, for justification of the advice in regard to ergot contained in this chapter, and we condemn the advice more strongly because we believe that many a young practitioner will be attracted by the name of Mundé to read this appendix, and will start out in life with knowledge which may be dangerous, even though it emanates from such a high authority. On the subject of the management of the breasts, with special reference to mastitis, the author condemns strongly the routine practice of rubbing and manipulating these organs, recommending the method in use at the Maternity Hospital, New York, which has given such excellent results, and which depends on bandaging and rest. The bandage in use at this institution, devised by the head nurse, is described, and we trust every reader

of this appendix will give the method a trial in place of the manipulations ordinarily resorted to, for the evidence points to the fact that hereby abscess may be certainly prevented.

Of the drugs noted in this chapter, it is with pleasure we find such a prominent place given to chloral. For controlling false pains, for regulating the pains of the second stage, for annulling after-pains, for the nausea and vomiting of early pregnancy, we know of nothing so valuable in most instances. Cotton root (gossypii radix) the author has found useful in metrorrhagia resulting from subinvolution; mistletoe (viscum album), it is stated, has decided oxytocic properties, differing from ergot, however, in the fact that it does not tetanize the muscular fibres of the uterus; viburnum is considered a standby in threatened abortion; cocaine has been found to possess surprising effects in the nausea and vomiting of pregnancy; hyoscyamine, in addition to its sedative and anesthetic properties, would seem, from a case related by Wells, to possess marked oxytocic properties, and is certainly worthy of trial in case of mania during labor, although, the alkaloid not being officinal, the safe dose is rather doubtful. Electricity receives in this chapter the prominence which it deserves, and we believe for the first time obtains sufficient recognition in a treatise on obstetrics. As the author says, "No one in this age of progress can dare say where or when the limits of electric power or application will be reached," and he proceeds to show that no one need be deterred by the question of cost of appara tus, or necessity of prolonged study of the mysteries of electricityfrom utilizing either the galvanic or faradic current in the vomit, ing of pregnancy, the induction of premature labor, the destruc-tion of an extrauterine fetus, subinvolution, and as an oxytocic in normal or complicated labor. The value, indeed the preeminence, of electricity in extrauterine pregnancy is noted at length in a separate chapter. For the other conditions it is probable that, in the near future, electricity will supplant many of the measures and agents to which we resort at the present day.

The subject of Posture in Obstetrics is dwelt on at sufficient length in the next chapter, and valuable hints are given in regard to the remedying of malpresentations and prolapse of the cord by change in the position of the parturient. The reposition of the gravid uterus by posture and atmospheric pressure, although a most valuable method, claims, we think, a trifle too much space. The observation of the phenomenon occurred independently, about the same time, to Mundé and to Solger, of Berlin, and the method usually will alone suffice for remedying the displacement. There are cases, however, where, possibly owing to undue projection of the sacral promontory, something additional to pneumatic pressure is requisite. The fundus must be dislodged from the hollow of the sacrum, and this may be accomplished by gently drawing down the cervix with a tenaculum. The author, of course, is familiar with this, but, since he is writing for non-experts, it would have been wiser to have laid stress on the point.

The following chapter, On External Obstetric Manipulation, is an admirable exposé of a subject which has received but scant notice in every treatise on obstetrics with which we are familiar, and yet is one of paramount importance to the practitioner. In this country, indeed, it constitutes the weak point of the majority of physicians, that they do not know what is to be learned by palpation, and what may be done through it. The routine custom

here is simply to make a vaginal examination. It should be the rule of every practitioner to do what is inculcated in this chapter, first carefully palpate the abdomen, if possible before labor has begun, and thus assure a diagnosis which, reached by the vaginal examination alone, is incomplete and often imperfect. The material for this chapter is drawn largely from Mundé's papers on Abdominal Palpation which appeared in this JOURNAL in 1879 and 1880, although written nearly ten years previously. The matter is supplemented by extracts and cuts from Pinard's monograph. The chapter is complete and concise, and at last there exists a treatise on the obstetric art where the student and general practitioner will find, in ample detail, information in regard to one of the most important subjects connected with pregnancy.

The chapter on Anesthetics discusses at length the agents which have quite recently been advocated as of value during labor-ethylic bromide, methylene bichloride, nitrous oxide. The conclusion reached is that "the superior advantages of any of the agents mentioned above over our old friends chloral, chloroform, and ether, have not yet been conclusively shown," and that, for the present, chloral remains the agent par excellence in the first stage of labor, chloroform during the second, and chloroform or ether for any operation requiring complete anesthesia.

The following chapter, on Antiseptics, describes the various measures and substances of use for this purpose, and the methods applicable to hospital and private practice. The author's belief in regard to the efficacy of any special antiseptic is clearly exemplified by the following quotation: "The essential element of successful antisepsis may be embodied in one word-cleanliness; and the most comprehensive rule for its application in two-be clean. So long as we obtain this ultimatum, it matters little how we proceed or what means we employ, pure water showing as favorable a record in one man's hands as strong mercuric solutions in another's." This is broad enough doctrine for all of us to stand upon, if it be only remembered that there is vast difference between practice in a public institution and in a private house. The measures indicated towards securing cleanliness of the surroundings and of the puerpera must necessarily be far more stringent in hospital practice. In this chapter this fact is sufficiently recognized, and the directions towards obtaining aseptic conditions in both spheres of practice strike us as ample enough without going to the absurd extremes which are frequently advocated. After normal delivery, both vaginal and intrauterine injections are deemed unnecessary, unless symptoms calling for such interference arise. In hospital practice, and in private where there exists suspicion of gonorrhea, Credé's method for the prevention of ophthalmia neonatorum is indorsed. The chapter concludes with a timely note of warning against the use of strong solutions of the sublimate salt, for there are cases on record of fatal poisoning from a 1:1,000 to 1: 1,500 solution. Mercurial douches, it is stated, would seem to be contra-indicated in cases where there is a history of renal disease, or there exists marked anemia, or extensive lacerations of the genital tract.

The chapter on Puerperal Fever, which follows, is admirable. In a few short pages the subject is most satisfactorily presented, and withal robbed of the manifold subdivisions which characterize the generality of obstetrical treatises. Mundé does not commit himself to the germ theory of the disease, since this whole