In

The peculiar dreamy expression of the eyes accompanied by occasional waking up looks are suggestive of epilepsy, as well as the seeking to avoid falling by lying down in a comfortable, safe place previous to attacks. Such expedients are familiar in epilepsia mitior, and in graver forms when there is a warning aura.

Again, the absence of hemianæsthesia on the side of the irritable ovary, or of any marked disturbance of cutaneous sensation, would counter-indicate the existence of hystero-epilepsy according to Charcot. If, however, it were certain that deep pressure over the irritable ovary would stop an attack, it would go far towards proving the existence of hystero-epilepsy, whatever anomaly there might be.

In event of the symptoms being those of hysteria in any of its hysteroid or hystero-epileptic forms, or of ovarian neuralgia associated with delirium, involving the sympathetic tracts of the ovarian tubes, that is, functional neuralgia, operative interference would be unjustifiable, as would be the extraction of a tooth for a trigeminal neuralgia, as Drs. Landau and Remak conclude1 after ably commenting upon a case of their own operated on for hystero-epilepsy which was much exacerbated thereby.

They state that "the diagnosis of functional neuralgia excludes surgical interference not only in distinct forms of the same, but for hysteria, ovarial hyperæsthesia, etc., as has been attempted by ovariotomy. Rosenthal and Neftel have detailed only bad results from such operations."

As regards the symptoms that simulate epilepsy, the condition that led to efforts to ward off attacks might exist from one to four days, and while it may be termed an aura-like malaise, it differs from that of epilepsy, and such conditions are common to hysteroid attacks. Seeking to avoid falling, by lying down in a comfortable place, is more common to hysteria than to epilepsy; and the dreamy expression of the eyes might recur many times before the attack is fully developed, and also during the attack, which Gowers thinks is diagnostic. It is most significant that the attacks can be warded off, sometimes altogether, and sometimes be long delayed by exertion, excitement, or by an effort of the will.

It should be stated that when the patient feels comfortable and well an attack, usually the precursor of a series, may be determined in two ways: By some emotional disturbance, or by the onset of pain in the left ovarian region, which once beginning from any cause, as during menstruation or from pressure, will continue and establish the initial condition of malaise. For many years the patient has been in the constant habit of making gentle pressure with the hand upon this region while going to sleep at night. The symptom of hemianæsthesia absent in this case as well as the effect of pressure on the ovaries is said by Gowers to be far less common than in France.

DR. FISHER remarked that the evening was so far

advanced that he would not discuss the paper, merely stating that as he has always regarded confirmed hysterical insanity, however originating, as a disorder of the brain and not of the ovaries, he could not advise Battey's operation except as an experiment, or a dernier ressort for the possible effect of the shock or moral influence, or the improved nutrition likely to follow it.

DR. COWLES said that his narrative of the long series of attacks and varying conditions of the patient had evidently given a wrong impression as to the prominence of mental symptoms, the fact being that all through the history of the case there were clear intervals between attacks, and that the patient appeared sane and well mentally much the larger part of the time. The mental symptoms were distinctly associated with the attacks except on two or three occasions, as when there was a period of painful inflammation of the ears and great physical exhaustion. Even when last

1 Ein Fall von Ovariotomie bei Hysterischen Hemianesthesie, Dr.

Theil 5, 1883.

D. F. Landau u. Dr. E. Remak, Zeitschr. f. klin. Med., Bd. vi., 2 Beiträge zur Lehre der Castration du Frauen, W. Fauffer, Cbl. f. Nvnhlkde, Psychiatrie, etc., No. 16, 1882. 8 William Goodell, Clinical Notes on the Extirpation of the Ovaries for Insanity, American Journal of Insanity, April, 1882; Cbl. Nvnhikde, Psych., etc., October, 1882.

C. B. NANCREDE, M. D., RECORDER. THURSDAY EVENING, March 13th. The President, DR. TYSON, in the chair.

DR. J. H. MUSSER presented a series of specimens illustrative of Hepatic Pathology. The accompanying paper will be shortly published in another form. DR. C. B. NANCREDE presented a penknife blade, with the portion of bone transfixed by it, removed from the cranium of a boy aged nineteen years, where it had remained undiscovered for over six weeks. Owing to later developments the history of this specimen is also, for the present, withheld from publication.

THURSDAY EVENING, March 27, 1884. Vice-President E. O. SHAKESPEARE in the chair.

CASE OF EPITHELIOMA OF THE STOMACH AND COLON, PRESENTING SINGULAR DIFFICULTY OF DIAGNOSIS.

Presented by DR. J. H. PACKARD.

Dr. Packard stated that this case was placed at his disposal for report by Dr. H. M. Fisher, in whose wards at the Episcopal Hospital the man had been.

Alex. R., aged forty-seven, single, was admitted July 9, 1883. He had for about four months been unable to follow his occupation, that of a wagon driver. No history of syphilis; none of his family are known to have had cancer. His first symptom was discomfort after eating; later he had loss of appetite and pain in the stomach.

Two mouths afterward he felt a hard tender mass in his belly, on the right of the umbilicus.

On admission the tumor seemed about the size of an orange, and was found to be on the left of the umbilicus. It was not very painful, but annoyed him. He was much emaciated, and in a cachectic state; his bowels were obstinately confined. Under treatment his condition improved, and he gained notably in appetite and strength. Subsequently a change for the worse took place, the tumor became more painful, he lost flesh and strength, and his appetite failed. As the tumor seemed to be entirely movable, it was decided that an attempt should be made to relieve him of it, and he was transferred to the surgical ward, under Dr. Packard.

October 11, 1883, after consultation, an incision was made over the tumor, in a vertical direction, and the tissues carefully divided until the abdominal wall proper was reached, when it became clear that there was firm adhesion between this and the new growth for a space of several inches in every direction. The operation was therefore abandoned, and the wound closed. Healing took place by the first intention, and the man even thought himself to have been benefited, although this was clearly imagination on his part. Emaciation steadily increased, and toward the middle of November the stomach became unable to retain food. From this time the symptoms progressed until death occurred, December 29th.

Upon post-mortem examination, it was found that there was an epithelioma of the pylorus, which had become adherent to the transverse colon, and the disease propagated to that structure, a communication taking place between the two cavities. Subsequently, by a local peritonitis, the affected parts had contracted adhesions to the parietal peritoneum at the point to which they had been displaced. The mechanism of this displacement does not seem to clearly appear.

MALIGNANT DISEASE OF THE PERITONEUM AND

ABDOMINAL VISCERA.

Presented by DR. JOHN B. ROBERTS for DR. V. HORNET, with an abstract of the latter's notes.

The patient, a woman of about fifty-eight years, had, four years previous to death, an attack of what was supposed to be gastro-enteritis of malarial origin. From this she never perfectly rallied, but had four or five intestinal hæmorrhages, at varying intervals. The last one occurred a few weeks before death. Recently she rapidly lost strength and became emaciated. When seen by Dr. Hornet, some time in December, 1883, she had a large tympanitic abdomen, and complained of a sense of tension. Constipation, jaundice, flushed cheeks. Pulse 100 to 110; normal temperature and a tendency to nausea and dyspnoea were the chief symptoms.

Ten days before death the thermometer in the rectum marked 103° F.; but stood, says Dr. Hornet, below normal in the axilla and under the tongue. Small nodules could be felt through the belly wall, which was less tympanitic than formerly. Death occurred suddenly while at stool.

Autopsy showed nothing important in the chest. The omentum and mesentery were studded with multitudes of tumors varying in size from that of a currant to that of a hen's egg. These were of globular form, firm in consistence, and on section showed a central hæmorrhagic clot. The parietal peritoneum was studded with a few small ones, as was the surface of the liver.

Dr. Hornet further says that he found in one part of the intestine an ulceration of the mucous membrane corresponding to an internal tumor, and a tumor

on each side of the rectum, high up. In one place he found a cyst, with yellowish serous contents, on the surface of a tumor. Most of the nodules were of a pale pink color; one noticed, however, was nearly black. I present a portion of the intestine and mesentery, and a piece of the liver with one of the secondary growths there found.

MALIGNANT DISEASE OF THE TESTICLE TAPPED FOR HYDROCELE.

Presented by JOHN B. ROBERTS, M. D.

This case is clinically interesting because it resembled a hydrocele, and misled me as well as another surgeon who had previously seen it. When the man came to me I found a large, oval swelling of left side of scrotum, which he gave me to understand had existed for two years. The tumor for six or eight inches long in the vertical direction had a sharply defined upper limit, as does hydrocele of the vaginal tunic, and was indistinctly elastic as is a tense hydrocele. The veins on the surface, however, were well marked, and it looked, at the lower part, a little as if the subcutaneous tissue was about to suppurate. It was this which gave rise to the pain that induced him to seek medical advice at this time, for he has previously postponed having another surgeon draw off the yellow water which he had been told was in it. I did not try to transmit light through the supposed hydrocele because it is very often a fallacious test. At least absence of light transmission does not negative the existence of hydrocele. I accordingly thrust a trocar into it, and drew about six fluid ounces of pure coagulable blood through the canula. Reinserting the trocar I pushed it in various directions, but met only solid tissue and no blood except when it was pushed in the direction originally taken. Then blood flowed in a quite free stream. No marked reaction followed, but the pain and tendency to suppuration was removed.

Two weeks later I removed the mass by enucleation, and found the solid tumor here presented, which is the enlarged and infiltrated testicle. The patient now says that fifteen years ago, when about eighteen years old, the testicle or scrotum began to grow larger. He is rapidly convalescing.

RUPTURE OF ONE OF THE AORTIC VALVES DURING SEVERE MUSCULAR STRAIN.

F. L., aged forty, laborer, married, was admitted into the Episcopal Hospital under my care February 21, 1884. His family history was good, and his own health, previous to his present indisposition, excellent. He denied ever having had syphilis or rheumatism.

His work compelled him to handle very heavy casks, and he had the reputation among his fellow-workmen of being a particularly strong man, he being able to lift, unaided, 500 pounds. Three weeks before admission he was subjected to heavy strains in lifting, and although no history of sudden cardiac pain or palpitation could be elicited, he did admit feeling a sense of tightness across his chest and some dyspnoea after his day's work. These symptoms gradually increased, and cough accompanied by bronchitic expectoration soon made its appearance. On admission the patient presented all the appearances of a remarkably well devel oped and powerful man; he was suffering from great dyspnoea, which was much increased upon exertion. Percussion showed impaired resonance over both lungs posteriorily, which was not altered by change of posi

tion, and auscultation revealed numerous moist râles. The apex beat of his heart, although perfectly regular in its rhythm, was extended in its area, and in the nipple line in the fourth left interspace. Auscultation revealed a loud, high-pitched musical murmur, systolic in time, with its point of greatest intensity over the upper part of the sternum; this was also audible over the whole chest. The peculiarity of this murmur was its decidedly vibratory character, like a torn sail flapping in the wind; the patient himself even noticed this.

With the diastole there was a second murmur of much lower pitch and not musical or vibratory in its nature. This had its point of greatest intensity over the aortic cartilage.

There was no apex murmur. Slight oedema of the legs and feet was present. The urine contained no

albumen.

The patient was placed in bed, and given digitalis, while counter-irritation and dry cups were applied to his chest posteriorly. Under this treatment he rapidly improved, and was soon considered well enough to be about the ward, the dyspnoea only showing itself after any unusual motion or excitement. The murmurs remained in much the same condition as on admission, although the intensity of the musical murmur had lessened.

On March 20th, in the evening, after a day as well as usual, he was seized with a severe attack of dyspnoea, with congestion of the lungs. He was considerably relieved by the application of dry cups. The next morning it was noticed that the oedema of the legs had increased, the dyspnoea was still present to a slight degree, and the only change perceived in the cardiac signs was a lowering of the pitch of the musical

murmur.

On the 22d the dyspnoea had increased again, and for the first time a low, long, apex systolic murmur was detected; this was conveyed plainly into the axillary line. The musical murmur was of still lower pitch than before, and at the aortic cartilage the murmurs were much more plainly of a see-saw character.

Irregularity of the heart's action occurred now for the first time. On the 23d the area of cardiac dullness was as follows: In the horizontal line, at height of nipple, the dullness began in the middle of the sternum, and extended to the left to a point half an inch beyond nipple. In the perpendicular line drawn midway between the sternum and left nipple the cardiac dullness began in the third interspace and extended downward till lost in dullness of left lobe of liver. The area of dullness was not triangular with the base downward. Impaired resonance was now present over the whole chest both anteriorly and posteriorly, and no cardiac sounds could be heard on account of the great stridor and the violent movements of the chest. The apex beat could not be detected for the same reason. After this the patient became more and more cyanotic and short of breath, and died on the same day, namely, March 23, 1884.

Autopsy. Each pleural cavity contained several ounces of serum. The pericardium contained about one and a half ounces of serum in which several shreds of lymph were discovered.

In both ventricles were large clots, partly chickenfat, extending through the semi-lunar valves.

The weight of heart, after being emptied of clots and blood, was one pound ten ounces.

The walls of the left ventricle were enormously hy

pertrophied, measuring seven eighths of an inch at thickest part; the cavity appeared slightly distended, as did also the mitral orifice, which would allow the tips of three fingers to pass.

The right anterior leaflet of the aortic valves was torn at its posterior insertion into the aorta, thus leaving a free pointed end about three eighths of an inch long to float in the blood current.

The left anterior leaflet presented two fenestrations, the posterior one the smaller and near the insertion of valve in aorta at its upper margin, the anterior one the larger and situated some distance down from the free border of valve.

The aorta at its origin was atheromatous in places and slightly dilated, a patch existing at the point corresponding to the former insertion of the torn valve. The valves were normal except for slight thickening. The coronary arteries were not atheromatous. Remarks. In this case the atheroma at the point of insertion of the torn valve must have been the cause of the rupture during a heavy strain; should a fenestration have existed near the point of insertion, as exists in the left anterior leaflet, this would be a further reason for the rupture occurring at this point.

Frequently repeated great bodily exertion was the probable cause of the atheroma, as the man was a moderate drinker and denied rheumatism and syphilis. A point of interest in the case was the peculiar character of the systolic aortic murmur, which was, as before mentioned, decidedly musical and vibratory.

As the patient did not suffer from sudden palpitation and dyspnoea at the probable time of the rupture, and as this murmur gradually diminished in pitch, while the regurgitant murmur became slightly more pronounced, it is probable that the tear at first was slight and gradually increased under the great strain thrown upon it, thus increasing the area of the loose edge to be thrown into vibration, necessarily lowering the note produced.

The systolic apex murmur heard one day before death was due to the occurrence of an incompetency of the mitral valves from over distention of this orifice.

NEW YORK ACADEMY OF MEDICINE.

THE REMOVAL OF THE AFTER-BIRTH.

AT a stated meeting of the Academy held Thursday evening, April 3d, DR. H. J. GARRIGUES read a paper in advocacy of the exclusive adoption of the Credé method in the delivery of the placenta after normal parturition. It was now thirty years, he said, since Credé had published his original communication on the subject, and since the date of this publication he had repeatedly reiterated his conviction of the correctness of his idea that the placenta should be removed, not by traction from below, but through the agency of pressure from above. Having described the method in detail Dr. Garrigues maintained that it was a mistake to practice compression on the fundus except during a regular contraction. At least three contractions were, as a rule, required for the expulsion of the afterbirth, and more frequently it was not until the fourth contraction that it came away. Of late years some of the German authorities had claimed that the Credé method was objectionable on the ground that it was likely to result in retention of the membranes, but he contended that there was no foundation in fact for such an opinion.

During the last eight years Dr. Garrigues had used the method constantly in his private practice, and when he was appointed attending surgeon to the Maternity Hospital on Blackwell's Island he had introduced it into that institution. During the last two terms of his service there 408 confinements had been recorded. Two of these had been cases of abortion at the fifth and sixth months respectively, and in both there had been adherent placenta, which he removed by means of the dull wire curette and forceps. Out of the 408 cases there were six of retained placenta, and six in which a portion of the membranes was retained, so that out of 400 cases the Credé method failed in six, or one and one half per cent. In four, however, there was the occurrence of true adhesion of the placenta, which he believed to be more rare than was generally supposed, most of the cases of retention being due, as he thought, to improper treatment. There were, therefore, in reality only two failures in 400 cases, or one half per cent., there being two cases in which there was simple retention without adhesion. In six cases (or one and one half per cent.) shreds of membranes of larger or smaller size were retained, but in only one of these was it necessary to introduce the hand into the uterus to accomplish their removal. Credé had said that he had never seen any had effects from leaving such portions of membrane, and advised that they should be allowed to remain undisturbed in the uterus, but Dr. Garrigues strongly deprecated this course as liable to expose the patient to severe hæmorrhage and other dangers. Whenever the membranes could not be removed otherwise, the hand, disinfected with a solution of bichloride of mercury (1 to 2000), was to be carried up into the uterus, and the cavity afterwards thoroughly washed out with the same antiseptic solution.

The Credé method, Dr. Garrigues continued, was modeled strictly after the regular course of nature, and its action was simply to assist nature in completing the normal process of parturition. After the strong expulsive efforts of the uterus during the second stage of labor some atony of the organ was, as a rule, apt to result, and the manipulations comprised in the method had the effect of spurring it on to the still further action required. In the large majority of cases there was, therefore, a call for artificial aid at this stage of labor, and this, there could be no doubt, was better supplied by the method in question than any other plan of procedure. Having spoken of the action of the two sets of muscles entering into the structure and controlling the contraction and movements of the uterus he showed how, in the manipulations of Crede's method, the action of nature was assisted by the compression of the organ between the thumbs and fingers, and the pressure downwards and backwards, forcing it towards the hollow of the sacrum.

By shortening the third stage of labor the method tended to prevent post-partum hæmorrhage. In the 408 cases mentioned serious hæmorrhage occurred in only two, and in but two others was there the slightest loss of blood beyond the normal amount. In all these four cases, however, the hæmorrhage occurred before any attempt had been made at expression of the placenta, so that in not a single instance was there any hæmorrhage after the removal of the after-birth. When properly carried out, therefore, the Credé method was the best preventive of post-partum hæmorrhage. Inversion of the uterus, which was facilitated by traction,

was also powerfully counteracted by it. In some instances the whole after-birth was expelled completely outside the genitals, and where this was not the case it was advised that the membranes should be twisted into a rope before their withdrawal. There was, as a rule, no necessity for the introduction of the fingers into the genital canal, and the avoidance of this constituted one of the points in the modern antiseptic treatment of midwifery cases. Dr. Garrigues said that in his own practice he delivered the child while the woman was lying on the left side, but after the second stage of labor was completed he had her turn upon the back as the most advantageous position for the satisfactory completion of the third stage.

In his last published communication Credé stated that in 2000 cases the average duration of the third stage was four and a half minutes. The average time in the 408 cases at the Maternity Hospital on Blackwell's Island was somewhat longer; but while in the lyingin hospitals in Europe the same medical attendant remained on duty for several years in succession, and thus had the opportunity of acquiring special skill in all obstetrical manoeuvres, in the latter institution the resident accoucheurs were changed every two months. Still, in his opinion, Dr. Garrigues said, it was totally unimportant whether a few minutes more or less were consumed in the third stage, as long as the correct principles were carried out in the treatment of it.

In making a plea for the orginality of Credé in the method he had advanced (which, he said, had been impugned in certain quarters), Dr. Garrigues claimed that he was entitled to the credit of advancing uterine compression as a means for expelling the placenta because (1) he advised it in all cases; (2) he directed that the uterus should be firmly grasped on all sides; (3) that the whole organ should be pressed downward and backward in the direction of the pelvic axis; (4) that the cord or placenta should not be touched unless there was adherent placenta; and (5) that the fingers should not be introduced into the genital canal. The advantages which he claimed for the Credé method were: (1.) Its certainty. (2.) Its efficiency in exciting uterine contractions. (3.) The prevention of postpartum hæmorrhage. (4.) The prevention of hourglass contraction of the uterus. (5.) The prevention of inversion of the uterus. (6.) The prevention of avulsion of the cord or uterus. (7.) The prevention of uterine inertia.

There was still another plan of procedure, sometimes called the Strasburg method, which consisted simply in the absence of any kind of interference whatever, and which was as yet but an experiment. In 100 cases reported in which it had been tried, the placenta came away within half an hour in twenty-four cases, within one hour in twenty cases, within two hours in twenty-five cases, within three hours in eleven cases, within four hours in nine cases, within five hours in five cases, within six hours in three cases, within eight hours in two cases, and within twelve hours in one case. In every case it was found that the foetal surface of the placenta presented first. In two cases there was hour-glass contraction of the uterus, and in one case there was a decided putrid odor. Dr. Garrigues said that he failed to see a single advantage in this method, and that it was not even natural, since the recumbent posture, in which the women referred to were kept, was unfavorable to the spontaneous delivery of the placenta. Dr. Engelmann, in his comprehensive

In the 408 cases at the Maternity Hospital there had been no instance of hour-glass contraction, and this accident, according to the statistics of the best authorities, was more liable to occur where no compression was made than where the Credé method was employed. It was hardly necessary to point out, Dr. Garrigues continued, that it was positively dangerous to allow a placenta to remain in the uterus till it became offensive. On the other hand, there was no necessity for undue haste in delivering the placenta, and all that the accoucheur was required to do was to abridge the third stage of labor in such a way as to keep the patient from danger.

DR. ALEXANDER HUNTER, in opening the discussion on the paper, spoke of the advisability of commencing the uterine compression just before the delivery of the child, and said, in the course of his remarks, that he believed that the uterus should always be allowed to expel the foetus from itself, and from the vagina also, unless the foetus were in danger of suffocation. By thus resorting to abdominal pressure early he thought the delivery of the placenta was much shortened, as well as the danger of post-partum hæmorrhage diminished.

DR. HADDEN spoke of the evil consequences that were liable to result from improper management of the third stage of labor, and of the coolness, judgment, and intelligence required in conducting it satisfactorily. During the last twenty-five years he said he had attended about twenty-three hundred cases of confinement, and had never lost sight of the importance of attending with special care to this part of labor, the neglect to do which, if it was not followed by any immediate bad results, might leave the patient a chronic invalid. In his last thousand cases he had had one fatal case of post-partum hæmorrhage, but the patient was the subject of purpura hæmorrhagica. For the expulsion of the placenta it had been his practice to depend partly on gentle traction and partly on abdominal pressure. He always took pains to see that the uturus was afterwards firmly contracted, presenting a distinctly globular outline, and was accustomed to watch the patient for at least an hour and a half after the completion of labor. In the only case in his experience in which there had been an attempt at inversion of the uterus the accident occurred before any effort whatever had been made to remove the placenta, and was due, apparently, to a relaxation of the circular muscular fibres while the longitudinal ones were in active contraction. The fundus, to which the placenta seemed to be attached, was thus forced down so that it could be felt through the os, while there was a cup-shaped depression in the top of the uterus as felt through the abdominal walls. Up to that time he had been inclined to believe that traction on the cord might possibly induce inversion of the uterus, but now he was somewhat skeptical on this point, and it seemed to him that the cases which had been reported as of this character

were in reality due to the fact that the placenta was attached near the fundus (a comparatively rare condition), and the effort to expel it resulted in the inversion of the organ.

DR. MARY PUTNAM JACOBI remarked that the expulsion of the placenta was being prepared for all through the later weeks of utero-gestation by the formation of thromboses around its edges. Up to that time the uterine circulation was predominantly venous, but when the time approached when the uterus was expected to undergo the active contractile efforts which were necessary for the expulsion of its contents the circulation gradually became more and more of an arterial character, through the formation of these thromboses and the migration of leucocytes, which caused coagulation and tended to cut off the supply of venous blood. The stimulus required for exciting uterine contraction could be supplied alone by arterial blood, and hence it seemed probable that in those cases in which there was a failure to contract there was an abnormal continuation of the supply of venous blood. The Credé method had the direct effect of diminishing the amount of venous blood going to the uterus, thus continuing the process already begun in the ordinary course of nature, and she believed that it was the only plan of procedure to be thought of at the present day. DR. MUNDÉ, who had arrived too late to hear the paper, made some general remarks on the Credé method, in which he went over much of the ground covered by Dr. Garrigues. In the course of them he remarked, however, that after expression had been made, and the reduced size and spherical form of the uterus, as felt through the abdominal walls, indicated that it had left the cavity of the organ, the placenta sometimes did not appear at the vulva. In such cases it was probably retained in the cervical cavity (the cervix being of exceptional length), and no amount of pressure on the fundus would cause its expulsion. Here slight traction on the cord, or, what was safer, the introduction of the fingers or hand into the vagina to get hold of the placenta, was advisable, and if the ordinary rules of cleanliness in obstetric practice were observed he did not believe that the slightest danger could result from this procedure. Where the placenta was retained simply by the firm contraction of the os, as sometimes occurred, he recommended that its relaxation should be secured by the administration of chloroform. In some cases the repeated compression of the uterus required by the Credé method gave the patient more pain than was at all desirable, and here he thought it well to follow this up with gentle traction on the cord. Dr. Mundé was strongly opposed to leaving the delivery of the placenta entirely to nature, and thought it simply criminal to allow it to remain too long in the uterus. At the same time he did not believe in expelling the placenta too rapidly, for the reason that it was liable to thus become stripped of a portion of the membranes, which would be retained in the uterus.

DR. ISAAC E. TAYLOR spoke of the effect of stimulation of the cervix by the touch of the hand in exciting, through reflex action, the fundus to contract and throw off the placenta. He believed in imitating the process of nature, and strongly deprecated too hasty interference in the removal of the after-birth, which, he claimed, should be left largely to nature, and ought ordinarily to occupy from twenty minutes to one hour or more. Ile was in the habit of taking hold of the cord but of making little or no traction, and he thought