Miscellany

1915 Journal of the American Medical Association  
This book is a successful attempt to supplement the rather general instruction, given in the textbooks, in the management of the different problems of obstetrics by detailed rules of procedure elucidated by suitable examples. The author gives the histories of seventy-six actual cases illustrating twenty-eight obstetric problems, such as diagnosis of pregnancy, forceps, breech delivery, contracted pelvis, sepsis, mastitis, etc. The unnecessary details of every entry in each case are not given,
more » ... se are not given, but an attempt is made to bring out every important point in at least one case of the group. Following the reports of the cases of a group a summary is given of all of the points pertaining to the management. This plan is executed so well that hardly any question concerning the management of any obstetric problem can be raised that has not been clearly discussed and answered. Of course the plan is not new: it was adopted by Smellie and all the earlier English and French writers. The school textbook and lectures of fifty or sixty years ago were illus¬ trated by many reports of cases. As the theory of obstetrics has developed in recent years, more space has been required in the textbooks to present the science in a systematic form, and the case histories have been gradually crowded out. In this country, especially, didactic teaching in obstetrics has largely usurped the place of clinical teaching. The lack of clinical material, or rather the indolent failure to make use of the clinical material at hand, is responsible for the fact that many students have been graduated without even having personally supervised a confinement. Textbook reci¬ tations, lectures and quizzes were sufficient to qualify a student for the written state board examinations, and the teaching was largely adapted to this end. Dr. DeNormandie's book would have been a very valuable supplement to the old didactic teaching. It is no less valuable as a model for, the new method of clinical instruction. More and more the tendency is to divide the obstetric teaching into a year's work in theory and a year's work in training in the obstetric art. For the latter course this book could be used with great profit. In the large number of practical problems discussed, it is unavoidable that the views of the reviewer must sometimes differ with those of the author. The Prochownik diet is indicated in a variety of conditions, but as a routine in all cases in the last two months of pregnancy in order to obtain a smaller baby it is hardly advisable. The cases of nausea and vomiting of pregnancy are not well selected to show severe vomiting of the first trimester, nor do they demon¬ strate the value of rectal injections of dextrose solutions. One is somewhat surprised at the nonchalance with which the report is made, of the detection of ether in the baby's breath in a case of partial asphyxia of the baby after a for¬ ceps operation made under ether narcosis. Manual dilatation and extraction in placenta praevia is generally held to be dangerous and responsible for many of the bad results in this serious complication. Holding the uterus during the third stage of labor to prevent hemorrhage is of doubtful value, and frequently leads to harmful massage that inter¬ feres with the normal mechanism in the expulsion of the placenta. Why use an intra-uterine mercuric chlorid douche for postpartum hemorrhage when sterile water is just as efficient and carries no danger of poisoning? The temper¬ ature of the douche recommended, 110 F., is much too low. It is not clear why a patient should remain absolutely flat on her back for six hours after labor, or why she should remain in bed from eighteen to twenty-one days. A temper¬ ature in the puerperium of 102, ascribed to excitement due to visitors, probably could be better explained by the fact that the abnormal temperature followed a manual dilatation of the cervix and a forceps delivery. Likewise a high tem¬ perature on the fourth day of the puerperium, ascribed 10 the appearance of milk, followed a bag and manual dilata¬ tion and fórceps delivery with deep tears in the vagina and cervix. More serious criticism could be made of the practice of the author in applying high forceps in occiput posterior positions. In Case 19 this resulted in laceration of the perineum and relaxation of the sphincter ani, and in Case 21 in shock, and laceration of the cervix and perineum. A study of the histories does not convince one that forceps were indicated, but rather leaves the impression that with suffi¬ cient and careful analgesia, the patient could have been satisfactorily managed either till labor was ended spon¬ taneously or until dilation was completed and the head descended, thus avoiding the difficulties and dangers of high forceps. Notwithstanding these exceptions, to a very few details, we find that most of the rules show wisdom, common sense and ripe, well-used experience. It deserves to be and prom¬ ises to become one of the most popular books on obstetrics that has appeared for some time. Miscellany Errors in Bactériologie Milk Analyses Great differences in the results of the bactériologie anal¬ ysis of identical samples of milk have in some places led to a discrediting of such analyses. No single count can be relied on. An average of two or more plates should be required in determining the bac¬ terial content of any sample of milk. Wide variations in the composition of the culture mediums do not make any noticeable difference in the bacterial count. In these tests it was found that variations in analyses were due largely to differences in technic. Among the reasons for differences were : laboratory errors, irregularities in methods of lab¬ oratory technic, such as shaking of the samples, amount of dilution, methods of counting by a counting lens, or with¬ out the use of one, etc. For instance, the extent of shaking makes a difference in the result. Counts from highly seeded plates are uniformly lower than the counts from low seeded plates. Best results are obtained when the plates contain somewhere between forty and 200 colonies. Another factor modifying the counting is the practice followed by labora¬ tories of estimating number rather than actual counting. It was found that there are irregularities in samples of milk from the same bottle, explained as due to the clump¬ ing of bacteria, and that the bacteria being solid objects cannot be expected to be distributed uniformly through the liquid. One sample may contain one fourth as many bac¬ teria as another from the same bottle. After determination of these causes for variations in the count and the adoption
doi:10.1001/jama.1915.02580090070033 fatcat:wr5bla2uufazzch6ajoszcorfu