The greater portion of the tumor lay at the entrance of the vagina, the remainder being within that orifice. The treatment consisted in absolute rest and the application of a lead wash. Four days later the tumor burst spontaneously. The sac was emptied of clots and the patient made a good

recovery.

In the second case, the patient, a secundipara experienced a burning sensation in the abdomen accompained by pain. Examination showed the left labia very edematous, and the seat of a tumor the size of an orange which extended up into the vagina. The same treatment was employed as in the first case and the patient was doing well with diminution in the pain and the size of the tumor, when the latter became infected from the insertion of a gauze tampon by the husband. An abscess formed which only healed after evacuation and long continued irrigation.

There probably was some connection between the varicose veins and the vulval tumors. Probably in the first case the hematoma was not caused by the midwife, but resulted from the rupture of varicose veins of the vagina as the head of the child passed through the birth canal.

TREATMENT OF CONTRACTED PELVIS.

R. P.

PROFESSOR FEHLING, of Strassburg, in his paper given before the Section of Obstetrics and Gynaecology of the British Medical Association in July, 1909, tells of his remarkable success in treating cases of contracted pelvis (British Medical Journal, October 9, 1909, page 1034).

He advises for multiparæ having simple flattened and rachitic flattened. pelves or slightly generally constracted pelves the induction of premature. labor between the thirty-fifth and thirty-seventh weeks. He uses a hydrostatic dilator and endeavors to secure a vertex presentation. His results are: eighty per cent of the children are born alive of which seventy-six per cent are discharged living. Of the latter eighty-two per cent were found to be living at the end of the first year (more than in the case of children born by Cesarean section).

With regard to the operative methods, the author's rule is to wait as long as possible, until it is seen that stretching of the cervix, fever, or slowing of the fetal heart sounds indicate danger to mother or child, or until it is clearly impossible to end the labor by any of the more usual means. With this method spontaneous labor occurs in eighty per cent of the cases. It is impossible to state in centimeters the exact indications for the different operations but in general he regards Cesarean section as absolutely indicated. when the true conjugate is 6.5 centimeters or less and the child is viable. The relative indication for Cesarean section is given when the "true conjugate of a multipara lies between 6.5 and 8.0 centimeters, and when other methods, as forceps, premature labor, even pubiotomy itself, have given bad results for the child. With a true conjugate measuring from 7.5 to 9.0 centimeters he performs pubiotomy.

He reports thirty-two cases of pubiotomy, seventeen done by the Döder

lein method and fifteen by Bumm's subcutaneous method. The technic and after treatment of the latter operation are carefully given.

Of the thirty-two cases one mother died. In this case the placenta. required manual extraction, and the mother succumbed to sepsis more than two months later. Twenty-seven children were born alive. The maternal mortality is thus 3.2 per cent, the infantile 9.2 per cent.

In regard to Cesarean section he states that he intends to replace the classical Cesarean operation with the cervical and expects better results from this than from the extraperitoneal operation.

In closing the discussion of his paper Professor Fehling states that the chief thing in determining for operative interference is the exact consideration of the labor and that after many years' use of all kinds of pelvimeters he has returned to the use of the hand; the first time he measures the pelvis under chloroform, and then remeasures two or three times without; then he takes the average.

N. N. W.

CHECKING THE SECRETION OF THE LACTATING

BREAST.

STORRS (Surgery, Gynecology, and Obstetrics, October, 1909) gives the results of his experiments along this line. His investigations were instigated by the report that the lacteal secretion could be successfully checked without complication by so simple a remedy as twenty grains of the acetate of potash administered three or four times a day, with the use of codia or morphia if the breasts were painful. The previous practice in the Johns Hopkins Hospital had been to use a belladonna plaster with a tight breast bandage, with the employment of massage and the use of the breastpump, and often several weeks elapsed before the secretion had entirely disappeared.

Although skeptical, the acetate treatment was tried, with very satisfactory results. Patients at various stages were treated and observed. Not a single case of mammary abscess developed.

In general his observations were that on the third day after nursing had been discontinued the breasts would become engorged with occasional "caking," and lumpiness in the axila. The engorgement persisted from twenty-four to forty-eight hours, and was associated with a varying amount of pain. The engorgement then began to disappear and the pain left immediately after the engorgement had reached its height and always by the end of a week lactation became entirely checked. Occasionally it was necessary to give codia or morphia for the pain.

A series of experiments was made to ascertain how potassium acetate. gave such good results. Three groups of patients were experimented on, one group receiving potassium acetate, another sodium chloride, and another no drug. All did equally well, showing that the acetate treatment had nothing specific about it. It apparently made no difference how much fluid was used by the woman during the checking of the milk-flow. The main point is not to touch the breasts, not to massage them, and not to use a

breast pump. The act of drawing milk is simply the stimulus for more milk to be secreted. The old methods at Johns Hopkins are now abandoned, and the breast pump, belladonna plasters, tight breast bandages and the act of breast massage are no longer used. The breasts dry up quicker and the patient has less discomfort than before.

G. K.

UTERINE CANCER COMPLICATING PREGNANCY. LOCKYEAR reports two cases of carcinoma of the cervix complicating pregnancy at term, (British Medical Journal, October 9, 1909, page 1044). In one case the condition had been mistaken for placenta previa. What was taken for the placenta, however, proved to be a cancerous mass which completely blocked the vagina. Cesarean section was done, but the carcinoma was so far advanced that no operative curative measures were attempted. The mother died in a few weeks, the child lived and was strong and healthy.

In the second case, Cesarean section followed by Wertheim's panhysterectomy was done during the thirty-third week of pregnancy. Some five weeks previously it had been necessary to excise a large cauliflower growth from the anterior lip of the cervix because of severe hemorrhage. The Cesarean section was done as soon as it became evident that there was a local recurrence of the malignant growth. The child only lived twenty-five hours. The mother made an afebrile and uneventful recovery and no recurrence was found in her when examined six months later.

In regard to the feasibility of the Wertheim operation in the gravid uterus the author states that all the details of this procedure were much more easily carried out than in any of his other thirty-two cases of the Wertheim operation for removal of the nongravid uterus.

PEDIATRICS.

ARTHUR DAVID HOLMES, M. D., C. M.

N. N. W.

A PRACTICAL METHOD OF REDUCING THE INFANT MORTALITY FROM SUMMER DIARRHEA.

HERMAN says (Pediatrics, August, 1909) the problem of infant mortality must be solved in the tenements, as by reason of the large numbers and gross ignorance, the vast majority of deaths occur here. It is a significant fact that the infant mortality is highest in those countries where illiteracy among the women is greatest. The questions of proverty, poor housing, alcoholism cannot be materially influenced within a few years, but the colossal ignorance on questions of infant feeding and hygiene can be immediately dealt with. In no department of medicine are proper measures more likely to be followed by striking results than in the reduction of infant mortality. The author advises sending nurses to the tenement mothers

soon after receiving the birth certificates from a midwife, or person not a physician. The mother is given the necessary instructions in infant feeding and hygiene. Printed directions are left, especial attention being given to ignorant, careless mothers and to illegitimate, artificially fed, and boarded babies. By this method the vast majority of these babies can be kept at the breast, and the mortality lowered even under the most unhygienic surroundings. A canvas of the city by the department of health, which included almost all the tenements of the burrough of Manhattan, showed that about eigthy per cent of the mothers give the breast. A much larger number could nurse their offspring if they received the proper encouragement and assistance, as many stopped nursing or are advised to do so for insufficient reasons. The absolute contraindications to breast feeding are very few.

OPHTHALMOLOGY.

WALTER ROBERT PARKER, B. S., M. D.

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.

ETIOLOGY OF IRITIS: A REPORT OF FIVE
HUNDRED CASES.

CHARLES W. JENNINGS and EMORY HILL (Ophthalmology, Volume VI, Number 1) give a full report of five hundred cases of nontraumatic iritis taken from the clinical records of the Wills Eye Hospital.

Syphilis, rheumatism and gonorrhea together caused ninety-two per cent of the cases. The majority of the cases of syphilitic iritis occurred between the ages of twenty and fifty.

Of the three hundred and seven cases, the iritis occurred in fifty-two cases within one year following the chancre, and in fifty-six cases was coincident with the various secondary lesions. Thirty-four cases presented syphilitic nodules on the iris, which the majority of writers claim are secondary lesions, rather than true gummata. This would seem to be the case in the series reported since twenty-one of the thirty-four cases developed the nodule within eight months after the chancre, or else were coincident with the secondary lesions elsewhere. The comparative infrequency of recurrences in syphilitic iritis as compared with rheumatic and gonorrheal iritis is shown by the fact that in only 19.4 per cent of cases had there been previous attacks of iritis.

Rheumatism was the etiologic factor in 25.4 per cent of cases. Recurrences were noted in 55.1 per cent cases, a striking contrast to the small per cent in syphilitic iritis. The iritis was coincident with the rheumatic attack in twenty-two cases, while in sixty-five it followed from a few months to thirty years later.

Gonorrhea was the etiologic factor in twenty-six cases, all of which gave a clear history of gonorrheal urethritis of which ten had articular rheumatism. All the cases were in males. The urethritis coexisted at the time of the iritis in three cases, and preceded the iritis by from one to twelve months in six cases, the longest interval being eighteen years. Eight of the twenty-six cases gave a history of fourteen previous attacks of iritis, a much larger proportion than in the syphilitic cases. In no case did a recurrence of urethritis accompany a recurrence of iritis.

Seven cases gave a history of influenza, four of which showed posterior synechiæ persisting after treatment.

Tuberculosis was the etiologic factor in six cases or 1.2 per cent, five of which showed corneal involvement seemingly secondary to the iritis. Two of these cases are being treated with subcutaneous injections of tuberculin and show improvement.

Exposure to wet or cold was evidently the cause in seven cases or 1.4 per cent. Malaria caused six cases or 1.2 per cent. Three cases occurred in women who were nursing infants without any history of definite cause. Syphilis must be considered here. Also autointoxication, which can give rise to iritis, must be considered as a probable factor in iritis following childbirth.

Intrauterine iritis occurred twice, which is of interest because of its rarity. Hutchinson states the average time at which infantile iritis shows itself is about five months.

Diabetic iritis and gouty iritis occurred once each. The remaining seven cases were due to the following causes: typhoid fever in two cases; pneumonia, cerebrospinal meningitis, measles, lead poisoning, and rhus toxicodendron poisoning, each in one case, which go to show the manifold etiology of iritis.

"In conclusion we would write that syphilis causes the majority of cases. of iritis, rheumatism a large minority, gonorrhea a small minority, while