there might be some unusual stomach coadition and so I advised the use of a test breakfast and a systematic examination.

The patient came in two days later according to appointment, accompanied by her landlady. She seemed to be a well developed and healthy looking country girl. Now it happened that it was a rainy day when she same in, and I questioned her about wet weather and she told me she came to town only when the weather was fine, and excepting for this appointment she would not have come on a day like this. I expressed a hope that she would not get sick this time, but without giving any reason. She returned home at once, after swallowing the stomach tube which brought up a slightly greenish colored fluid. A urinary examination made at the same time proved negative.

The patient came back the next day and at once remarked that she did not get sick on the way home and that this was the first time that she had been to town without getting sick. This was gratifying news-and incidentally confirmed my views on the causation of her illness.

I questioned the patient and she confirmed what had already been stated by her landlady. She says she does not go to church or sunday-school because she always gets sick afterwards. She gets along comfortably at the house, at home, excepting at times of company for dinner when the distressing feelings in the nose, forehead and back of the head come on; if there is a large company the after effecis are the same as going to church or of trip to town, that is vomiting will come on. Her landlady suggested that perhaps it wis the noise that made her sick, to which the girl dissented and remarked about coming to town yesterday and that it was noisy and that she did not get sick.

I now explained my views on the influence of dust, that is dust due to human activity and mixed with sputum (excluding dust of country roads), of dust carried into rooms by trailing dresses and of poor ventilation. I then advised her to come to town only on wet days and not to stop where people are massed together. She saw the point at once and readily assented to my views.

The patient of course expected some prescription to help her and she was given a prescription for a tonic. What to do fo

such cases to enable them to permanently overcome this susceptibility to the dust s another question; it is a question that I shall not take up at present.

Another case which I would like to mention in extenso, is that of a young man of 24, who ordinarily would be regarded as a neurasthenic but whose difficulties are due wholly to the influence of polluted air.

I may say that occasionally we meet with intelligent patients who do not expect impossibilities from a physician and who fully realize the importance of prophylactic measures and with whom we can discuss conditions freely.

The patient referred to belongs to this class and at my request he has written a history of his case to which he has appended some observations on dust and how it affects him.

Case of Mr. C., as written by himself, May 16, 1904:

"Age at this writing, 24 years.

Family: All long lived-no tuberculosis as far as can be traced. Mother and mother's family both subject to colds and nose, throat and stomach troubles. Mother always extremely nervous and exhaustel after such attacks. This condition also occurs in subject.

First appearance of complaint: Up to about five years of age no inflammations or cold troubles of any kind. Then a great susceptibility, always beginning in respiratory organs and canal, and ending in disturbed stomach-and muscular exhaustion. End in prolonged cough.

Conditions when in school and the vacation periods: Up to the time of starting to school no evidence of these symptoms, after that colds very frequent-growing less frequent and ceasing during summer months of vacation. Several vacations spent in country, where no disturbances occurrred. Recurrence of disturbances upon continuing school sessions.

Office work:

At 18 years leaves school. At 18 leaves school and takes office position. At first this position was not confining and allowed of one-half time in open air-during which time no great disturbances occurred. Then work became more confining and finally inside exclusively. Cold conditions became aggravatel immediately. After about two years of this work subject was compelled to quit work entirely for over eighteen months

during which subject suffered from continued colds, excessive nervousness and general weakness. This condition was owing partly to confinement and partly to overwork. About three months of the last part of this eighteen months of enforcel idleness were passed in the country. Those three months were more beneficial than anything else toward improving condition. Occupation since 18: Both indoor clerical work and outside work-no manual work. Habits sedentary, body sluggish. General condition pretty good until increased application to inside work-then condition became worse. Overwork and confinement to quarters in which practically no ventilation was possible, finally produced same condition as before—continued and frequent colds, followed by stomach disorders and nervous exhaustion.

Observations:

1. Office in which subject was occupied (was) below level ground with no facilities for ventilation, consequently dust and spittle deposited or blown into the room was held, and the air was never more than a slight per cent. pure. Whenever subject's work confined him to this place condition became rapidly worse.

2. Dust: It was observed that on clear sunny days condition very much improved, but two or three days of dusty weather again produced first nose and throat and bronchial irritations, and then stomach disorder, accompanying or following the cold condition, that disorder followed on exposure to blowing dust or indoor confinement with impure air. When at home. subject experienced no such disagreeable sensations as in the down town districts and districts where impure air was the irritant.

3. Railway trains: Two very severe colds can be traced directly to confinement for three hours or less in railway coach-in both cases all windows were closed and cars full of people-some of whom spat upon the floor frequently.

4. It has been observed that overheating in impure air will always produce cold condition.

5. Conditions always worse after attending public gatherings, meetings, etc., especially where the majority of the people assembled are men. At one political meting especially, where expectoration was unL

BY EDWARD J. McOSCAR, M. D., FORT WAYNE.

This paper is presented to advance a single point, viz., the delivery of that most difficult class of presentations with preservation of the pelvic floor.

The frequent occurrence of perineal rupture during labor especially in primipara has led physicians and laity alike to regard such injury as an unfortunate occurrence which is necessarily one of the penalties of child bearing.

That the condition is not infrequent, the numerous operations which gynecologists are called on to make give ample testimony. The still greater number who bear their sufferings for years without accepting relief but add to the evidence.

The process of labor is chysil gicl. Un. doubtedly it was designed to be accomplished and still maintain the function of parts which it calls into action.

In the normal positions of the head much may properly be left to nature

*Read before the Indiana State Medical Association June 10, 1904.

perform and the attendant has little else to do than to contemplate her ways and marvel at her accomplishments. In abnormal positions he should none the less recognize these and direct his efforts in accord therewith. Just so far as he disregards and runs counter to physiological aids will disaster to some degree follow in his wake.

In the occipito-posterior position, unless the child be diminutive, an effort should be made to change the position to the normal. This may be undertaken with reasonable assurance of success if the position is recognized before the head is well engaged in the pelvis. When the latter condition has obtained, the best directed efforts, even with the patient under complete anesthesia, will sometimes fail to accomplish the result.

Delivery must then be made, the position of the head favoring the greatest possible injury to the pelvic floor.

The successful management under such unfavorable conditions with a minimura destruction of the relation of the soft parts is a consummation devoutly to be wished, and the writer has reason to believe is more often obtainable than is generally taught and frequently experienced.

To

Many physicians who have had painful experiences with these positions assert that in many, perhaps in most cases presenting occiput-posteriorly, the destruction of the pelvic floor is well nigh inevitable. minimize such evil result and the better to facilitate repair, an able member of this society has suggested that the perineum be incised and thus prevent the ragged wound resulting from violence to be produced by the oncoming head. If it be true that perineal rupture is inevitable, this procedure of incising the perineum would no doubt better the resulting condition after labor and accordingly would merit consideration.

But many supposed inevitable tears are avoidable. There is a latent and unused elasticity of the perineum which is almost beyond comprehension until actually se n and realized.

It was when confronted by a bulging perineum with occiput posterior in a chubby nineteen-year-old primipara of short stature that the writer had this truth clearly demonstrated. With perineum stretched to its apparent limit the marginal line of marble whiteness and it might almost be

said of marble denseness, hugging a head the larger portion of which was a waiting claimant for space through which to make its exit, it was self-evident that the tear must be wide and deep. Yet after an hour or more the child was delivered without producing what could properly be called a laceration in the sense that t would require repair.

Enormous swelling followed the prolonged pressure and stretching of the tissues, which gradually resumed the normal when sufficient time had elapsed.

There existed the looked for separations on the mucus surface while the skin margin and deep structures remained intact.

Since the above case nine additional have occurred in the practice of the writer, making a total of ten occipito-posterior presentations during the past eighteen months. Four were primipara, six were multipara. In one, a multipara, the child was below medium size and did not unduly tax the outlet.

The others fully verified what the first case demonstrated, viz., that the pelvic floor and vaginal outlet is possessed of an elasticity commensurate with the requirements in unusual conditions. In one case, a primipara, there was a tear at the fourahette, which should have been avoided had the time for gradual stretching been sufficiently prolonged.

Laceration of the perineum is preventable and should be a rare occurrence if due care is exercised. It should not occur at all in normal presentations with normal anatomical conditions.

The rapid delivery of a head through an unrelaxed perineum, whether by expulsive power of the patient or by artificial aid. means certain rupture.

The slow delivery of the head, the pregress of which is controlled by the receding perineum, means that relaxation will be finally complete and the per neum will measure the circumference of the head anl will remain in tact. It would probably be difficult to form a definite conclusion as to the full stretching properties of the perineum, but nature is wise and generous in her provisions, and probably has placed no real barrier to the proper egress of legiti mate passage through this exit.

Whatever then finds its way through the muscle-lined bony pelvis should pass the

them as close together as I could and successfully manipulate the delivery of the child and I have never had very much laceration.

Dr. P. C. Holland, of Bloomington. in pesterior vertex presentations it is quite difficult to recognize them early. Many times the head is low before we recognize them. Many of them are premature deliveries and my experience is that it is very dangerous to the child. So far as rupture is concerned, I don't believe I remember any serious rupture without interference.

Dr. E. J. McOscar, of Fort Wayne. As to the unusual number of these cases. During the previous twenty years that I practiced medicine I don't know how many cases I had. They were rare. I reported the first case to our society, and since then there are nine additional cases reported. I have not taken note of them myself alone, but I have called upon the nurse or members of the family to observe the case. I would not go out and report them without having the evidence at hand. There is no question about these being bona fide occiput-posterior presentations. It does not make much difference whether the presentation is right or left; the head is coming down and in the last stage if the occiput is posterior it must come through the perineum, and if we can prove to ourselves an 1 the patient that it can be delivered without destroying the pelvic floor that takes in the whole category of head deliveries. shoulders give trouble sometimes, but nevertheless there are a large number of these cases that are up to the head, and in posterior positions when there is a rupture they are produced by the head. The waiting position is not a good one.

The

The man

who stands by for five days has not been at work at all. The last s'age is not on. So that the waiting process of five days or five hours does no good for that particular woman. But the obstetrician can do the most for the women when the labor is well advanced, when the head is ready to tear through the tissues, when he is there to make the uterus wait until there is sufficient relaxation of the perineum. It is not a matter of theory with me. When I was in school and afterward in practice under experienced men of great reputations I was told that in every case of this kind we would have a rupture into ne rectum and

it could not be helped. When I bel eved in the gentlemen who taught that these heads could not be delivered without a rupture of the perineum I had ruptured per neum. I have quit it. It is a calamity and a serious one to the patient. Think of any rupture upon yourself that would involve anything so diastrous as this is to the woman and take it home to yourself. It will be a disgrace some time to every physician that has one.

THE TREATMENT OF INFLAMMATORY PHIMOSIS.

BY GOETHE LINK, M. D., INDIANAPOLIS, Demonstrator of Anatomy in the Central College of Physicians and Surgeons and Lecturer on Anatomy and Physiology in the Indianapolis City Hospital Training School for Nurses.

We

By inflammatory phimosis is meant that condition in which inflammation complicates a phimosis or is its direct cause. Infections accompanied by sufficient swelling may be causative; among which may be mentioned gonorrheal urethritis, balanitis, papillomata chancroid and chancre. have found the syphilitic sore on the mucous membrane of the foreskin or ou the glans penis by far the most frequent cause. The swelling accompanying sypnilitic infection is almost permanent in character and if not relieved will produce an extensive ulceration of the skin as shown in the picture. We have seen this ulceration, in a neglected case, extend onto the pubes, the penis being entirely denuded. The glans, however, is usually intact, though wrinkled from prolonged confinement and pressure.

Our method of treatment depends upon the amount of swelling and pain present, and especially upon the cause of inflammation. An occasional case will yield to palliative treatment such as hot baths, subpreputial irrigations, etc. Measures to reduce swelling may avail if there was merely a redundant prepuce before the advent of inflammation. The surgeon is most often rewarded for his efforts in these cases due to gonorrheal urethritis and those which come early before swelling has resulted in hard infiltration. Owing to the anatomic structure this swelling produces a vicious circle; the more it progresses the less able the circulation is to combat it, and the greater the tendency to further