The third stage of labor is generally dangerous from hæmorrhage and sloughing. The doctor concludes his paper with the following resume: 1. Prophylaxis.-Every fibroid during the child-bearing period, with few exceptions, should be attacked by surgical means. During Pregnancy.-Safe fibroids, i.e., those beyond the dilating zone of the uterus, should be carefully watched. Every complication during pregnancy, depending upon the fibroid, should warrant our attacking surgically the condition, or, at least, provoke us to the indication for emptying the uterus. 3. During Labor.-(a) Again safe tumors need watching. The resultant complications must be met energetically, but gently, as they arise, i.e., hæmorrhage, tardy labor. (b) Tumors which cannot be displaced, blocking the bony passage, warrant vaginal enucleation (seldom possible), or Caesarean section, followed by hysterectomy. 4. Sloughing and Necrosis.-This condition of a puerperal fibroid must not be mistaken for retained secundines. This doubt must be eliminated by exploration with the clean, aseptic hand. Retained secundines are always to be removed manually and, under no conditions, must the curette be employed, because of the great danger of laceration of the capsule, and consequent sepsis. 5. Sloughing and necrotic fibroids are always to be attacked surgi cally, either by enucleation or by hysterectomy. BEARING-DOWN PAINS. Dr. Bedford Fenwick, of the Hospital for Women, Soho Square, London, recently gave a clinical lecture on this subject to the Out-Patient Department. Among the causes of this symptom he mentions : Cervical Polypus. He says this is an often-overlooked cause of "bearing-down", although it was the most prominent symptom in the patient presented. She was also very anaemie. This case was contrasted with another who complained bitterly of bearing-down pains, and who was found to be suffering from a small fibroid in the uterine walls. The latter by its mere weight pushed the uterus down just as the other growth, hanging from the cervix, pulled down the organ. The symptoms in these two cases were relieved-in the one by removing the polypus, and in the other by lifting up the heavy, enlarged uterus by placing a well-fitting ring pessary. Lax Abdominal Walls.-This, the writer thinks, is one of the most common causes of "bearing-down." In this case the patient was 45 years of age, had had seven children, and said that after each confinement this particular pain got worse, till it became almost unbearable. From the history of this case one would suspect she might be suffering from prolapse of the uterus. On examination that organ was found in good position, and there was no falling of the vaginal walls. The secret of her trouble was an extremely lax abdominal wall. There was considerable adipose tissue and the anterior wall dropped down over the pubes in heavy folds. The lack of support to the abdominal contents allows a considerable amount of dragging upon the intestines and mesentery. These cases are treated by the application of the interrupted current and the use of a well-fitting abdominal support. Chronic Constipation.-A patient was now shown whose chief symptom was "severe bearing-down pains," and on vaginal examination the pelvic organs were found in a healthy condition, nothing in either uterus or uterine appendages being found to account for the troublesome symptom. The rectum was found loaded, and the colon, as far as one could feel it, seemed equally distended. The doctor said, "It was evident that in such cases as this the one drug which could be used with advantage was the sulphate of soda-it answers much better with most women than the sulphate of magnesia. He then prescribed— A later report is, that the bearing-down pain of which she complained so bitterly had entirely passed away and she had improved in appearance and color, and increased in weight. Urethral Growths. The patient who illustrated this case was 53 years of age, and for the past three years, since the menopause occurred, she had complained of an increasing amount of bearing-down pain. Apparently this was her chief symptom. She gets worse after any exertion. The pelvic organs, on examination, were found quite normal for one of her age. There was found a flesh-like growth occupying the urethral orifice and extending half an inch below it. This is commonly termed a vascular growth of the urethra, an affection which is most common at her time of life. The cessation of the catamenial loss prevents the vascular system from being relieved, as it has been for some 36 previous years, and the natural consquence is that women suffer, at the so-called "change of life," from symptoms of abnormal vascular tension. They get the flushings of the face, the frequent perspirations, the great nerve depression, the various mental conditions, all and every one of which signify overloading of the vascular system. With these vascular growths there may be frequent micturition and sometimes bleeding in addition to the bearing-down pains. The only treatment for this condition is the removal of the growth freely with scissors, the patient being under an anesthetic, the base of the growth is seared well with Paquelin's cautery in order to prevent a recurrence. Growths in the Bladder.-In cases of disease of the base of the bladder and especially when this takes the form of new growths, the symptom of "bearing-down pain" is often acutely complained of. The doctor here mentioned the case of a lady with a large stone in the bladder. The stone was crushed and washed out and the bearing-down pain was immediately and permanently relieved. Vulvar Growths.--Various diseases of the Nabothian glands will frequently cause this troublesome symptom. Sometimes these are very chronic. It is perhaps only when they become much increased in size that the bearing-down pain becomes troublesome. After abscesses of these glands have been opened the after-treatment is important. The application of poultices to the labium often sets up considerable oedema, and tends to promote the formation of fresh glandular inflammation. The poultice should be small, should be applied simply to the opening of the abscess, and, as soon as the discharge has ceased, the poultice should be discontinued, and a dressing of dry lint applied. Bearing-down pains may also be caused, either by an enlargement of the labia, a normal hypertrophy in fact, or by a pedunculated growth. OBSTETRICS AND DISEASES OF CHILDREN. Under the charge of D. J. EVANS, M.D.. Lecturer in Obstetrics, Medical Faculty, ECLAMPSIA WITH REPORT OF CASES. Dr. L. M. Allan reports, in American Journal Obstetrics, February, 1905, 33 cases of eclampsia and 10 cases of toxæmia of pregnancy in a series of 3,400 confinements in the In and Out-door departments of the Free Lying-In Hospital of the University of Maryland. Nephritis was present in all the eclampsia cases and in 90 per cent. of the cases of toxæmia. 27 per cent of the mothers recovered and 59 per cent. of the children. In one case convulsions developed seven days after the death of the foetus, as could be proved by its macerated condition when born. The author's conclusions, whch sum up the results of this interesting study of clinical material are as follows: 1. Eclampsia is due to the toxin which very probably has its origin in the liver. 2. Its origin is maternal rather than fœtal. 3. Premonitory symptoms are always present. 4. The most constant and important premonitory symptom is frontal headache. 5. The diagnosis of toxæmia of pregnancy should be made early, and if the patient is under observation this can generally be done. 6. The mortality should be kept under 20 per cent. 7. Treat premonitory symptoms until, in spite of treatment, they get worse, then empty the uterus as in some cases this is the only method of stopping the progress of the disease. 8. Deliver as quickly as possible, consistent with cleanliness and preservation of the soft parts; bleed, removing from 300 to 700 c.c. as the case may indicate; infuse, giving from 500 to 1000 c.c. of salt solution, depending on the amount of blood withdrawn and the character of the pulse; this may be repeated later; morphia gr. 1, hypodermically, to relax the muscular system; croton oil gt. 1 to 11 in olive oil dr. i to dr. ii, followed by magnes. sulph. half ounce, in saturated solution, until effectual as a purgative. 9. Milk and water diet. 10. Other conditions treated systematically. DISTURBANCES OF DIGESTION IN INFANTS, RESULTING FROM THE USE OF TOO HIGH FAT PERCENTAGES. L. Emmett Holt, in Arch. Ped,. Jan., 1905, states that excess of proteid in milk, the mixture supplied to an infant has long been recognized as the chief factor in the production of disturbances of digestion. In this paper, Holt calls attention to the serious consequences of a too high percentage of fat in food mixtures. Several cases are reported. In all, the infants at first thrived on high percentage fat mixtures, but usually suddenly severe symptoms of indigestion developed. These symptoms were general convulsions, enlargement of the liver, rickets and severe indigestion. In a few of the cases constipation was a marked symptom, the motions, when pass ed, were hard, dry and of a grey color, and consisted almost entirely of undigested fat. In all the cases, the food mixtures administered were found to contain approximately 7 per cent. of fat. The cream used was obtained from the milk of a herd of Jersey cows. When the fat percentage in the food mixture was reduced to a low limit, the cases improved. In all the digestive disturbance was of such severity that recovery was slow. Physicians may avoid such mistakes by ascertaining approximately the fat content of the milk, cream, or top milk used in making up food mixtures. To be successful in the feeding of infants the physician must learn to think in percentages. Holt considered that infants differ considerably in their capacity to digest fat as in other respects. He considers that four per cent. is the limit for the average child, and states that he has never seen any advantage, but often much harm result from raising above this. The bad results of the higher percentages may not be at once apparent, but they are almost certain to come later A CASE OF CAESAREAN SECTION WITH TWO UTERI Dr. Ranken Lyle, in the Scottish Medical and Surgical Journal, gives some "Notes on an interesting case of Cæsarean section at full term in a patient with two uteri and two vagina." The woman was thirty-one years of age, and had had three abortions in successive years. Prolapsus uteri followed the ultimate abortion and was treated for seven months with a Smith-Hodge pessary. A year later her doctor found her in labor at full term. The os uteri was then the size of a florin, and was displaced forward by an irregular hard mass (the size of a closed fist) immediately in front of the sacrum. An aperient and an enema were given under the impression that it was due to hardened fæces, but with no effect on the obstruction. After the lapse of two hours, as the pains were strong and the head high up in the pelvis, and its advance impossible, Dr. Lyle was asked to see the case. On examination, the rectum was found empty and the mass was diagnosed as a fibroid in the pouch of Douglas. As delivery per vias naturales was impossible, Cæsarean section was decided upon. On opening into the abdomen, the uterus was found in front. It was opened and a living child with the placenta removed. The wound was closed and the mass being lifted up was found to be a myomatous uterus independent of the other and attached to the top of the vagina on the right side; it had one ovary and tube on the outer side, but none on the inner. There was a reflection of |