a careful bacteriological investigation of the sputum of these patients, determining the kind of infectious organism that is associated with the tubercular infection, and when the use of an autogenous vaccine to get rid of the so-called mixed infection, will accomplish a great deal. In other words, to clear the deck for action, as far as possible, get rid of the accessory infection, and then we have to deal only with the tubercular organisms. Such a condition lends itself much more readily to those measures and means which experience has taught us in the way of rest, sunshine and fresh air, and nutritious diet, which will cause a satisfactory arrest of the condition.

If a few of these practical facts can be borne in mind, it seems to me the place of vaccine therapy would be definitely established much more satisfactorily and much sooner than might otherwise occur.

J. D. Allen, (Closing): In regard to the use of stock vaccines, I have seen some brilliant results from them, and I always recommend their use while an autogenous vaccine is being prepared, especially in acute conditions where some time is required in the preparation of an autogenous vaccine.

One point of interest in regard to vaccine therapy with reference to tuberculosis of the genitourinary tract is the use of tuberculin in conjunction with the vaccine. I do not think in advanced cases tuberculin should be used in conjunction with the vaccine for the simple reason that vaccine in causing a reaction at the point of infecion liberates a certain amount of tuberculin. That is to say, the patient inoculates himself. We all know that tuberculin is a very toxic agent and when used in excessive doses does harm. So in these advanced cases it is wise to care for the mixed infection with a vaccine, and then later use tuberculin.

LACERATIONS OF THE PERINEUM.*

By HUGH D. RODMAN, Bardstown. Lacerations of the perineum is an accident of childbirth which occurs in the hands of every physician who delivers babies; whether he be the ocuntry doctor, depending wholly on his own skill and judgment, or the college professor, who is regarded as an expert, and who can call to his aid, in a few minutes any number of his "expert" associates. The best accoucheurs in the world have reported lacerated perineums. And the most humble backwoods-doctor, will tell you that he sometimes has a torn perineum but not often. I shall class myself between these two, that is the teacher of obstetrics and the back-woods-doctor, and I say that I frequently have lacerations of these parts.

Obstetrical writers divide these tears into four varieties. This is well enough in a descriptive sense, but for all practical purposes we need no division of this injury; a tear is a tear and should be repaired; it matters not to what division or variety it may belong. I shall not include in this paper the tear of the mucous fold known as the fourchette, which some authors say is torn in all primipara, if this is torn it is of but little importance and does but little or no injury except as a nidus for sepsis. The tears with which we are concerned and which give the doctor and patient both great anxiety are those which divide the muscles and integument. It matters not for how short a space. All such tears are serious and should have our attention at once. We should always go prepared to repair a torn perineum and not leave it to fate or for the future work of a surgeon. Just how often lacerations of the perineum occur it is impossible to say, but that they occur very much more frequent than many of us are aware is certain, and this acident cannot always be avoided even in the most skillful hands and under the most judicious treatment is also certain, and that it happens very much oftener in primiparous than in multiparous women is also certain. Schroeder observed that it occurred in 34.5 per cent. of primipara and about 9 per cent. of multipara. Balandin says that it happens in about 26 per cent. of primipara and about 4 1-5 per cent of multipara, while Olshausen believes that 21 per cent. of primipara and about 5 per cent of multipara are torn. My own observation teaches me that in every 100 primipara deliveries at least 30 are lacerated, and 4 or 5 in every 100 multiparous cases.

Causes: Certain anatomical conditions of the maternal parts are especially liable to this

*Read before the Nelson County Medical Society.

accident. A large open pelvis with a sacrum as straight as a male sacrum in which little or no resistance is offered to the descending foetus, permitting the uterine contractions to force it violently down onto the perineum, which yields to such force and is torn. We have all seen that the vulval opening differs greatly in different women. In some it is almost on a line with the trunk and in others, is nearly at right angles with this plane; or to make this plainer, in some women the direction of the vaginal canal is nearly parallel with the axis of the pelvic cavity. In such conditions the descending head meets but little or no resistance, and active and strong uterine contractions force the head violently down on the unyielding perineum, and it is bound to tear. The extreme smallness of the vulva is another cause of lacerations. The average size from the clitoris to the posterior commussure is one and a half inches. I have seen cases which would not admit of but one finger on an examination. In this condition a tear is almost certain. On the other hand an excessively large head or shoulders of the baby is liable to tear the perineum. Certain presentations of the foetal head are liable to lacerate the perineum when forced against it by active and frequent uterine contractions. in a vertex presentation where the occiput rotates backward into the hollow of the sacrum, which places the largest diameter of the head in a position to pass first through the vulva; also in face presentations, where we have the longest diameter of the foetal head being foreed against the perineum, first, and the face being a bad dilator, we are almost certain to have a tear. When the labor is too rapid from the severity and frequency of the uterine contractions and especially if the sacrum is less curved than usual the head is driven through the vulva before the perineum has time to extend and a tear is the result. And if the labor is too tedious and the head remains a long time in the lower strait until the perineum becomes hot, dry, congested, and unyielding, and we proceed to bring about a rapid delivery, either by some of the oxytocides or by the unskilled use of the forceps, we may be sure of an extensive rupture of the perineum.

In excessively nervous women who will strain their very hardest, in spite of our advice not to do so, thereby forcing the head hurriedly against the perineum and through the vulva before the parts are dilated, we may look out for a serious tear. There are many other causes for this accident, but I will mention only one other, which is the unskilled or careless use of the forceps. This probably causes more lacerations of this part of woman's anatomy than all other causes combined. Gentlemen, I want to say to you that the perineum is frequently torn in deliv

ering the shoulders. I have seen a number of cases, in which I am sure the head passed over the perineum safely, and when I went to adjust things about the vagina, I found a serious tear. A notable case of this kind occurred in my hands a few months ago. A primipara who had been in labor for several hours, without satisfactory results. I made up my mind that a high forceps delivery was necessary and asked for a consultation. Dr. Gore was at once called. He agreed with me, and chose to give the anaesthetic. When she was well under chloroform, I adjusted the forceps and made intermittent tractions when the contractions came, until I was well nigh exhausted, when we exchanged positions, and after several minutes pulling and manipulating, he succeded in bringing the head into the world, and after removing his forceps we both made an examination of the perineum and congratulated ourselves that we had no tear, the shoulders were hard to deliver and when delivery was complete, we discovered to our sorrow that the perineum was laid open through the sphinter ani. So we cannot be sure that we will not have a tear till the second stage is complete.

Prevention: The question of the greatest importance now, is what means have we of preventing this accident from the various. causes mentioned and not mentioned. The old works on obstetrics all taught that to support the perineum was an absolute duty of the attending physician. But in recent years

that idea has changed. Writers now say that support does no good. I cannot agree with this opinion. I believe that the palm of the hand against the perineum at the proper time. does good. Williams advises that the best measures of preventing this accident is to place the thumb and three fingers against the vertex just as it begins to distend the vulva and in this way make forcible pressure against it during each pain thereby holding it back until the perineum is fully relaxed and yieldy, and in this way prevent the sudden rush of the head against the unyielding perineum. There are a number of other modes recommended to prevent this accident but none of them are eminently satisfactory. Quite a number of devices, one of which I will show you. have been invented to protect the perineum, but all are no good.

The best prevention of this accident in my hands is summed up in two words, support, and chloroform. Support applied in the following manner will do good. Apply the tips of two or three fingers of the right hand just behind the anus, and during the pain draw the anus and the entire perineum forward. This brings the palm of the hand directly against the distended perineum, to which firm pressure should be made during the entire

time of the pain. During the rest between pains make gentle friction to the perineum with the palm of the hand. Keep this up till the occiput begins to force through the vulva, then put your patient thoroughly under the chloroform and let the head pass slowly over the perineum. If you will follow this practice up closely. you will in many cases prevent a tear. Chloroform should be given in all cases where there is danger of a torn perineum. It is a good preventive of this accident.

As

Treatment: We have done our best to prevent a tear and have failed. What are we going to do now? Send for a surgeon? No! Sew up the tear yourself. Every physician should carry in his obstetric bag, a needle holder, a strong pair of hemostatic forceps will do, a few curved and half curved needles, some good twenty-day catgut sutures. soon as your labor is over, placenta delivered, parts thoroughly cleansed with an antiseptic solution, plug the vagina tightly with antiseptic gauze and proceed to sew up closely and neatly the torn parts, cover thoroughly the seam with sterate of zinc, remove the tampon from the vagina, place a thick fold of gauze over the vulva and the perineum, tie the patient's thighs together, instruct the nurse to keep her clean and use freely the zine dusting on the tear, keep the bowels quiet for two or three days, empty the bladder with the catheter for 48 hours if possible and in 99 out of every 100 cases you will have good

results.

Friedmann's Treatment of Tuberculosis.Wolff reports discouraging experiences with Friedmann's remedy, which he applied in 60 cases of pulmonary tuberculosis. Among 47 patients weighed at intervals, 28 lost weight, some losing from 8 to 22 pounds during the course of the treatment. Seven of the patients have died since. He gives the details in regard to the symptoms and Roentgen findings in 26 cases before and for several months after treatment and reviews his extensive experimental work with the Friedman. remedy, saying in conclusion that the experiences of the last thirty years in the treatment of pulmonary tuberculosis have all proved so disap

pointing that he thinks the victims of tuberculosis should be left in peace now and not have their hopes being constantly aroused with new medies, only to be dashed down again with t disastrous consequences for the patients.

TREATMENT OF DISEASES OF THE BREAST.*

By GUY P. GRIGSBY, Louisville.

My dealing with the treatment of thevarious lesions of the breast in my limited time, will necessarily be superficial in its scope. I wish Diseases of the Breast. As a matter of convenito acknowledge the liberal use of Rodman's ence I have arranged them as follows: Congestion and engorgement, acute mastitis, chronic mastitis, acute and chronic abscess and tumors of the breast, benign and malignant.

The treatment of congestion or engorgement, so-called caked-breast, usually occurs about three or four days following labor. Pressure and irritation at times is so great as to cause a slight rise in temperature that may be suggestive of suppuration. Hot, moist applications to the breast in the form of stupes and gentle massage with the object of emptying the breast is used. The effect of massage is best accomplished by the application of a flannel moistened with a hot, boric acid solution, applied to the breast and the massage being carried out while this is still in position. I would add a word of caution, and that is, that all applications and treatment of the breast should be done with utmost cleanliness, otherwise infection will ensue with a formation of an abscess. The breast may be gently rubbed with a mixture of benzoate of lard and lanolin: this to be sterilized by boiling before each application. The breast should be supported by a bandage. Later as the congestion subsides, pressure may be used, accomplished by the insertion of cotton or wool beneath the bandage.

Mastitis. Acute.-Prevention of this condition should be our endeavor and this may be accomplished by the rigid cleanliness of the breast and nipples before and during lactation. Prevention of fissures and their proper treatment will diminish greatly the occurrence of mastitis and abscess. It is quite unnecessary for me to mention to you the proper care of the breast and nipples during the nursing period. It consists mainly of cleanliness of the baby's mouth and the mother's breast. If despite this precaution, the nipples become inflamed, a shield may be worn or some bland ointment may prove of benefit to prevent or cure fissures of the nipple.

The treatment consists of combating the in

flammation by the use of hot moist applications, supporting breasts, discontinuance of nursing, use of breast pump, application of aluminum acetate or lead water. If these measures are unavailing and an abscess occurs, a

*Read before the Nelson County Medical Society.

free incision and drainage may be necessary. It is sometimes advisable in superficial abscesses to make a small incision and by the use of an instrument or tip of the finger to open up all the areas of infection; this may prove sufcient. Incision should be made to radiate outward from the nipple in order to keep from dividing the lacteal ducts. Drainage may be necessary and a counter opening may be indicated. Abscesses are located superficial, in the gland itself, or beneath it. The abscess should be opened at its most dependent point to favor drainage. It is sometimes possible to make the incision at the juncture of the breast and the chest wall; this obviates the presence of an unsightly scar. In those cases in which spontaneous rupture has occurred, one or many sinuses are usually present. These should be curreted thoroughly. Sometimes it is found necessary to excise them with some of the surrounding tissue. We are very prone in this class of cases to delay until extensive destruction of tissue has occurred, while an early incision would have saved the loss of gland tissue and much pain to the patient.

Chronic Mastitis.-There is much discussion still as to the etiology and the pathology of this condition and the treatment of the same is equally unsatisfactory. This is particularly true of those cases occurring without any well defined cause. Use of compression, iodine and belladonna ointment in equal parts or a phenol-glycerine 5 per cent, sometimes seems to favor resolution. In older patients amputation of the breast is advised because of the fear of malignancy.

Chronic Abscess. As soon as the presence of the pus is discovered, incision and evacuation of same is indicated. Drainage should be maintained a little longer in order to allow the gradual obliteration of the abscess cavity. Diagnosis of this condition usually gives more concern than the treatment, since this may be mistaken for a malignant affection.

Tuberculosis.-The treatment of this condition is open to much discussion, namely, as to the advisability of conservative measures. There are perhaps cases in which the disease is limited to a small portion of the breast, in which the excision of the diseased portion would be comparatively a safe procedure. Unfortunately, this seldom occurs and since there is no way to tell as to whether the disease has not already invaded other portions of the breast, it would seem that the safe procedure in cases in which there was doubt, that amputation of the breast should be done. Tuberculin has been used and some observers report rather favorably. I personally have never used it. Biers passive hyperemia induced by the means of a large suction cup would appeal as a very hopeful conservative measure in tuberculosis of the breast. It has

proven efficacious in bone and joint tuberculosis and this would seem a place where it could be used to advatnage. It should be used for five minutes at a time until the breast is a deep red color and then removed for five minutes, then reapplied for five minutes. The application by this method should extend over a period of forty-five minutes to an hour, daily.

Diffuse Hypertrophy.-The course of this disease is usually progressive, since it is due to a diffuse fibroma. Therefore, any results from local treatment should hardly be hoped for, and the logical treatment would necessarily be surgical. In fact amputation of the breast would seem to be the treatment indicated. In cases associated with pregnancy, expectant treatment is indicated, for often these cases will subside after delivery.

Tumors of the Breast.-Regarding treatment of tumors of the breast they are divided into benign and malignant growths. Unquestionably diagnosis of breast tumors and especially an early diagnosis is of vast more importance than the treatment. There has been so much written lately in regard to cancer, its diagnosis and treatment that there is a constantly increasing hope that something definite regarding diagnosis and treatment will emerge from the scientific investigations and experiments that are being carried on at the present time. Our diagnostic methods by means of the microscope are at present very accurate. Up to the present time, however, there is no definite means of determining the fact of malignancy or the benign nature of the tumor of the breast while it is in situ. Two facts, however, are clearly shown at the present time, one is that cancer is steadily on the increase and the only form of treatment of definite value is a wide removal of the diseased area while it is still a localized condition. The proportion of cancer to other tumors of the breast is about 80 per cent. and among the other 15 to 20 per cent. there is included other forms of malignancy such as sarcoma, and other new growths that early manifest the tendency to become malignant. So that it leaves us the startling fact that there are nine chances to one that a breast tumor is malignant. We are not interested particularly in the treatment or the diagnosis of these cases of carcinoma of the breast whose nature is hopelessly obvious to anyone, because these cases can only, very exceptionally be cured by the most skillful efforts. They are usually doomed when we see them. It is cases that may, or may not be carcinoma, that should be our chief concern. The cases so little pronounced that if they are really malignant they afford a reasonable chance for treatment. Unfortunately, it is in the simple conditions, namely of chronic mastitis, cysts, and other benign