focus of tuberculosis in children is the bronchial glands. The lungs may be infected secondarily, directly from these, or the softened gland may ulcerate into trachea or bronchi, and the bacilli be drawn into the lungs. The tonsils are infected in several ways: the bacilli may be inhaled, they may be absorbed in some point in the pharynx, tonsils or esophagus, or they may be absorbed from the intestine and spread from the mesenteric gland upward.

Aufrecht believes that the lung tissue is never infected by the penetration of a mucous membrane of the respiratory tract, but that the main portal of entry is the mucous membrane of the digestive tract.

Behring argues against primary infection by way of the respiratory organs, and asserts that in order to have pulmonary tuberculosis to follow infection with inspired tubercle bacilli it is necessary to have constitutional changes in the organism due to a previous infection. Behring states his conclusions as regards consumption in the following words: "The milk fed to infants is the chief cause of consumption." In experiments on guinea-pigs he found that very young animals became tuberculous after a single feeding with the bacilli, and from this he concluded that the young of all mammals were very susceptible to infection through the intestine because of a lack of protective agencies in the alimentary system which are developed later in life. In this connection it might be well to mention the statement of Welch that one of the functions of the mother's milk was in transferring proper antibodies to the child, increasing the resisting power of the infant to infection. Behring investigated the intestinal mucous membrane of the young in order to discover why so little resistance was offered to the passage of bacteria. He found that the mucous membrane

in infants possessed no continuous epithelial covering, and that the gland-tubes of the ferment-producing glands are little if at all developed. He states that although phthisis pulmonalis may not develop until adult life, the real beginning of the infection dates back to infancy when the disease germs were first introduced into the body. He does not state that milk is the only source of infection, but that the bacilli-laden particles of sputum scattered in coughing gain entrance to the nose and mouth of infants and from there reach the intestinal mucous membrane. His main conclusion is "that an infantile tuberculous infection predisposes to pulmonary consumption."

The old assertion that the lungs are the primary seat of tuberculosis in man, the infection being conveyed by inhalation, is not susceptible of proof, and is no more probable than the assertion of those who have gone to the other extreme and attributed tuberculosis mainly to the ingestion of infected food. In considering this question, we are at present wandering in the vague domain of theory, but it seems, in the light of our present knowledge, that the digestive tract is the most frequent route of infection, the two main ports of entry being the tonsils and the intestines. We have also underestimated the importance of glandular tuberculosis contracted in childhood to pulmonary tuberculosis in later life. Baumgarten holds that the tubercle bacilli can remain latent in the tissue for a long period of time until, for some reason, the resistance is lowered and tuberculosis results. The cells of the lungs lending themselves most readily to influences of a trophic, toxic or traumatic character become the seat of a secondary infection. The portions of the lungs which are first affected are much more readily en

tered by the bacilli through the blood-stream than through the air-current.

The evidence as to the communicability of bovine tuberculosis to infants is so conclusive that there is no longer any room for doubt. The only point in question is as to the comparative frequency of this mode of infection. This source of infection is much more frequent than has been generally supposed. Certainly we have underestimated the frequency of abdominal tuberculosis in children. It is our duty to guard against tuberculosis infection in every way possible, and to insist on milk absolutely free from tubercle bacilli for infant feeding. The cows should be tested with tuberculin, and those which react positively should be separated from the herd. The statement that only milk from cows suffering from tuberculosis of the udder is infected, acording to the investigations of Mohler, is incorrect. Twelve out of fifty-six cows examined by him which showed no sign of tuberculosis of the udder gave milk containing tubercle bacilli.

It is to be hoped that the immunizing procedure of Behring, that is, the prevention of tuberculosis in cattle by the inoculation of a protective virus which is now being extensively tried in Europe, will prove a success, and we can remove this source of infection. Tuberculosis amongst the negro children of the South can be diminished to a large extent by improving the sanitary conditions of their surroundings.

ETIOLOGY AND PREVENTION OF PERINEAL LACERATIONS, WITH SPECIAL REFERENCE TO THE SHOULDERS.

BY ARCHIBALD SMITH, M.D., ATLANTA

Perineal lacerations of ordinary degree, though not usually considered serious complications of labor, are perhaps, on the whole, the most troublesome that we have to deal with.

The great trouble caused by them is due in part to their frequency, and also to the fact that an open wound in this locality, especially if not properly treated, greatly increases the danger of sepsis, not to mention the increased liability to displacements of the pelvic viscera. The frequency of perineal lacerations has been stated as ranging all the way from thirty-five per cent. in primipara and ten per cent. in multipara, in some of the large maternity clinics, down to one per cent., or even none, in the practice of some men who claim to have delivered large numbers of women, but probably never had any hospital experience.

Two comments might be made, in passing, on the latter statement-first, that it is not based on the observation of facts, and second that it is largely from the patients of such men that the gynecologist derives his perineorraphies, and Lydia E. Pinkham her customers.

The proper handling of the perineum, though much less spectacular in appearance, is, nevertheless, more important to the average practitioner than the performance

of a Cæsarean section, for he will seldom encounter a case where the latter is required, and when he does he will, as a rule, find it both practicable and advisable to summon the aid of a man skilled in abdominal surgery. But he will have an opportunity to show his skill or lack of skill in handling the perineum at almost every labor he may attend.

Briefly and in general terms, lacerations of the perineum may be said to be due to the fact that the parts of the child are larger than the vulvar orifice through which they must pass, and in order that passage may take place, the tissues surrounding this orifice must be either greatly stretched or sustain a solution of continuity.

Therefore, in avoiding perineal lacerations, we must, as far as possible, bring the smallest diameters of the child to coincide with those of the pelvic outlet during their passage through it, avoid direct impact of abrupt parts, like shoulders, against the perineum, and last, but not least, allow ample time for enlargement of the vulvar orifice to take place by stretching instead of tearing.

In delivering the head all of these points must be taken into consideration, and as the anterior positions of the occiput are most favorable to them; when a posterior position is diagnosed before engagement of the head an attempt should be made to convert it into an anterior position by external manipulation and postural treatment.

Now suppose the head to be at the perineum in the L.O.A. position, and making the usual progress: our chief concern will be to regulate its rate of progress and degree of flexion.

When a pain occurs the head should be allowed to advance till the perineum is well stretched, and then firmly held in position with the thumb and forefinger till the pain passes off. If after this the perineum remains thin