Health Department acted at once upon this information, it is probable that we will soon hear of cases developing in this dealer's route.

This emphasizes a point given some prominence not long ago, namely, that pasteurization and sterilization methods will never be sufficiently effectual barriers against disease-in so far as bad milk may be a factor in its causation-until the dairies situated without the city's corporate limits and distributing milk within the city are under municipal control. Eternal vigilance only is the price of safety.

REDUCTION IN INFANT MORTALITY IN NEW YORK.

The Medical News of Sept. 5, 1903, contains an article by Dr. R. G. Freeman, on "The Reduction in the Infant Mortality in the City of New York and the Agencies which have been Instrumental in Bringing it About." Some startling figures are given, and graphic charts assist a proper appreciation of the results accomplished. While the steady reduction in mortality during the past few years is not charged entirely to the activity of the changing city administration, yet the impetus which an eye to the health of the city on the part of the administration gives private individuals, and the force it lends to enterprises having infant health in mind, are unmistakable. Therefore, with an efficient health department, we are not surprised to find that there is an ever increasing and fruit-bearing interest taken in the infants' welfare, and that new "guilds" and other charitable organizations are taking up the matter of summer feeding. Among the various causes enumerated as bearing upon the improved conditions, are: City administrations, sterilization of milk, milk inspection, Strauss milk charity, St. John's Guild, other fresh air charities, street cleaning, garbage and refuse removal, diphtheria antitoxin, asphalt pavements, recreation piers, small parks, improved tenement conditions. What relative value each one of these has, can, of course, not be estimated, but it is a grand array of disease fighting elements, and an object lesson par excellence.

An analysis of the figures given shows that the total infant mortality has decreased from 242 to 158, or about two-thirds, while the deaths during June, July, August and September, have decreased to somewhat more than one-half. The deaths from infantile diarrhea in summer, shows a reduction by one-half of the rate of 1901 or 1902. If statistics of this favorable character are obtainable in large cities, the improved conditions obtaining in smaller, well administered communities will doubtless demonstrate similarly good results. The agencies now at work in Milwaukee will still further reduce our rela

tively low infant mortality through the season is too far advanced to demonstrate the results of the recently introduced milk depot distibution as now employed here. This and the watchful supervision of schoolhouses, bakeries, dairies and water supply ought to place Milwaukee, already ranking high, highest on the score of healthfulness among the large cities.

NURSING MADE EASY.

We are in a progressive business age, when a new breakfast food or a new correspondence school is oftentimes developed in a night. One who is familiar with the advertisements in the lay publications can hardly be surprised to see an attractively illustrated notice stating that nursing can now be learned by correspondence! It may be something of a shock to the old-time practitioner, who has been used to the accurate, unobtrusive, trained nurse of the present time, to think of having to work with an artificially trained nurse, one made by a few weeks' cramming of correspondence.

We are not, as yet, familiar enough with the idea to understand how these graduates will learn to make beds, how they will become accustomed to seeing instruments and blood without fainting, and how they will learn to make those observations which are so helpful to the physician. Their gowns and caps and red crosses can easily be fashioned along with the engraving of their diplomas.

Foreign languages are now successfully taught by means of the phonograph, at least we are told so by the advertisements, and a correspondence school nurse might do wonderfully well with a moving picture device. First, she could study pictures of the movements and actions of those about the operating room, and after she had thoroughly familiarized herself with these she could reverse the machine and send to her teachers a series of pictures demonstrating how she would act and what she would do in certain emergencies. A phonographic attachment might be added to such a machine to accustom her to the scolding of some of the more crabbed old operators.

We trust that the demand for this type of trained nurse will not exceed the supply for some vears to come, and that in the meantime there will be enough old-time nurses to keep our hospitals running along the present lines.

SPECIAL CORRESPONDENCE.

OBSTETRICS AND GYNECOLOGY IN VIENNA,

On the whole, the practice of surgery in Vienna is much like that in America. In the lines of gynecology and obstetrics, however, there are very material differences. Things greatly dreaded in the States are done here frequently without fear of the results. On the other hand, measures which are undertaken almost daily in the practice of a busy American gynecologist are here rarely used. The practically universal occurrence of rickets is the chief cause for operative interference in obstetrical cases. A pelvis with normal measurements is indeed a rare sight in Vienna. Cæsarean section is practiced quite frequently-about ten times a year at each one of the clinics. Halban says that in the last six years not a single death has occurred as a result of the operation at the Schauta clinic. Therefore this has come to be looked upon as a relatively harmless procedure. Halban accounts for this good record by the fact that the contraindications to the operation are religiously observed. Cæsarean section is never undertaken if the patient has been examined vaginally before admission to the hospital-in which case she is treated as infected-or if her temperature is over 100° F. Probably at least one other factor contributes to the splendid results of this operation-the experience of the operators. At the Allg. Krankenhaus almost 10,000 women are confined annually in the three clinics. In the Schauta clinic I have seen the eighteen beds for women in labor all filled and three women sitting in chairs' waiting for a chance to go to bed. This vast material helps to make the assistants expert gynecologists and obstetricians after a few years of service. If the child cannot be delivered per vias naturales and Cæsarean section is contraindicated, craniotomy is given the preference of any operation, whether the child be alive or not. Symphysiotomy is not employed at all; it is claimed that the relatively slight increase in the pelvic diameters obtained by it, does not compensate for the dangers of laceration of the soft parts-that this is especially true if the forceps must be applied in addition. Judging from their results with Cæsarean section, they believe it to be the safer procedure, when the choice lies between the two.

In the matter of gynecology, the treatment differs radically in many respects from that practiced in America. In spite of the conservatism advised by modern teachers, surgical treatment is even much. less frequent in Vienna. Gonorrheal cases in the acute stages are never operated; when the infection becomes chronic, many measures

are employed before resorting to the knife. Thus, the appendages are rarely removed on account of gonorrheal pyosalpinx, and what may be effected by conservative means is really surprising. Tubbaths, sitz-baths, hot vaginal douches, tamponades, or, when the pain is not so very severe, pelvic massage by bags of mercury, are all employed. It is not at all unusual to note that in the course of a month a large painful swelling of the adnexa, in which the different parts cannot be distinguished, has almost completely disappeared, and that the tube and ovary can be felt as masses not much greater than their normal size. Large pelvic exudates are caused to be absorbed by similar methods, and there is no resort to operative measures unless fluctuation is very distinct. It is considered hasty and dangerous

to introduce a needle for exploratory purposes, until an abscess can be diagnosed with relative certainty.

When the appendages on both sides have become involved by gonorrhea, and conservative treatment proves of no avail, usually a complete extirpation of the uterus with its adnexa is carried out. In most gynecological operations, where such a thing is possible, the vaginal route is chosen. A myoma as large as a child's head, or an ovarian cyst of much greater size may be removed in this way without trouble. The chief difficulty lies in the existence of pelvic adhesions. Carcinomata of the uterus, however, no matter how small, are always removed by laparotomy, and Wertheim recommends removal of the iliac glands at the same time. The existence of demonstrable metastases in the pelvis is considered sufficient contraindication to any operation. If such are not palpable, Wertheim recommends laparotomy, no matter of how long standing the uterine tumor may be or what size it may have attained. The size of the primary tumor, he claims, is no indication whatever of the nature of the secondary growths, and hence, when in doubt, an exploratory laparotomy is always advisable. A case in which the whole uterus was carcinomatous, but in which no glandular or peritoneal involvement could be demonstrated, was operated upon, and now-four years afterwards-there is no recurrence.

Wertheim's first step in the abdominal extirpation of the uterus, whether surrounded by adhesions or not, is the exposure of both ureters throughout their pelvic course. The procedure is a very simple one: he incises the peritoneum over the ureters at the pelvic brim and follows them down to their entrance into the bladder. Since they remain exposed throughout the operation, there is no danger of their being cut or tied off. This appears to be much easier and more rapid than the preliminary catheterization of the ureters, which some have recommended in recent years.

In the case of ovarian cysts, Schauta advises the removal of the cysts in toto if a laparotomy is performed. The cyst may not be punctured or incised, no matter how large may be the opening required. He bases this recommendation on five cases, in which cystic metastases grew in laparotomy wounds in his experience. When, however, the cyst is removed by the vaginal route, he does not hesitate to puncture it. These apparently contradictory measures remain unexplained, but Schauta states that in his experience a cystic growth has never occurred in the vaginal wound. Wertheim believes that the danger of inoculation of a cystic growth into the laparotomy wound-indeed a rare occurrence-is out of proportion to that incurred by an enormous abdominal opening.

While each man of large experience in Vienna, as elsewhere, formulates his own indications and his own methods of surgical treatment, one striking fact appears common to all: that resort to the knife is much more carefully considered and much less frequent than among their American confréres. (L. M. L.)

Clinical Diagnosis of Intestinal Parasites.-STILES (Jour. A. M. A., July 18, 1903) refers to the difficulties in the way of diagnosis from the symptoms alone except in extreme cases. Blood counts are of great value and it is important to bear in mind the fact that an increased eosinophilia is an indication of possible infection with animal parasites. When this is present an examination of the feces for eggs or embryos of parasites should be made at once and if these are not found the possibility of trichinosis should be considered. Gross examination of the stools may reveal segments of tape-worm, or the entire adult worm in nematode infections, especially if the patient has taken a dose of calomel or of some anthelmintic, or has abstained from food for 24 to 48 hours. In the first stage of trichinosis the adult trichinae may be found; in hunting for them the stool should be diluted with warm water and examined in a flat glass dish over a black background.

A routine microscopic examination of feces is urged as a duty in all hospital cases and as far as practicable in private cases as well. The technic is simple as staining is unnecessary. A minute portion of feces is taken on the end of a match or a glass rod and thoroughly mixed on a large glass slide with enough water so that the resulting mixture is not too thick. Next drop on a cover glass, several may be used on the same slide, and the specimen is ready for examination. At least two cover glass preparations should be examined before a negative opinion is given. In this work the specimen and the preparation must be carefully protected from flies and the hands must be immediately disinfected if soiled by the feces to prevent accidental infection.

(A. W. M.)