ovaries diseased in the abundant material coming under his observation at Pozzi's clinic.

The condition of the appendages when the uterus is the seat of fibroid changes has been dismissed by most authors with a few words. A few authors speak of inflammatory and cystic disease of the appendages, and Tait and Jones have endeavored to show that one was the cause of the other. But on the whole literature does not throw much light upon the subject.

There were two hundred eight operations for fibroids in Pozzi's clinic during the ten years from 1893 to 1903. Of these seventy-two or 34.6 per cent showed diseased appendages. If from the two hundred eight cases be deducted eighty-four cases where no reports were made, 59 per cent showed lesions of the appendages. Twenty-five per cent showed normal appendages.

The author has based his work upon two hundred five cases, seventy occurring at the clinic and one hundred thirty-five collected from the literature. He has found it convenient to divide the changes in the tubes and ovaries of the fibromatous uteri into three groups: (a) changes in the tubes, (b) changes in the ovaries, (c) changes in the remnants of the Wolffian bodies, and to these he adds a fourth group, (d) changes in the tissues near the appendages.

(a) Changes in the Tubes.-He finds that the tube can be the seat of all kinds of pathologic changes, the ovary almost always being affected as well. In the seventy cases from this clinic, twenty-five per cent showed catarrhal salpingitis-in the majority of cases accompanied by localized peritonitis with pronounced lesions of the ovaries.

Elongation of the tube is to be noted in a certain proportion of the cases. The most frequent change is hyperplasia of the mucosa and muscularis with round-celled infiltration, diminishing the calibre of the tube and at times causing obliteration.

Chronic parenchymatous salpingitis is not infrequently to be found accompanying fibrous tumors of the uterus, both in its hypertrophic and atrophic form. The tubes may be very much changed and very adherent to ovaries and the pelvic tissue.

Noncystic acute purulent salpingitis with patency of the uterine portion of the tube, was very infrequent. Pyosalpinx on the contrary was very frequent as proved by numerous observations. It was present in over eleven per cent of the clinic cases and may be unilateral or both sides may be affected. In the cases collected from the literature the percentage was even higher, sixteen to seventeen per cent.

Hydrosalpinx is quite a frequent accompaniment of uterine fibromata, fourteen per cent of the writer's cases being thus affected. The hydrosalpinx may be of any size, but is usually not larger than an ordinary pear. The abdominal ostium is always closed, the uterine opening may or may not be. The hydrosalpinx may be single or double, free or densely adherent with or without disease of the ovary.

Hematosalpinx is not particularly common, only 2.88 per cent of the cases showing this complication. It may be consecutive to a hydro

or pyosalpinx from a rupture of the blood-vessels in the walls or it may arise from torsion of the pedicle.

Tubercular disease of the tube exists in connection with similar disease of the ovary or there may be tubercular infiltration of the tube without tubercular pelvic peritonitis. On the whole it is rather a rare complication of uterine fibroids.

Ectopic gestation occurred in three per cent of Martin's ninety-one cases of fibroids. In fifteen cases where this complication has been observed, twice the tumor actually compressed the tube, but the abnormal gestation is probably not so much due to obstruction of the tube by this means as from the changes in the tubular mucosa which interfere with the downward progress of the fecundated ovum.

(b) Changes in the Ovaries.-According to the testimony of various observers the ovaries are frequently diseased in connection with uterine fibromata, and according to Gecco the ovary is more frequently affected than is the tube. The chronic forms of ovarian inflammation, both hypertrophic and atrophic are most commonly met with in connection with fibroids of the ovary.

As showing the frequency with which the ovaries are affected, it may be said that forty per cent out of seventy cases were diseased, while in the same number of cases only in seventeen per cent were the tubes the seat of disease.

Two forms of cystic ovarian degeneration have been noted-hydrocystic and hematocystic ovaritis. Besides these, according to the observations of Pilliet and other authors, certain changes in the corpus luteum have been occasionally recognized.

Suppuration of the ovary is comparatively rare unless accompanied by pyosalpinx. The same may be said of primary tubercular disease of the ovary.

Large cystic tumors of the ovary, associated with uterine fibroids, may be said to be rather uncommon. They may be divide into mucoid, dermoid, and mixed forms. There were two mucoid ovarian cysts in the seventy cases taken from the clinic, one being intraligamentous. They are more often unilateral than bilateral.

Dermoid cysts are even rarer complications and are more often situated upon one side. The rarest forms of ovarian neoplasms in connection with uterine fibroids are the solid tumors of the ovary (sarcoma, fibroma and epithelioma). Only one case was observed in seventy. In almost half the cases of coincident solid ovarian and uterine tumors, the former are also fibroid in character. Sarcoma, on the other hand, is extremely rare, and the same may also be said of epithelioma of the ovary. The author places the papilliferous cystomata with the malignant ovarian growths. They are occasionally met with as complications of uterine fibromata.

(c) Changes in the Broad Ligament Accompanying Uterine Fibroids. These may be considered under three divisions: cysts of the broad ligament, solid tumors of the same, and pelvic varicocele. The effects of the pelvic venous stasis, brought about by the uterine fibroma,

is especially to be observed on the ovary. Rousseau points out that the ovary, from the pelvic varicocele, may be increased in size, be edematous, and even pseudocystic. Again, it may, from the same causes, be the seat of atrophic changes.

(d) Changes in the Tissues Near the Appendages.-In this final division the author considers the changes in the appendages which are to be met with where the uterine fibromata are the seat of certain pathologic changes due to degeneration, malignant or benign.

An interesting case of this kind is reported by Mermet, where a fibroma the seat of telangiectasis showed changes in the appendages approaching gigantism. Both the ovaries and tubes were enormously hypertrophied, hard and indurated.

While true cancerous degeneration of a fibroid is not possible, carcinoma may develop simultaneously with a fibroid and be deposited secondarily in the appendages.

Suppurating fibroid, which Martin found ten times in two hundred five cases, can show purulent changes in the ovary while the same cannot be said of aseptic gangrene of the fibroid tumor.

Septic gangrene or necrosis of a fibroid due to putrid infection differs only from suppuration in the nature of the microorganisms. The appendages are acted upon variously by these gangrenous fibroid growths. The tubes may be infected by an extension of the septic process from the cavity of the uterus and a fatal peritonitis may result from the passage of the bacteria through the dilated abdominal ostium. Again, peritonitis may arise by direct extension to the peritoneum from the necrotic growth and the tubes and ovaries be involved secondarily. Cystic changes in the ovaries may follow twisting of the pedicle of a fibroma. At other times it merely produces an obliteration of the tubal cavity.

Daniel concludes as follows:

"The changes in the appendages when the uterus is the seat of fibromata are more frequent than we would think, as they occur in fiftynine per cent of all cases. These, however, include microscopic as well as macroscopic changes. All the pathologic lesions met with in connection with the tubes and ovaries will be found to exist with uterine fibromata."

PEDIATRICS.

BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN.

PROFESSOR OF PEDIATRICS IN THE MICHIGAN COLLEGE OF MEDICINE AND SURGERY.

REFLEX CONVULSIONS IN GROWING BOYS AND GIRLS. DOCTOR EUSTACE SMITH (London Lancet, January, 24, 1903), in speaking of reflex convulsions in growing boys and girls, says that convulsions due purely to reflex worry may be found in children as late as the twelfth year, and that in such cases there is almost invariably a history of a neurotic family and of convulsions during infancy. He

says these cases are often classified and treated as epileptics, but upon careful examination the convulsions will very often be found to be referable to the alimentary canal, excited by undigested and fermenting food. The nervous attacks are usually at long intervals and the children suffer from poor circulation and cold feet. The attacks invariably coincide with digestive disturbances or with some other form of local irritation, and when these cease the convulsions are relieved. Frequently irritation may be trivial, as, for instance, only a postnasal catarrh or adenoids. Many young persons who are so afflicted may with proper treatment grow into perfect adults, showing no further symptoms of the weakness of their childhood.

STERILIZED MILK, PASTEURIZED MILK, OR CLEAN MILK.

DOCTOR C. W. M. BROWN, in a paper read before the New York Medical Society, January, 1903 (Archives of Pedriatics, Volume IV, Number IV), in comparing the relative value of these as food for infants, summarizes briefly as follows:

(1) Sterilization at 212° is of great value especially in cities, and to the poor who lack intelligence, because it may be performed by anyone with simple apparatus, or in fact none at all.

(2) Pasteurization at 148° to 158° is to be preferred as milk is little changed in its taste or its chemic properties from the raw milk, and this temperature is sufficient to kill the pathogenic organisms and lactic acid producing bacteria. However, all agree with Holt, that heating of milk sufficient to kill bacteria does impair to some extent its nutritive properties and to a degree proportionate to the height of temperature. employed and the length of time it is continued.

(3) Fresh, pure, clean milk used raw is much to be preferred and it is now supplied to many of the larger cities.

(4) Fresh, pure, clean milk can be supplied to all cities and towns of even moderate size and should be sold only by those milk dealers having a license.

CHRONIC JOINT DISEASE IN CHILDREN.

DOCTOR HENRY LING TAYLOR (Medical News, August 16, 1902) says nine cases out of ten of chronic joint disease in children are due to tuberculosis. About forty per cent of these cases are vertebral, forty per cent are situated in the hip and about twenty per cent in all the other joints. One of the most marked characteristics of tuberculous disease of the joint is insidiousness. Another marked characteristic is stiffness or limitation of motion due to spasmodic contraction of the muscles. Pain varies much in location in cervical disease. It is found in the neck, the shoulder and the back of the head. In dorsal disease it is found at the sides or in the front of the chest and in the abdomen. In lumbar disease in the loins, back, lower abdomen, hips, down the thighs and sometimes in the knee, ieg, ankle or foot. The author says it is well to know that diseases of the lumbar spine, knee disease and

other affections, may cause pain in the knee and that it quite frequently is absent in hip disease. The limitation of hyperextension at the hip is the earliest and most delicate test in the disease of that joint. There are few chronic diseases in which early treatment is so beneficial, and in which delay is so serious as in chronic joint diseases in children.

INTESTINAL DISEASES IN INFANTS.

KERLEY (New York Medical Journal, November 22, 1902) contributes an article, covering a period of five years' experience, upon the prevention of intestinal diseases in infants during the summer among the most unpromising classes, namely, outpatients, which may be summarized as follows: One of the principles established was the necessity of temporarily discontinuing the milk diet in every case of vomiting and diarrhea, regardless of the nature of the attack, and the substitution of a carbohydrate diet in the form of plain or dextrinized gruel. He has demonstrated that egg albumen water is a dangerous milk substitute, and that beef juices and animal broth should be used. sparingly, and says it has been made clear that milk should not be resumed until the stools and temperature are normal, and then only in small amounts. It has been the custom for several years to discontinue the milk, to give a teaspoonful of castor oil, and to put the child on barley water diet upon the first signs of gastrointestinal derangement, regardless of the season, and then consult a physician or bring the patient to the dispensary. The large mortality from summer diarrhea is preventable and will be done away with when infants of the poor receive what they are entitled to-clean, suitably prepared, properly cared for and properly administered food. His dispensary work covers seven hundred sixty-two cases of intestinal disease, with a mortality of a trifle under four per cent. This low mortality is due to proper medical and dietetic treatment of the ill, to a fairly good milk and to the education of the mothers.

THE CAUSE OF DEATH IN DIPHTHERIA.

KOHN (American Medicine, January 10, 1903). In a general way death in diphtheria is due

(1) To mechanical causes.

(2) To the action of the toxin on the system.

(3) To one of the complications.

(1) Death from mechanical cause may be due in the early stages to spasm of the glottis; in the later stages it is nearly always due to occlusion of the glottis, either by membrane or by swelling and edema of its lining mucous membrane.

(2) Death from toxemia usually occurs at the height of the disease, that is, between the fifth and tenth days. In certain cases of so-called malignant diphtheria the fatal issue may be reached in twenty-four hours. In cases of mixed infection, notably when a streptococcus