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Etiology .—The great frequency with which fibrosis occurs as the cause of true primary cervical dystocia is indicated. Conclusive evidence of the presence of continuous circular fibers (sphincteric type) is not forthcoming. It seems that ordinarily the caliber of the canal is maintained passively by the anatomic conformation of the organ as in the case of other nonsphincteric orifices. Doubt is cast upon the existence of such a condition as "spasmodic cervical contraction" during labor. In cases where such a diagnosis has been most frequently made, there are very often psychic or other general factors which, on careful analysis, will prove to be the actual cause. Other factors which may occasionally cause a cervical dystocia are discussed: syphilis, displacement of the os, adhesive membranes, overlapped cervical lips, etc. The condition called "Conglutinatio Orificii Externi" is considered. Diagnosis .—In the diagnosis, extracervical factors must be eliminated and fibrosis should always be suspected. In its absence, the most frequent factors causing an apparent cervical dystocia are (1) a misinterpretation of the patient's reaction to the very early stages of labor, giving the impression of prolonged labor without commensurate cervical change. (2) Active voluntary resistance to descent occasioned by the pain consequent upon pressure on the cervix. Treatment .—If an apparent cervical dystocia is not due to fibrosis, the most favorable results will follow watchful expectancy and the advised use of sedatives. Such methods will decrease in efficiency in direct proportion to the degree of scar tissue involvement, but may be helpful in any case. The use of bleeding and the warm bath is discussed. The insertion of weighted bags where fibrosis is a factor is condemned. Manual dilatation is seldom advisable, and instrumental dilatation never. The correct use of incisions is advised and described. Vaginal and abdominal cesarean section are discussed.

1. 1. Sixty-five cases with the pathologic diagnosis of ectopic pregnancy are reviewed. For this report some general considerations are omitted in favor of the more pertinent and timely aspect of the problem. 2. 2. The impression that previous operations, abortions, and pelvic infection contribute to the incidence of ectopic pregnancy is supported by our findings. 3. 3. Hematology and blood pressure observations support generally accepted conclusions. Our experience with transfusion parallels that of most other observers. Autohemoclysis, as an emergency measure, has been used with consistent benefit, where more suitable blood is not available. 4. 4. In 28 cases surgery other than removal of the ectopic pregnancy was performed but not in the presence of infection or free bleeding. These patients did exactly as well as the rest of the group. It is thought that this surgical attention may account for the fact that no second ectopics are recorded (28 per cent sterilized). Other reported incidence is 3.6 to 22 per cent. 5. 5. Our mortality rate is 3 per cent. Diagnosis was 80 per cent correct. The routine use of the Friedman test has improved our percentage of correct diagnoses. 6. 6. Seventeen endometriums were available for pathologic examination. Had these tissues been obtained by curettage, diagnosis would have been assisted in only 6 out of the 17 and definitely confused in the remainder. 7. 7. Microscopic examination of the tubes and other tissues indicates some further basis for the hypothesis of ectopic placentation in areas of ectopic endometrium or decidua. 8. 8. Cul-de-sac puncture has been harmless and exceedingly valuable in diagnosis. The peritoneoscope has been used. Its status is discussed. 9. 9. Three unusual cases are reported and illustrated.

To the Editor: —An article in your June issue by Drs. Stein, Leventhal and Sered, entitled "Cervicovaginitis," I feel is of considerable interest and importance. As these authors noted, Hess' observations on autopsy material long ago called attention to the presence of "cervicitis" as a factor in the stubbornness of infections of the lower genital tract in female infants and children. I also called attention to clinical observations of the same condition in October, 1927. An important point that was not stressed in Dr. Stein's recent communication is that this "cervicitis" is in the vast majority of cases strictly a cervicitis and not an endocervicitis. This point was made clear by Hess and has been verified in my experience, almost without exception. The condition, then, since it involves the vaginal portion of the cervix and seldom the endocervix, is really an integral part of the vaginitis. That this is true

The usual treatment for acute vulvovaginitis in infants and in little girls has seemed fairly satisfactory, because, with ordinary measures insuring cleanliness and mild antisepsis, the condition is apt to be self-limited. The treatment for chronic vaginitis or vulvovaginitis, especially with a complicating endocervicitis, offers a much more difficult problem. I will present some material which has been of great assistance in the study and treatment of these obstinate cases in private and in institutional practice. The common complaint is of a vaginal discharge of long duration which is noticed because the clothing is stained, or because there is irritation about the vulva. Burning urination or the presence of an odor may be the complaint. Occasionally there is a history of atypical acute vulvovaginitis, preceding the chronic condition, but it is uncommon to obtain a history of real value in regard to the possible source of infection. The picture is

Cysts of the vagina are by no means uncommon. The presence of a congenital benign cystic neoplasm in the labium minus, however, is unusual and interesting. The American literature contains a dearth of such reported cases. Dr. Fredrick J. Taussig 1 stated that, "Neoplastic cysts of the vulva are extremely rare." Included in this statement are such rare conditions as tumors of the sweat glands, mucous cysts, papillary cystomas and epidermoid inclusion cysts. It is because of the extreme scarcity of reports of lymphangiomas or lymphangiectasis in this location that we feel justified in presenting a case of this sort, which has recently come under our notice. REPORT OF CASE History.— A white girl, aged 17, about five months in her first pregnancy, was seen in October, 1927. In the course of a routine examination an unusual prominence of the labia minora was noted. Close inspection showed a cystic growth

through the gamut of emotional problems that are created by ignorance or physical embarrassment, or by the girl's special environment. Finally the nurse becomes a court of appeal in questions concerning true anatomical or pathological irregularities. She can, by virtue of her special training, and by her personal example, prove that menstruation is a harmless physiologic function and need seldom be accompanied by psychologic disturbance, physical pain, or incapacity to work. An understanding of the normal menstrual cycle is important as a preface to a consideration of the irregularities which occur when it is beginning. The estrous or ovarian cycle begins with the rupture of a graafian follicle through the covering of the ovary, freeing the ovum, which then enters the Fallopian tube (oviduct) to be met by a sperm from the male and to be fertilized. In the meantime preparations are going on in the ovary and in the uterus for the expected pregnancy. The follicle from which the egg has ruptured now fills in with yellow cells and becomes the corpus luteum, an important organ of internal secretion during the first three months of pregnancy. The walls of the waiting uterus become deep and soft and richly supplied with blood vessels to nourish the awaited inseminated ovum. The fertilized egg itself undergoes certain changes en route through the oviduct which will enable it to attach itself to the walls of the uterus when it arrives. This is the biological cycle that nature has pla n d. However, if, as is most often the case, the ovum is not met by a sperm in the oviduct, these preparations have been made in vain. The follicle heals over, the ovary sets about readying another egg for the next cycle, the unfertilized ovum descends through the uterus and on out, and the uterus, defeated in its purpose, sheds its endometrium and begins to weep its biological tears of blood. But its frustration is not for long. The allseeing pituitary at once begins the preparations for another, and another, ovum until pregnancy can take place and the true biological purpose be fulfilled. This, the tale of a disappointed uterus, is the story which nurses will be called upon time and again to tell. It is, perhaps, the biological frustration underlying the entire phenomenon which lays it open to so many trials and tribulations. Often the sincere telling will be helpful enough to the adolescent, but, unfortunately, all the problems attending menstruation at its onset are not so easy. To give direction to our necessarily brief discussion of these graver issues, we have chosen the following headings: (1) psychic and emotional disturbances, (2) precocious cyclic bleeding, (3) delayed menarche and primary amenorrhea, (4) cryptomenorrhea, (5) oligomenorrhea, (6) menorrhagia, and metrorrhagia, (7) dysmenorrhea, and (8) intermenstrual pains and tenderness.

GENERAL STATEMENT Shortage of man power and economic pressure necessitate the employment of millions of women in industry. Sufficient medical data are not available to draft final recommendations about the effect of various kinds of employment on the gynecologic or future obstetric health of unmarried or childless women, on the pregnant, puerperal or lactating women or on mothers with home and family responsibilities. However, it is common experience in industry that women absent themselves from work much more often than men and that the duration of individual absences tends regularly to be longer. The available data do not clearly assign the responsibility for this tendency directly to obstetric or gynecologic functions (although it has been taken for granted by some) as against ordinary causes of disability which are equally applicable to men. All of these relationships need careful study over an extended period of time. Therefore, the present report is

In the last six years I have seen 11 patients1with more or less complete duplex anomalies of the uterovaginal tract, each of whom has had one or more pregnancies (a total of thirty-two). The present discussion applies strictly to the association of the two conditions; no attempt is made to present embryologic or purely gynecologic considerations, and my approach is from the clinical rather than from the academic side. Briefly, duplex anomalies of the uterovaginal tract are due to (1) irregularities of fusion involving the normal junction of the mullerian ducts to form the symmetrical halves of the corpus of the uterus and (2) irregularities in canalization involving the urogenital sinus or lower uterine and vaginal tracts. The most common anomaly is simple uterus arcuatus, departing little from the normal contours and hence not as often important clinically. I have not included such cases. The misfortunes that occur

Clinical observation of the results of measures empirically prescribed to curb postpartum retroversion suggested that this empiricism might be without basis in fact. Therefore controlled observations were started. Certain factors appear to favor the production of postpartum retroversion. The tendency toward descensus inherent in the mechanism of labor weakens the supports of the uterus and draws it down, swinging the corpus into a type of retroversion that is identical with early prolapse. Following delivery, the uterus is normally in a position approximating first degree retroversion. Theoretically, this tendency is increased through the dorsal posture of the patient in bed, which is more or less routine. The natural tendency of the heavy corpus to drop back against the sacral promontory is thus accentuated. Subinvolution increases this tendency. The size and weight of the congested uterus (with the patient on her back) work against the normal tendency toward anteversion exerted by shortening

Any one who has operated on a sufficient number of Bartholin cysts has found reason to dislike the routine procedure of surgical enucleation. There is often technical difficulty in complete enucleation, nearly always primary hemorrhage, frequently severe secondary hemorrhage, always postoperative discomfort, edema and relatively prolonged disability, and too frequently a recurrence. The routine practice of simply incising and draining the abscessed Bartholin area frequently proves to be ineffectual because of recurrence of the abscess or the later development of a cyst. I now use the technic described in the illustrations to the exclusion of any other for both abscess and cyst. I have treated sixteen cysts and ten abscesses in this manner. During an observation period varying from three months to two and one half years, I have noted no recurrence of cyst and only one recurrence of abscess. 1 As the electrode follows a spiral path outward from

There are numerous reasons why Dewhurst's text is a valuable contribution to the literature of our specialty. In the first place there seems to be only one other text in the same field–and this we understand will not be revised after the expiration of its 5th edition. So there is a need for a new book and especially for a book as authoritative and up-to-date as this of Dewhurst's. And it is a very good book all the way through, but it is just the least bit lumpy in spots.

Our material comprises a study of 256 patients over a period of nine years in private and clinic practice. An additional group of 261 cases is reported from a national questionnaire relative to the use of sulfanilamide. DIAGNOSTIC METHODS Smears by Gram stain have been studied in all cases. Occasional disagreements with regard to diagnosis have been finally settled on the basis of cultures. We have learned to rely very strongly on the Douglas chocolate agar method and are at present using it as a routine. Criteria for cure have remained as formerly outlined 1 —exacting in the extreme. Such a program has, we believe, been instrumental in our satisfactory final figure for cure and our low figure for late recurrence. We prefer to regard recurrence and even possible reinfection as relapse, which of course increases our figure for average time before cure. METHODS OF TREATMENT Distention with Silver Nitrate

There is definite need for a revision of antiquated ideas and some clear, simple instructions in regard to the management of vaginal infection in the immature. I shall limit this discussion to the treatment for this condition1and to the cause only in so far as is necessary to a clear understanding of the reasons for a modified technic. Directions and illustrations are purposely simple and fundamental for the reason that I am convinced that many physicians have no clear conception even of the gross anatomy of the infantile female genitalia. RATIONAL CONCEPT OF ETIOLOGY The time worn theory that the infantile vaginal canal is carpeted by a thin, weakly resistant mucous membrane is untenable, as proved by repeated gross and microscopic examinations. In the infant and small child, the vaginal canal constitutes an ideal "harbor of infection," whereas in the adult it does not. Obvious characteristics of the