good care, proper food, and fairly clean surroundings, they will thrive tolerably well. On the other hand children living in the country, but lacking good food and proper care, often fail most miserably.

Reduction of Infant Mortality.

What has been said concerning the causes, suggests measures for the reduction of infant mortality.

What goes into the child's stomach, and the manner in which it is given, is probably the key to the whole situation, since upon proper nutrition depends the child's very existence. Undoubtedly the encouraging decrease in mortality during the past few years has been brought about very largely by improving the milk supply, instruction of mothers in regard to proper methods of preparing food, and urging the necessity of nursing whenever possible. It is estimated that 85 per cent. of all infantile diseases are in those artificially fed. It is not difficult to see why this is So. The most ignorant mother can usually successfully nurse her infant. It requires no experience; but artificial feeding requires considerable intelligence, much care, and what is often unobtainable, money to buy suitable materials and clean milk.

The conditions of poverty and ignorance, then, must be looked squarely in the face, and intelligently and hopefully met. Milk depots are being provided, and more will be provided for the distribution of clean milk for a small pittance, or free where needed, and these depots will become centers for the instruction of mothers as to the care of children, with a corps of nurses to follow up the work and keep track of mothers and babies.

If the work is to be at all effective it must go even further and provide for women just before, during and immediately after confinement. As long ago as 1876 a society was formed in England which provides food and clothing for the pregnant woman, and even care for some time after confinement when necessary, and this is done today in France and Germany. Nor is it at ali unlikely that we shall eventually have a law to prevent women working in factories during the weeks just before and after confinement, but, of course, there is no use in doing this unless some provision is made for mothers to whom such work may be a necessity in order to keep body and soul together.

Our child labor laws are not all that might be desired, and there is urgent need of reform along these lines. We can hardly expect a healthy development of manhood and womanhood in boys and girls who slave from seven in the morning until six at night under conditions which are well nigh beyond description on account of the filthiness and degradation present in the factories of the manufacturing towns of the country.

But when all is said and done it is to the encouraging of breast feeding that we must direct our efforts. Four-fifths of the deaths in the first year are in children artificially fed.

When we come to consider the reduction of mortality from respiratory diseases and tuberculosis, the situation is not so hopeful. These diseases are the result of overcrowding and bad housing conditions. Improvement must come from instruction concerning the importance of fresh air, erection of sanitary dwellings, and the advantage of country living.

Poverty, ignorance and vice are back of most of these early deaths, and probably alcohol is the underlying evil back of all three. We cannot say that poverty is entirely the result of laziness, lack of training, or lack of stamina in a people. These are all present surely, but other forces are at work in society which constantly tend to pull men down.

Now I am not a temperance lecturer, but it seems to me that before very much headway is made in reducing infant mortality, there must be developed an enlightened public conscience which will not tolerate the manufacture and sale of liquor except for medicinal purposes, or, which will not tolerate the open saloon and selling of liquor to the laboring man, who receives his pay envelope only to empty it on the counters of the saloon. This is where a very large proportion of the money goes which should provide proper care and feeding of mothers and children.

So also must we develop a public opinion which will not tolerate fifthy, tumble-down, rat-infested crowded tenements, where children die by the thousands.

There should also be considered the matter of making and enforcing laws which shall prevent the marriage of the unfit, such as those having syphilis, tuberculosis, the feeble-minded and the alcoholic. At present marriage laws are extremely inadequate, and thousands of miserable weaklings are born annually to swell the list of those who are too feeble to successfully make the fight for life.

In conclusion of the whole matter, let me say, that it is the mother who dominates the situation. Poverty and intemperance, the two most important fundamental causes of infantile mortality, bear down the hardest on the mother. It is toward the betterment of conditions which effect the welfare of the mother, then, that we must direct our efforts. She it is who controls the destiny of the child.

It is an open question whether our system of education is planned to develop the right kind of fathers and mothers. It is one-sided and poorly balanced; there is lacking the training of conscience and character, and, say what you will, these are very largely concerned in the making of good fathers and mothers. There is needed a more wholesome ideal in the education of boys and girls. We are getting too far away from the fundamentals of simple living. There is needed less of the embellishments of education, and more of the kind of training which shall prepare for the everyday life experiences of men and women.

There is also lacking in our country, it seems to me, a proper

appreciation of the tremendous value and importance of the work of the mother. The work of the conscientious wife and mother in the household of moderate means is never done.

No amount of written heroics in regard to the glory of motherhood from the pens of wealthy sociologists can do away with the deadly drudgery and monotony which falls to the lot of the average wife and mother of moderate means; nor can it obliterate the fact that a large proportion of the inmates of insane asylums are overworked and worn-out mothers. May not this to some extent explain the rapidly declining birth rate of our country?

I venture to say that the nearer we can come to some betterment of these fundamental conditions which so affect the lives of mothers; to a better training of girls; to a higher appreciation of the value of the mother's work, and to a realization of a more wholesome ideal of motherhood, the nearer we will come to the solution of the problem of a declining birth rate and an excessive infantile mortality.

OCULAR CHANGES OCCURRING DURING PREGNANCY, AND THEIR DIAGNOSTIC IMPORTANCE.

BY ALBERT E. CROSS, Worcester, Mass.

In the presentation of this paper, I make no claim to originality of the views expressed, and neither do I expect to present any new truths, but rather in a general way to discuss the ocular changes which may occur in pregnant women, and their importance to the obstetrician.

The role of ophthalmology in preventive medicine should occupy a more important place than at present in this class of cases, and all that is necessary is the co-operation of the obstetrician in all cases, showing ocular symptoms during this period.

You all recognize the importance of ocular examinations during the progress of many systemic diseases, and your prognosis is often dependent upon the character of these changes.

Pregnant women are perhaps especially liable to diseases of the kidney, and it is not unlikely that many women become pregnant when there is an existing chronic nephritis of which they are ignorant.

Obstetricians have paid but little attention to the effect of pregnancy on diseases of the eyes, and none to these diseases as an indication for premature labor, but at the recent congress at Rome, these were more definitely defined, and only in exceptionally rare cases would the termination of pregnancy be justified in eye diseases, yet a question might arise as to whether the sight of the mother was not of as much importance as the life of the child.

Albuminuric retinitis, and uraemic amaurosis caused by nephritis would by all be considered as unqualified indications for the termination of pregnancy, as experience has shown that in the majority of cases both the nephritis and the accompanying retinitis, are either greatly improved or become entirely well.

It is of course understood that the desires and social position of the parents, the nutritive condition of the mother, the extent of the pathological changes in the fundus, must all be carefully considered before deciding whether artificial termination of pregnancy is necessary or not.

There are many ocular conditions which have been observed during pregnancy which are not dependent on renal changes, and many others in which ocular symptoms are present where examinations of the urine are negative.

It would be exceedingly interesting to know just what effect repeated pregnancies would have upon cases of high myopias. Here is a condition where the eye is easily distensible, where the oculist is always careful in giving advice against any eye strain. Feger reports one case where after each pregnancy there was a marked increase in the myopia, and sums up by saying that nine months of disturbed metabolism, the clogging of the circulation, the straining of parturition, and particularly the abdominal pressure on the patient, cannot help but affect this type of case.

Scholer reports two cases of detachment of the retina in pregnant women, albuminuria was absent and no causal relation could be found, but when we investigate our own cases of retinal detachment we find that most of them occurred during some special stress, as in coughing, sneezing, lifting or jumping. In one case of my own, detachment of both retinae occurred immediately after a fall. It is surprising that more cases have not been reported as a result of straining during parturition.

I have found other cases of blindness transient and complete as a result of jaundice, occurring during pregnancy, and yet no cases so far as I know have been reported from jaundice when occurring distinct from pregnancy.

We are all familiar with the ocular symptoms accompanying renal disease, especially when albumin appears in the urine; on this account obstetricians frequently send their cases for ocular examinations, and the prognostic importance of retinitis albuminu rica gravidarium is well understood.

Disturbances of vision may also occur in the form of transitory blindness without any retinitis being present. The patient complains of everything suddenly becoming dark before the eyes; this may increase very rapidly until blindness is complete, and yet when blindness is absolute the ophthalmoscopic examination may be negative. With these attacks the accompanying headache, nausea and vomiting and dyspnoea help us to determine the diagnosis of uraemic amaurosis due to nephritis.

Yamaguchi reports a case of xanthopsia, occurring during

The

pregnancy, vision reduced to counting fingers. In this case, the nerve was pale, the retina oedematous but no hemorrhages. urine was loaded with albumin.

Pregnancy may, however, be complicated by a serious condition known as toxaemia, in which albumin does not appear in the urine. There is no condition occurring during pregnancy upon which so much has been written, and is even now so little understood as the toxaemia of pregnancy. It seems to be a symptom complex, characterized by headaches, nausea, vomiting, visual disturbances and finally ending in delirium and coma, or possibly in eclampsia.

The frequency of this condition is hard to determine, as probably only a small percentage end in eclampsia-yet we find 250 cases of eclampsia reported in 14,899 labors, or about 1.7 per cent., the frequency being nearly double in hospital records to those in private practice.

There seem to be two distinct views, one that toxaemia and eclampsia are different manifestations of the same primary disorder, and the other that each disease shows distinct and characteristic pathological changes.

Often in these cases, repeated examinations of the urine give negative tests for albumin, and as the tests for urea vary so from day to day, it is impossible to draw any accurate conclusions from the urinalysis.

Williams divides toxaemia into three types (1) Acute yellow atrophy (2) Pernicious vomiting and (3) that type which produces eclampsia. In all of these types the liver and kidneys are unequal to the task put upon them by the excessive tissue changes accompanying the pregnancy. He further states that only in the third type are there marked urinary changes, and here the change is only in the nitrogenous. content, the proportion excreted as ammonia is much increased.

It is in these very doubtful cases where analysis of the urine is negative, and where the vague general symptoms lead us to suspect a toxaemia, that ophthalmoscopic examination is particularly indicated; any corroborative tests would be of great value in determining the severity of the disease.

When you remember that very often retinal changes precede the appearance of albumin in the urine in diseases of the kidney, so may ocular changes occur in toxaemia, which may precede more serious lesions in other organs.

The ocular signs of toxaemia do not as a rule appear before the fourth month of pregnancy and may be delayed until the seventh month. Randolph states that when these symptoms appear before the sixth month, they are positive signs for the induction of artificial labor, and if during the last seven weeks they should be carefully watched unless the lesions are very extensive.

Although the ocular lesions of toxaemia have not been dif