In the abdominal cavity we found an acute fibrino-purulent peritonitis, most intense upon the anterior surface of the stomach. No perforation could be found. The stomach appeared large and felt very heavy, as though there were considerable substance within its cavity. When opened, it was found entirely empty, the unusual weight being due to its immensely thickened walls, which were in places one-half of an inch in thickness. The cut surface was very pale, and when squeezed creamy pus welled up from the submucosa. The interior of the organ presented a mottled appearance, the mottling being due to patches of intense congestion of the mucosa. There were several large superficial ulcers, which I believe were the result of sloughing. Under the microscope the stomach wall presented the following appearances: The mucosa was greatly congested and infiltrated with leucocytes. The submucosa was necrotic, the few cells not entirely disintegrated could be recognized as a polymorphonuclear leucocytes. The muscularis and subperitoneal tissue were infiltrated with leucocytes and serous fluid. Stained for bacteria, streptococci and bacilli were found. Cultures from the stomach wall were examined by Dr. Brefney O'Reilly, who isolated two organisms, a proteus and the colon bacillus, the streptococcus so evident in the stained section having evidently died out in the culture. At a meeting of the American Medical Congress, in May, 1900, Kennicut, of New York, showed a specimen from a very similar case. A streptococcus and a bacillus, which he believed was probably the colon bacillus, were found in the stomach wall. This case was discussed by Welch and others. As in my case, a friction sound had been heard over the stomach. This friction sound is due to the roughening of the peritoneal surface of the stomach upon the development of peritonitis. Its early disappearance in my case I ascribe to the exudation of pus upon the peritoneal surface acting as a lubricant. The rash which was such a prominent feature in my case would appear to be unique in connection with this disease, and beyond the suggestion of sepsis can have no diagnostic signifi cance. REFERENCES. 1. Mayo Robson and Moynihan. Text book on diseases of Stomach. 2. Asverus, S. Zeitschrift für Med. Natur: Jena, 1866, Bd. II. s. 476-482. 3. Habershon, S.O. 4. T. N. Kelynack. Lancet, March 14th, 1896. BY DAVID JAMES EVANS, M.D. Assistant Obstetric Physician Montreal Maternity Hospital E. M., aged 24, III-para, was admitted to the Montreal Maternity, September 8th, 1906. Her two previous pregnancies had been terminated at term by craniotomy. The last had taken place a year ago. This was followed by prolonged sepsis, and she was admitted to the General Hospital, where she spent nearly a year. There she underwent an abdominal operation, one tube being removed. The last menstrual period began January 1st, 1906. Patient first noticed fetal movements in May, 1906. There had been persistent nausea and vomiting throughout the pregnancy, and moderate severe frontal headaches. There had been edema noticed at times, but no disturbance of vision. The bowels had moved regularly with cathartics. The patient stated that she had learned to walk at twenty-four months of age, and that she was married in 1903. Her previous pregnancies had gone to term, the children being lost as above stated. There was no history of any previous disease. The kidneys were normal. On examination the fundus uteri was found to be two fingerbreadths below the ensiform cartilage. The abdomen was in the condition of a full term pregnancy. There was a scar of an incision in the middle line half way between the symphysis and the umbilicus. The child was presenting in R.S.A., the presenting part being well above the brim. The fetal heart was heard from 144 to 156 on the right flank at the level of the umbilicus. The pelvic measurements were Sp. 26.5 c.m.; Cr. 28 c.m.; Troch. 32 c.m.; Conj. Diag. 9 c.m.; the true conjugate was estimated at 8.5 c.m. The pubic arch was very wide, and the transverse diameter of the outlet was 12.75 c.m. A diagnosis of flat rachitic pelvis was made. She had been seen in the Out-Door Department on August 29th, 1906, and her measurements having been taken at that time, she was advised to come into the Hospital when the pains began, and it was the intention, if the condition warranted it, to deliver her by means of abdominal Cesarean section. In accordance with this plan she was, put to bed when admitted. as she was having irregular abdominal pains, and small doses of morphia were given to secure rest. On the night of September 10th, patient began to have fre quent and severe pains. My attention was called to her on the morning of September 11th, when I had her removed to the labor room and prepared for examination. The position of the fetus was found unchanged by external examination, the fetal heart being heard in the same position, and at the same rapidity. On vaginal examination the parts were found relaxed. The vagina was short and there was nothing unusual about the vaginal discharge. The sacral cavity was markedly accentuated from above downwards, and decreased laterally. The promontory could easily be reached by the finger. The os was found three-quarters dilated, and the left hand of the fetus prolapsed into the vagina. The fetal breech was felt above the internal os in R.S.A. position. No record could be obtained as to when the membranes had ruptured. Under the circumstances I decided that to deliver the patient by the abdominal route would necessitate a Porro operation, so I decided to attempt delivery by means of pubiotomy. The patient having been prepared for operation in the usual method, she was catheterized in the dorsal position, and the catheter was allowed to remain in the urethra as a guide. A short incision was made parallel to the upper border of the left ramus of the pubes, down to the bone. The finger was inserted behind the symphysis, stripping off the bladder, and a Bumm-Stockel needle was then passed carefully down behind the symphysis, guided by the internal finger, and brought out midway on the left labium majus. A Gigli saw was then attached to the needle and drawn back through the wound. The bone was sawn through exceedingly easily, but it did not separate with any sudden snap. Just as the bone had been sawn through there was a gush of blood, which was readily checked by pressure from gauze packed into the wound and over the pubes. The legs were now flexed and held in position by assistants. Dr. Little, who was assisting me, undertook the delivery. The right foot of the child was seized and brought down, and the body as far as the umbilicus delivered without difficulty. The right arm was found to be displaced upwards, and around the child's neck, and it was removed without much difficulty, but the child could not be turned to allow the biparietal diameter to come down on the left side, as is directed in such cases. Some considerable force was necessary to bring the head down into the pelvis: as it passed the brim the pelvic bones separated to the extent of 2 c.m. The child was deeply asphyxiated on delivery, but was re suscitated with hot and cold baths and insufflation. After the birth of the placenta, which was expressed without difficulty, the patient was examined internally. A deep tear was found extending high up into the uterine segment on the left side. As it did not bleed it was decided not to suture. The skin incision was then closed with four silk-worm sutures, the lower wound being covered with iodoform collodion. The pelvis was surrounded by a broad strip of adhesive plaster, and sand bags applied along either side. A small band was placed about the knees of the patient to keep them together. After operation the patient's pulse was very weak, but soon after being put to bed it became about 116 per minute. She was given a saline solution of 700 c.c About three-quarters of an hour afterwards the patient showed evidence of collapse, the lips and finger nails becoming deeply cyanosed. There was no definite sign of hemorrhage, nor was there marked abdominal tenderness, though the pulse rose to 144 per minute. Under prompt treatment she rallied. The child was a male and weighed 2,600 grammes. The Bi. P. diameter was 8.75 c.m.; Bi. T. 8 c.m.; O. M. and the O. F. 11.5 c.m. The further history of the child was uneventful. It weighed when it left the hospital, 2,670 grammes. The mother was unable to nurse the child, and it was fed on a cream and whey preparation. The recovery of the patient was on the whole uneventful. The highest temperature recorded was 101.5, which was reached on the fifth day. As a rule the temperature remained below 100. The patient required to be catheterized but twice, when she regained complete control of the bladder. She complained of considerable pain over the right sacro-iliacsynchondrosis throughout. The incision was dressed on the sixth day and everything was found in good condition. There was marked swelling and induration of the left labium. On the eleventh day dressings were removed, the wound was dressed, and the sutures. removed. A quantity of peculiar blood-stained fluid escaped from the outer edge of the wound at this time, and more could be expressed by pressure. This sinus was somewhat enlarged by a probe, a sterile gauze drain was inserted, and the wound was dressed every day or two until this discharge ceased. The patient was a very sensitive and rather complaining type of woman, and very apprehensive about beginning movements of her limbs. She sat up for the first time on the thirtieth day and was discharged on the forty-seventh day. She was detained longer than necessary in the hospital in order to permit of certain examinations being made. On discharge the pelvic examination showed the cervix lacerated on the left side. The uterus was well involuted, not tender, and in good position. The adnexa were free. The Diag. Conj. twice measured 9.25 c.m., showing a slight permanent increase. The left ramus of the pubes was markedly thickened in its entire extent, but there was no definite callous noticed at the line of division. The genitalia were practically in the same condition as when the patient was admitted. The patient could stand on either leg without difficulty, and there was no evidence of undue movement in the pelvis. This operation was first suggested by Gigli, in 1894, his object being to retain all the advantages, and do away with some of the dangerous features of the operation of symphysiotomy. He proposed that the pubic bone should be sawn through to one side of the symphysis by means of a fine wire saw which he had designed for the purpose, since known as the Gigli saw. The operation was first performed by Bonardi. of Lugano, in May, 1897. The operation was first introduced into Germany by Döderlein in 1904, who largely improved the technique. Since then the operation has been done in practically all the German clinics, and in France. The operation has been steadily growing in favor and the results have on the whole been very satisfactory. It has been performed many times in the United States, and once in Canada by Laurendeau, of St. Gabriel de Brandon, who reports a case in La Union Medicale du Canada. Jan., 1906. As has been suggested by Gigli the operation consists in making a large vertical incision to one side of the symphysis pubis, and then sawing through the bone from the outside. · Döderlein's modification has made the operation practically a subcutaneous one. The operation performed in the case here reported is practically that of Döderlein. Bill, in a recent paper on this subject to which I am much indebted, claims the following advantages of the operation over Cesarean section: (1) The fact that the peritoneal cavity is not opened, and that the field of operation does not connect with the generative tract, allows of its being done in cases in which there is infection already present, or where there is a suspicion of infection on account of examination under doubtful asepsis. (2) The greater simplicity allows of its being done in a |