insistent, is gastroenterostomy to be done in the absence of demonstrable organic disease. 7. Regurgitant vomiting, formerly the most troublesome of all complications, is dependent upon faults in the operation which result in some mechanical obstruction to the intestine. These faults are chiefly dependent upon the presence of a "loop" in the jejunum, but may also be caused by a twist in the intestine around its longitudinal axis at the time of its application to the stomach. 8. The posterior no-loop operation with the vertical application of the bowel to the stomach is the best procedure. and Diabetes. CLINICAL PATHOLOGY AND DIAGNOSIS. UNDER THE CHARGE OF The Laboratory of Clinical Observation, 616 Madison Avenue. The Infectious Origin Hirschfeld (Berl. of Chronic Pancreatitis Klin. Wchschrft., No. II, 1908). A number of patients under the author's observation presented the signs of pancreatic disease as a sequel to influenza or angina. These signs consisted in gastrointestinal disturbances, frequently combined with attacks of colics; a sensation of thirst, and glycosuria, but without polyuria. The duration of these attacks amounted, as a rule, to from one to five months; they were repeated at the end of six months to three years in the majority of the cases. These patients without exception had a diabetic family history, and all of them were highly neurotic individuals. In two cases there was a swelling of the liver, which disappeared again at the end of some time. According to the au thor's observations, this transitory enlargement of the liver is usually found in those cases of diabetes which later on develop a grave clinical picture, whereas the cases of diabetes associated with a permanent enlargement of the liver take a remarkably mild course. Alcoholism and syphilis, which favor the occurrence of hepatic cirrhosis, seem to have a favorable influence upon the course of diabetes. Infections are often followed, in addition to acute pancreatitis, by acute hepatitis, which, in the presence of syphilis or alcoholism, leads to a permanent enlargement of the liver. The acute inflammatory conditions of the liver and the pancreas are very often overlooked. It is probable. that they are suggested only in pre-disposed individuals by glycosuria and swelling of the liver. F. R. OBSTETRICS AND GYNECOLOGY. UNDER THE CHARGE OF WALTER B. JENNINGS, PH.B., M.D., Formerly Assistant in Gynecology, New York Post-Graduate Medical School; Attending Physician (O. P. D.) St. Mary's Free Hospital for Children. Treatment of Abnor- Dr. Nathaniel R. cases. From his operations he concludes that where immediate delivery is demanded in the presence of an undilated and rigid cervix, multiple deep incisions from the border of the external os to the uterovaginal junction furnish the most rapid and safest method of emptying the uterus. There is no danger of the incisions tearing in cases under full term or in cases at full term where the pelvis is normal and the foetus is of moderate size, nor risk of hæmorrhage when clamps are employed before making the incisions. The chance of septic infection is no greater than after the lacerations occurring at the time of normal delivery, and the scars in the cervix and vaginal vault will cause no trouble in the course of subsequent pregnancies and labors. Hygiene and Manage- Dr. Austin Flint, Jr., ment of Pregnancy. says that the first point to impress on physicians generally and on patients is the wisdom of assuming charge of the patient as soon as the diagnosis is made. (New York Medical Journal, June 13, 1908.) It will be more convenient to consider the management by dividing pregnancy into three periods of three months each. Under ordinary circumstances a patient is allowed to lead her usual life without restriction. Vomiting is the only symptom which needs careful investigation. A convenient working rule is to recognize three distinct types-neurotic, reflex and toxæmic. The first is the most frequent, but as soon as the diagnosis of toxæmic vomiting is made the uterus should be emptied. The change in the nitrogen distribution in the urine is an absolute indication for early abortion. Pelvic examination is now the routine, almost as much in private practice as in hospitals. It is the only way that a diagnosis of pelvic contraction can be made. When we remember that contraction occurs in from 12 to 14 per cent. of all cases, the importance of careful measurements can be appreciated. About six weeks before the date of confinement the patient should be instructed to stay in bed, and a physical examination, including the pelvic measurements, should be made. I have found that there is seldom any objection on the part of the patient when its importance is explained. In cases where the pelvic measurements are small. six weeks allows ample time for interfer ence. A factor in labor which can never be definitely prognosticated is the quality of the labor pains. In a vigorous woman. with good muscular development and in good health, nothing need be done in the nature of trying to improve the strength of uterine contractions. On the other hand, if the health is below par, if the patient says that she tires easily and cannot walk as far as she should, and especially if the pulse is weak, moderate doses of strychnine, with small doses of quinine, should be given regularly three times a day for the last six or eight weeks. This plan has been used by many observers with results that seem variable. There is no doubt that in suitable cases it is a most valuable aid. I have made use of it in a number of multipara, with histories of prolonged labor, and have invariably found that it caused stronger pains. a shorter labor, and guarded against the danger of postpartum hæmorrhage, or a relaxed flabby uterus after the birth of the child. Comments Upon an Un- Dannreuther deusual Case Requiring scribes this case as Cæsarean Section. follows: The patient. 18 years of age, belonged to a troupe of midgets. She had had rickets when six. months old. She was well nourished and apparently in excellent general health; height three feet eight inches: had no perceptible enlargement of the thyroid gland and no pressure symptoms; abdomen measured three feet six inches in circumference; no cardiac murmurs; lungs clear. The diaphyses of the long bones were underdeveloped, while the epiphyses seemed almost normal in size. Pelvic measurements were: Interspinous, seven inches intercostal, eight and one-half inches; external anteroposterior, five and one-half inches; right external oblique, six and one-half inches; left external oblique, six and one-half inches; internal conjugate, one and one-quarter inches; internal anteroposterior, one and one-half inches. An incision was made through the abdominal wall in the linea alba, extending from one and one-half inches below the ensiform cartilage to the symphysis pubis; second incision through the uterus in situ, in the middle third of the median line. Time, 13 seconds. No attempt was made to control the bleeding from the abdominal wound, which was inconsiderable. The child was quickly seized, the cord being clamped and cut, and was taken to another room. Artificial respiration was unnecessary, as the child cried lustily immediately after extraction. The child delivered, a nurse began pouring a continuous stream of normal saline solution, at a temperature of 120 degrees F., directly upon the uterus. This promoted rhythmical contractions, facilitating the removal of the secundines, and controlling hæmorrhage. Three layers of continuous catgut sutures were introduced into the uterine wound; two into the musculature and one into the peritonæum. One operator completed the first suture while the other began the second, etc. No attempt was made to sponge out the abdomen, the saline solution being purposely allowed to remain. The abdominal wound was closed by a continu ous through-and-through chromic catgut suture, reinforced by silkworm gut interrupted skin sutures. Time, from the first incision to the last suture, 13 minutes. The anesthetic used was chloroform, followed by æther, which the patient took well. The pulse did not rise above 88, and was of good quality throughout. The baby was well nourished and developed in all respects: weight, seven and one-half pounds. Mother rallied well after operation. Recovery was uneventful, the abdominal wound healing by first intention. Sutures were removed on the tenth day. The cervical canal being well open, dilatation for drainage was unnecessary; lochia normal. The mother secreted but a minimum quantity of milk, so the baby had to be fed artificially. Both were discharged from the hospital in excellent condition four weeks after the operation.-Medical Record, June 6, 1908. Lobenstine Complete Rupture of R. W. the Pregnant Uterus. (Bull. of the Lyingin Hospital, N. Y., Vol. III, No. 4) presents a study based on 37 cases of complete rupture which have been observed in approximately 41,800 labors at or near term. Complete rupture of the uterus may be either spontaneous or traumatic: it may only be large enough to admit the finger or so extensive that the child is delivered into the free peritoneal cavity. The most frequent point of rupture is the lower uterine zone, and the two fundamental types are (a) the transverse and (b) the longitudinal, which extends upward through the cervical portion along its lateral wall towards the fundus or actually to it, involving the uterine vessels and producing extensive damage to the layers of the broad ligament. Lobenstine finds that these types are usually more or less associated and but rarely sharply defined. The method of occurrence, i. e., whether due to intra-uterine manipulation or spontaneous in origin, largely determines the primary nature of the rupture, the former giving rise to the longitudinal type, the latter to the transverse rupture of the lower zone. In the writer's series, 19 cases probably started as the longitudinal type and 17 as the transverse. Rupture in the fundal region seems to be very unusual, only one instance being noted in this series of cases. The etiological factors in the author's cases are stated to have been as follows: Spontaneous rupture due to pelvic contraction, 17 cases; to feeble scar after amputation of the cervix, I case; traumatic rupture due to high forceps, 2 cases; internal podalic version, 12 cases; accouchement force, 4 cases; embryotomy, I case. The mortality in the 37 cases under consideration was 73 per cent., 23 being treated by hysterectomy, with a mortality of 60 per cent., and 14 were treated by packing, with a mortality of 92 per cent. Of the last six cases treated the mortality was 33 per cent.; in 5, hysterectomy was done, with 2 deaths, the other was packed and lived. The writer claims that laparotomy should be done in all cases of complete rupture with two exceptions: (a) Clean cases with a small amount of damage, where the hæmorrhage is easily controlled by the packing; (b) bad cases with marked shock, which will not go through an immediate operation. Here the child may be extracted from below when possible and tamponade relied upon until the patient's condition improves sufficiently to permit of subsequent laparotomy. Hysterectomy seems to be the preferable operation in most cases, suture of the wound in the uterus being only possible in the simple, uncomplicated cases. PEDIATRICS. UNDER THE CHARGE OF VANDERPOEL. ADRIANCE, M.D., Consulting Physician to the New York Orphan Asylum and Pathologist to the Nursery and Child's Hospital. the Navicular Tuberosity and the Tubercalcanei. Juvenile Fractures of Kirchner (Zur Frage the Tibial Tuberosity, der juvenilen Frakturen der Tuberositas tibiæ, Tuberositas navicularis, und des Tuber calcanei) v. Langenbeck's Archiv., Vol. 84, p. 3, 1907. A number of cases were published by Schlatter, and after him by Haglund, for the purpose of illustrating the frequent occurrence of fractures at the tibial tuberosity, the navicular tuberosity, and the epiphysis of the calcaneus, upon the basis of X-ray pictures. The author is of the opinion that the cases described as frac tures of the os calcis concerned the physiological process of epiphyseal ossification from two nuclei, the clinical picture alone rendering the existence of a fracture improbable. In those cases which were assumed by Haglund to be fractures of the navicular tuberosity, the tibialis externum was concerned, as shown by the symmetrical bilateral findings. With special reference to the fractures of the tibial tuberosity, the author believes that there may occur typical findings of detachment of a portion of the inferior nucleus of the tuberosity, but even these cases are rare, although perhaps a little more common than total detachment of the entire tuberosity. It is important to know that inflammatory conditions of the tibial tuberosity may likewise be rendered by the X-ray picture, and also that the tuberosity itself presents an extremely variable picture during the ossification of the bony nucleus in different individuals, with possible variations in the two knees. Upon the basis of his observations the author holds that injuries of the bony nucleus at the os calcis have not been unobjectionably demonstrated, they do not occur at the navicular tuberosity, and are not as commonly met with at the tibial tuberosity as assumed by the above-named observers. F. R. berculin Reaction in Infantile Tuberculosis. The Diagnostic Value Pirquet (Wiener of the Cutaneous Tu- Klin. Wchschrft., No. 38, 1907). The final conclusions are to the effect that a positive reaction reliably indicates tuberculous changes, while a negative outcome in a general way points to the absence of tuberculosis, but is also almost invariably met with during the last days of a fatal tuberculosis. The 100 cases are grouped as follows: 52 cases without tuberculous changes, in which the test remained negative; 34 cases with fatal tuberculosis, the first 24 of which, examined during the last 10 days of life, yielded 13 negative and II positive results. A positive reaction was obtained in II cases examined at an earlier stage. Among 13 cases showing tuberculosis as accidental post-mortem findings, 9 had presented a positive and 4 a negative reaction (3 in the last 10 days of life). In one case the test was positive, whereas the autopsy findings were negative. All the remaining cases with a positive reaction (31) showed at least the presence of caseous lymph glands. F. R. Hydatid Cysts of the Thevenot-Barlatier Liver in Children. (Gazette des Hôpi taur, No. 39, 1907.) One of the patients. observed by the author was a child 12 years of age, who presented an enormous swelling in the anterior aspect of the body. This tumor was found to be connected with the liver. On account of the existence of a bulging in the lumbar region a lumbar incision was made in order to secure the best possible conditions for drainage. A cyst was found, having the size of a man's first, and readily detachable from its surroundings. The wound. margins were sutured to the margins of the skin incision. Another cyst was then opened through an incision along the external margin of the rectus muscle. This was likewise readily enucleated. The two cavities were found to be separated only by about 4.5 cm. of liver substance; they were transformed into one cavity and drained together. At the end of a week the anterior wound was allowed to close, the posterior drainage proving sufficient. The patient was quite well at the end of five months after the operation. F. R. Robère (Journal de Méd. de Bordeaux, Osteomyelitis in a Nursing Infant. No. 9, 1906). The case reported by the author serves to show how readily a grave disease in a young child may be recovered from. The patient was an infant only two weeks of age, whose disease began with painful swelling and redness of the right leg. Within the next 24 hours several abscesses formed on the limb. There was only a slight elevation. of temperature. The infant slept well and continued to nurse. A number of incisions were made down to the bone, and the periosteum was found to be detached for a considerable distance, with soften |