ingworth, infant five weeks of age). (Widerhofer, congenital gastric cancer). Lebert, among 314 cases, observed only three in individuals under 30 years of age. According to Schaffer, who contributes a personal observation on a case of gastric cancer concerning a boy of 14, the cases of cancer of the stomach in the first three decades amount to 2 per cent.; according to Reichert, 3 per cent.; according to Brantigam, 2.5 per cent., and according to Reiche, not quite I per cent.

The geographical distribution of gastric cancer presents certain variations. The disease is very rare in the tropics. Griesinger states that he never observed gastric cancer in Egypt, and Heizmann did not see a single case in Vera Cruz.

On the other hand, cancer of the stomach is of remarkably frequent occurrence in Switzerland, much more so than in Prussia, Austria and England. Cancer is also claimed to be very common in the Black Forest and in Mecklenburg.

ULCER OF STOMACH AS CAUSE.

PERCENTAGES.

The frequency with which carcinomata develop in connection with preceding ulcers has not as yet been ascertained by statistics of sufficient size. Haeberlin calculated a percentage of 7 per cent. carcinoma after ulcer, according to observations in the Zurich clinic. Rosenheim found carcinomatous ulcer in 8 per cent. of his cases, and Gluzinski in 8.4 per cent. At any rate, clinical observations suffice to show that this occurrence is not so

very rare.

Polyadenoma has also been brought into connection with cancer. According to Bouveret, there are only two diseases of the stomach which create a predisposition for cancer-polyadenoma and ulcer. Adenoma represents a glandular hyperthropy in which the general form of the

Serum.

gland may be preserved, but certain cases show all the transitions up to a typical cancer formation. These adenomata usually appear in shape of polypoid growths, multiple in number, and may be located in any region of the stomach. F. R. Antimeningococcic S. Flexner and J. W. Jobling, New York (Journal A. M. A., July 25), have tabulated 357 cases of epidemic cerebrospinal meningitis treated with the antimeningococcic serum, taking account of all the leading features, all having been diagnosed bacteriologically as well as by the usual clinical tests. Forty-three moribund patients or fulminant cases, in which the patients survived the first serum injection less than 24 hours, were excluded from the tabulation. Under one year of age the recoveries were 50 per cent., and the ratio rapidly increased with the age, being 92 per cent. in patients between 5 and 10 years of age. Above that it again fell to 67.9 per cent, in those over 20, which is accounted for in part by the fact that a large number of these were treated by scattered physicians who had had little experience with the serum. Wherever a series of cases have been treated by one observer, the recovery rate at this age has been high. The histories were sufficiently explicit in 328 cases to show approximately the period of the disease when the injections were begun. In 121 patients injected between the first and third days, there were 103 recoveries (88.1 per cent.); in 100 first treated between the fourth and seventh days, 78 recoveries (78 per cent.); in 107 treated only after the seventh day, 68 recovered (63.6 per cent.) The benefit of early injection is clearly shown, but the authors think the outlook for later cases is still encouraging with the treatment. In 207 cases the histories were sufficiently definite as regards

the mode of termination of the disease to show that 201 terminated by lysis, and 69 by crisis. The average duration of active symptoms in the 220 cases where it could be ascertained was about 11 days. This later study has confirmed the former observations of the rapid decrease of the diplococci under the influence of the injections, the lessened turbidity of the meningeal exudate and the decreased leucocy

tosis in favorable cases. This series of observations also shows, like the earlier ones, that in the great majority of the cases the recovery after the serum treatment is complete. The number of complications was small and the only persistent defect noted was deafness in a few instances only, and more often than not observed before the beginning of the injections.

Is Pubiotomy a Justi- Dr. J. W. Williams fiable Operation? of Baltimore had had an experience of 13 cases of this operation, with no maternal deaths, and in only one case had a woman been seriously sick. He employed the Döderlein technique, and had observed hæmorrhage in only one case. The puerperium had been normal in only six of the cases, various minor difficulties having developed. The average duration of the puerperium had been 30 days. In all the cases the women began to walk by the end of the third week, and were dismissed in good condition less than a week later. In onethird of the cases there was a permanent mobility between the cut ends of the bone. This did not interfere with locomotion, and perhaps was of assistance in permitting subsequent spontaneous delivery in one of the cases. In 10 of the cases the patients were as well as before the operation; three had had subsequent deliveries. The operation came into competition with premature induction of labor and other operations in favor of the child. Patients usually did well, unless infected. The

foetal mortality was 2 per cent., which was greater than after the induction of labor; but, on the other hand, the children were better developed, and it would probably supersede that method of delivery. It was much better than symphysiotomy, both for child and mother. It was indicated only in cases in which the conjugata vera measured more than 7 centimeters; hence it was not a competitor of the Cæsarean section. Its mortality was far lower than that of the last-mentioned procedure, but the latter was to be preferred if the case is seen just before labor began. It was particularly applicable to the border-line cases, affording a safe method of delivery, after subjecting a patient to the test of several hours in the second stage of labor, while in Cæsarean section the mortality rose steadily with each hour that elapsed after the onset of labor. It compared favorably with craniotomy, the high-forceps operation, symphysiotomy and version. It should be a primary operation as an alternative to craniotomy; it should not be performed in cases of infection, and it should not be

performed by the general practitioner.New York Medical Journal, July 11, 1908.

The Relative Value of Obstetric Forceps and

Version as Methods of Delivery.

William H. Wells, M.D., read a paper upon this subject before the Obstetrical Society of Philadelphia and drew the following conclusions:

Where rapid delivery is necessary, the pelvis being of normal size or flattened very slightly in the antero-posterior diameter, the transverse diameter being of normal size or increased, the cervix and vaginal canal dilated and well softened, version is preferable to forceps when mechanical interference is necessary. Among the special indications for version may be classed the following: Brow or face presentations, with no rotation of the chin; certain cases of occipito-posterior position; parietal presentations; placenta prævia, if the presenting part is high up in the pelvis and the soft parts dilate slowly; certain cases of deficient uterine contractions; prolapse of the cord; transverse positions; excessively large capus succedaneum; some cases of eclampsia.

Forceps delivery gives best results in the largest number of labors delayed by weak uterine contractions where interference is necessary and in the majority of cases of posterior rotation of the occiput. Forceps are also to be used in cases of rachitic, generally contracted, or in justo-minor pelvis, providing the contraction is not great enough to prevent the head and shoulders of the child from passing through the inlet, and in those patients having certain constitutional diseases, when manual labor is to be performed. Neither forceps nor version should be attempted in any case of hydrocephalus or abnormally enlarged foetal body, unless craniotomy or evisceration has first been performed.

The Early Diagnosis Dr. Albert Martin of Cancer of the Uterus. Judd read this paper before the Medical Association of Greater New York (New York Medical Journal, June 13, 1908). Although the subject had been brought to the attention of the profession very frequently during the last decade, his experience had taught him that the question of an early diagnosis could not be too frequently brought to the notice of the general practitioner. In order to make an early diagnosis, the physician, wholly ignoring the climacteric as an entity, should insist upon a digital and speculum examination whenever his patient complained of any untoward or unwonted pelvic symptom. More was learned by the finger than by the speculum. If the cervix was sound, and the discharges, whether bloody or leucorrhœal, came from the uterine cavity, the curette should be used as an aid to diagnosis. In all cases the microscope was to be called into requisition. While much was still to be desired in this regard, an early diagnosis was made more frequently at present than formerly, and, consequently, a less serious view of the disease must now be entertained, for many series of cases had been reported by the wisest and most respected surgeons in which a large percentage of cures were effected. By complete cure he meant with no recurrence after five years. Our operative treatment of cancer had taken a long step forward when the modern theory that it began as a local disease was established. There were certain types of uterine cancer which ran a more malignant course than certain others, and two cases illustrating this aspect of the disease were cited.

The classical symptoms of cancer of the uterus were hæmorrhage, offensive discharge and pain. Unfortunately, when these were all present the disease was but

too often no longer localized in the uterine tissues. When the symptoms of cancer were analyzed, therefore, it was seen that the early diagnosis must depend upon other than the classical signs. Very often women would complain of pelvic symptoms common to several diseases, and the diagnosis had to be made by the physical findings, aided, perhaps, by a microscopical study of a portion of the suspected tissue. It was his opinion that one should not say that a given case was inoperable until the patient was examined under an anaesthetic, the uterus drawn down by a volsella and a thorough curetting done, unless (and this was very important) there was unmistakable evidence of the existence of secondary cancerous growths in other portions of the body. The ordinary appearance of the symptoms of carcinoma of the uterus

was in the following order: Ichorous leucorrhoea, pelvic pain, fœtid discharges and general cachexia. But while these symptoms were characteristic, some of them might be absent or their sequence might be variable. Thus pain might not be present. In other instances hæmorrhage would be the first symptom, and, again, loss of weight and general cachexia, ordinarily the final manifestations, might be the first to attract attention. As had been stated, a digital examination, supplemented by the microscope, was the only method of arriving at any conclusion. This should never be neglected in any case of painful coition, stubborn pelvic pain or backache, leucorrhoea, and especially metrorrhagia or menorrhagia. A show of blood, however slight, following sexual intercourse, should always awaken suspicion.

Children.

The Treatment of Sur- Tietze (Medizin. gical Tuberculosis in Klinik, 1908). In order to improve the prospects of therapeutic measures, notably operative interference, in the treatment of tuberculosis in youthful individuals, the author raises the following requirements:

1. Systematic statistical compilations. 2. Proper nutrition, adapted to the age of the children.

3. The combination of surgical and physico-dietetic measures.

4. Sanatoriums for scrofulous and tuberculous children.

5. Establishments for the cure of surgical tuberculosis, open during the summer not alone, but the year around.

6. Public hospitals for children, es

pecially arranged for the treatment of tuberculosis, and provided with bathing facilities, including air and sun baths, and recreation halls for recumbent treatment.

With special reference to the treatment of tuberculous abscesses, the method of election consists in the injection of iodoform, total extirpation entering into consideration for exceptional cases only. The body of the child is far more likely to triumph over the tuberculous process than is the body of the adult; hence operations should be omitted as much as possible until the epiphyses have become ossified. The re-examination of the tuberculous children treated by the author in the course of seven years' surgical activity in the hospital yielded results which

were in a general way satisfactory in character. In 28 cases systematic injections of old tuberculin were administered with such poor results that this procedure was again abandoned. F. R.

Infant Feeding.

Joseph Brennemann,

Chicago (Journal A. M. A., July 11), criticises the percentage method in vogue in infant feeding, the fundamental principles of which, he thinks, have been discredited by an overwhelming mass of evidence during the last few years. The normal healthy infant, he says, has a broad tolerance for widely different food mixtures and for varying amounts and strengths of the different food elements, fats, proteid and carbohydrates. Practically, it will be found that most new-born babies will bear well after the second day of life a dilution of one part of milk to two parts of water, with the addition of a little milk sugar, say from one-quarter to one-half ounce in the 24 hours' food. This dilution can be gradually strengthened till toward the end of the first year the child is on whole milk. The total 24 hours' food need rarely exceed one quart, and at no time during infancy is it desirable to feed the child more than five or six times in the 24 hours, and toward the end of the first year the number of feedings should not exceed four. Too frequent feedings are the cause of much of the indigestion of bottle-fed infants. Brennemann gives the symptoms of milk overfeeding, the nutritional disturbances, wasting, eruptions, hardened light-colored fæces and constipation, which are due to too much fat, and which may result in the acute catastrophe called gastroenteritis, cholera infantum, etc., which Finkelstein has demonstrated is not in these cases due to an infection, but to a metabolic intoxication, more akin to uræmia

or diabetic coma, caused by the ingestion of more food than the baby can assimilate. This explains why these catastrophies occur most frequently in warm weather, when the baby, already debilitated by heat, is least resistant to the effects of overfeeding. Body weight, he considers, is a better guide to the amount needed than age, and it has been found empirically that the milk requirement of the great majority of healthy babies lies between one and one and a half ounces to the pound of body weight. Of course, a sick child can only take what it can assimilate in its actual condition. A still more useful standard, because it can be applied to all food combinations, is the calorimetric standard, according to which the food requirements are expressed in calories per pound or kilogram of body weight of baby. Heubner considers 70 as the approximate quotient on which weight equilibrium could be maintained. and Brennemann in his experience has been impressed with the practical value and accuracy of the figures laid down by Heubner. Often a satisfactory gain is made on energy quotient lower than those given by Heubner. The amount on which the child is thriving should not be increased, however low it may be. The process of determining the energy quotient is very simple. It is only needed to remember a few figures representing the caloric value of each different food used. Thus cream, 16 per cent., has a caloric value of about 54 to the ounce; milk, 21; fat-free milk, 10; sugar, 120; flour or cereal, 100; cereal water, 2 or 3, etc. It is only necessary to multiply the number of ounces of each ingredient of the food mixture by its caloric value, to add the products and to divide the sum by the number of kilograms the baby weighs. After a little practice the energy quotient can be mentally calculated, even for com