ADHESIONS BETWEEN STOMACH, GALLBLADDER AND COLON. Case 7. Referred by Dr. Dunn. Mrs. A. S., age 50, came with a history of indefinite abdominal symptoms covering the past twenty-nine years. When presented for examination she was emaciated, complained of distress immediately after eating; bloating with gas which she could only expel after massaging her abdomen in the cecal region. A dilated cecum was visible through the thin abdominal wall. Radiographic examination showed a narrowing of the pyloric portion of the stomach and a stenosis of the pylorus. The cecum ascending colon and that portion of the transverse colon lying to the right of the pylorus were considerably dilated. Beyond this point the colon was normal in size. A bismuth enema stopped at a point near the pylorus of the stomach. A diagnosis of adhesions between the pyloric portion of the stomach and the transverse colon, probably due to an old inflammation of the gallbladder was made and was proven at operation a few days later, five stones being present in the gallbladder.

Fig. 1. Normal stomach in small woman "Fishhook" type. Bismuth has not passed through pylorus but rests against it. Fig. 2. Stenosis of pylorus with gastric dilalation and "undershot" pars pylorica. The pars pylorica standing well beyond the pylorus. Proven at operation. Illustrating Case VI.

Fig. 3. Adhesions about pars pylorica, narrowing this portion of the stomach. Symptoms dated back twenty-nine years. Diagnosis: adhesions between pyloric portion of stomach, gallbladder and transverse colon. Proven at operation. Illustrating Case VII.

Fig. 4. Scirrhus carcinoma of pars pylorica involving entire circumference thus contracting the lumen. Proven at operation. Illustrating Case II.

Fig. 5. Annular carcinoma of pars media contracting lumen to size of little finger. Consulted physician one week before radiograph for hematemesis. Illustrating Case I. Fig. 6. Carcinoma of stomach on wall of perforating ulcer. Patient consulted physician because of obstruction of bowels shown in Fig. 7. Both proven at peration. Illustrating Case III.

Fig. 7. Adhesive band about lower part of descending colon allowing a loop of colon to fall over the band closing the lumen. Proven at operation. Same patient as Fig. 6. Illustrating Case III.

Fig. 8. Scirrhus carcinoma of lower two-thirds of stomach. Palpable mass present in left upper quadrant of abdomen. Doubt as to whether growth was on

stomach presses the colon downward before it. Illustrating Cace IV.

Fig. 9. Left half of colon of same patient as Fig. 8 See how growth on stomach or colon Illustrating Case IV.

Fig. 10. Normal cecum. Note normal large size and regular outline with haustra well marked. Compare with Fig. 11.

Fig. 11. Jackson's Membrane about Cecum. Note irregular, contracted appearance and partial absence of haustra. Compare with Fig. 10. Illustrating Case V.

The following half page cuts are intended to illustrate the paper by Dr. W. H. Mick on X-Ray Observations on Results of Fractures, which appeared in the July issue, but were received too late for publication.

Both joints had been reduced before the X-Ray examination was made which revealed the truth pathology.

Fig. 1. X-Ray of ankle joint with backward displacement of astragalus. Note the two loose chips of bone.

Fig. 2. Same as Fig. 1, after open operation; chips of bone removed. Result perfect.

Fig. 3. Fracture of humerous into shoulder joint. Recommended to place shaft of bone to outer side of head.

Fig. 4. This shows a crooked but useful shoulder joint from case shown in Fig. 3.

Symposium on Interruption of Pregnancy

Ihdications for Interruption of Pregnancy
*By C. W. POLLARD, A. B., M. D., Omaha.

This subject is usually considered under two heads, namely: first, the indications for interruption of pregnancy before the foetus is viable, and second, after the foetus is viable. But since the indications may be the same in the two classes, I will ask you to consider grouping the cases according to the cause namely, first maternal, second foetal and third intrauterine.

The maternal is divided into physical and mechanical. The physical will include toxaemia of pregnancy and disease of the mother. The disease may be one of acute infectious variety, or one from which the mother was suffering when she became pregnant, such as anemia or heart lesion or Brights.

Toxaemia of pregnancy is the special cause which we should endeavor to prevent in all cases. Whether it comes in the form of pernicious vomiting or with pre-eclamptic symptoms.

In cases of vomiting early in pregnancy, watch the rapidity and condition of the woman's pulse, as well as noting the amount of food retained. If the woman gives the history of having retained by stomach little or no food for two weeks and also states that the nutrient enemata are expelled shortly after they enter the bowel and yet she has a good strong pulse, there need be felt little anxiety about her condition. But on the other hand when the pulse begins to become rapid and weak and the vomiting leaves her exhausted, it doesn't matter how many days she has been vomiting or whether she is able to retain the enemata, it is wise to empty the uterus at once. The attempt to strengthen the heart by medication will only postpone the fatal result. The cause has to be removed.

In pre-eclamptic condition, the main symptom to be depended upon is the degree of tension of the pulse. I examine the tension of every pregnant woman as early in pregnancy as I can, in order to know her normal tension. If her tension is 120 at this time a later tension of 160 is comparatively higher than though her tension were 140 early in pregnancy.

Examine the urine to make sure of the condition of the kidneys but watch the tension. In case the woman has headache or dizziness, dark spots before the eyes or ringing in the

*Read before the Nebraska State Medical Association, Omaha, May 13-15, 1913.