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panying picture shows the length of the scar, photograph being taken on the 16th day, patient standing. The child has been nursed at the breast every three hours since birth, and has gained one-half pound.

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Mrs. J. Referred to us by Dr. Raschke. Age 30, 6 para, height 57 inches, weight 120 pounds, housewife. Pelvic measurements: inter. spines 23; inter. crystals 27; ex. conj. 18.5; R. Ob. 21; L. Ob. 20; post. spines 8.75; diag. conj. 9.75; the Michaels rhomboid unequal, upper apex being one-half the distance of the lower apex. Patient is markedly dwarfed, with a non-development of the sacral ale thereby decreasing the circumference of the pelvis, classifying it as a justo minor, or generally contracted pelvis of the Roberts type.

First pregnancy at 23. Craniotomy after a long and tedious labor. Second pregnancy, a podalic version at full term, with a dead fetus. Third pregnancy, podalic version at full term, with a dead fetus. Fourth pregnancy, induction with version at the seventh month; child lived a few days. Fifth pregnancy, Cesarean Section at full term, with a living child. These operations were all done in Germany. She came to this country about a year ago, and when referred to us, in view of the history given, Cesarean Section was again recommended.

Operation was begun at 12:15, child delivered at 12:16:22; uterus closed at 12:26; abdomen closed at 12:35. Convalescence has been uneventful. Stitches removed on the eighth day. Patient sat in a chair the 14th day, and the following picture was taken on the 16th day.

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Baby doing splendidly, nursing at the breast every three hours, and has gained 12 ounces.

CONCLUSIONS.

1st. To secure the best results in celiohysterotomy the operation must be one of first choice. Under these circumstances the mother's entire strength is conserved for her recovery.

2d. To attempt sterilization of the woman at the time of abdominal delivery for the purpose of preventing future conception is poor surgical judgment.

(a) In view of the fact that the mortality rate is under one per cent. in elective cases when adjunct operations are not performed.

(b) That repeated celiohysterotomy has now become a frequent procedure.

3rd. Our 22 five-inch incisions have conclusively proved the inad

visability of the long incision; except for pathology demanding a hysterectomy.

4th. The attitude of the medical profession towards Cesarean Section must change, for the operation has been so perfected and is being so successfully performed that to overlook its indications and deprive the pregnant woman and child of their rights, must be looked upon as carelessness and inadequate attention upon the part of the medical attendant.

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In presenting this case of abrupt and total blindness to you, I am using the above caption that you may better appreciate the extreme local possibilities of a general affection. Amaurosis, though now a discarded term, was formerly applied (before the use of opthalmoscope) to a condition of sudden blindness of systemic origin. Today, with the aid of the opthalmoscope, specific changes of the eye can be elicited and appropriately named.

There is little in the history of the young lady of twenty-one years, before you, excepting that from birth she has always been a weak, pallid child, in later years unable to undergo physical or mental strain, always semi-incapacitated for ordinary duties, subject to syncope, headaches, disturbed menstruation, obstipation, breathlessness, etc. The history has always been one of severe anemia.

She has been treated at various times for valvular insufficiency, the hemic murmurs present having been mistaken for those of incompetence. For some time past the mother has noticed an inequality of the pupils, the patient herself complaining of dimness of vision of the left eye. About six weeks ago she met with an accident, a clock having falien, striking her upon the bridge of the nose.

Following this pain was experienced in the forehead and temples, and in a week's time increased dimness of vision in the left eye began becoming complete, followed shortly by blindness in the right. This was abrupt and absolute, the patient not being able to discern the most intense light.

A thorough physical examination was made, the basic murmurs over the heart area only constituting those of any moment. No dilatation of the heart, no enlarged spleen, liver or lymphatic glands was to be found. A blood analysis was made with these resultant findings. Reds, 1,250,000, hemoglobin 40%, some macrocytosia, some poikilocytosis, leucocytes 21,000. No differential count recorded. The blood findings are somewhat difficult to diagnose.

With the marked oliogcythemia and the presence of some macro and poikilocytosis one might think of pernicious anemia. Nature in her attempt to compensate for the marked destruction of the red cell element, increases the size of the red cells, constituting a macrocytosis, also the hemoglobin content, but in this instance not to a sufficient degree to warrant a diagnosis of pernicious anemia. The leucocytosis must be regarded as such and not in evidence of leucemia for we find no corroborative physical changes of enlarged spleen, liver, lymph glands, bone tenderness or swelling.

The diagnoses is that of chlorosis, but the fact must not be lost sight of that an exceptional few of these cases ultimately merge into the pernicious type. Opthalmoscopic examination revealed a double optic neuritis of retro-bulbar origin. The margins of the disc appeared somewhat hazy, the retinal veins distended and spots of effused blood shown in the retina, the conditions not presenting, however, all the manifestations of a choked disc.

Retro-bulbar neuritis, in distinction from that involving the chiasm,

is usually dependent upon some toxic element-poisoning by tobacco, alcohol, lead, opium, etc., and is known as toxic amaurosis or amblyopia. On first consideration one is tempted to ascribe the condition to the local injury, but the previous evidences of inequality of pupils and dimness of vision tend to strengthen the diagnosis of one of general origin with the local trauma precipitating the attack in its severity.

The patient was put to bed, local cold compresses applied to relieve the congestion and partly to exclude the light, with Arnica 3x internally. Daily intra muscular injections of iron, arsenite 1 gr. in ampoule form as marked by P. D. & Co. were also instituted, but discontinued after four days because of the local neuritis occasioned. Bland's pills

3 gr. with cascara were then resorted to and continued. Today, five weeks later, the young lady is able to get about and even read large print. This case is demonstrated not because of any special efficacy of treatment, for that was most ordinary, but for its diagnostic

interest.

CLINICAL CASES.

H. V. HALBERT, M. D., CHICAGO.

Chlorosis. The case presented here is that of a young girl, 18 years of age who suffered from severe exhaustion and troublesome palpitation of the heart from the slightest exertion. Her palor was most pronounced, and when we sent her to bed in the hospital she looked very much like one afflicted with pernicious anemia.

The blood count, however, dispelled this fear for the red cells were 4,260,000 in number, though the hemoglobin was reduced to fifty per cent. Other features of the blood examination were quite normal. The diagnosis of course was chlorosis, and the attendant symptoms were in keeping with this disease; amenorrhea, anorexia, constipation, impaired mental capacity, depression and the marked hemic murmur and the veinous bruit in the neck which usually attend this disease. were present.

The patient was given absolute rest in bed and a diet with an abundance of proteid food. Iron, grain one, four times daily and Fowler's solution of arsenic min. five, well diluted in water after meals were prescribed. In the course of a few weeks she was greatly improved and in two months she was discharged from the hospital. She has reported at my Monday clinic regularly and so far as the chlorosis is con

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