allows the mucous membrane to bulge into the opening sufficiently to relieve the obstruction. Further scissors dissection at this stage carries with it the danger of tearing the mucous membrane. Even if the mucosa is broken, it does not entail any great danger because of sterility of the duodenum; yet one would rather not have it happen.

The pylorus is replaced and pushed up against the under surface of the liver, in order to facilitate clotting should there be an oozing from the cut surface. Closure of the abdominal incision is made with single strands of No. 1 chromic gut suture which include fascia, muscle and peritoneum (Cut III-D). Two or three silk worm gut sutures protected with rubber tubing are then passed through skin, fascia and muscle (Cut III-E). If there is any vomiting in these little under-nourished patients, where the tissue is so delicate and healing may be delayed on account of poor nutrition, the abdominal incision may be broken open unless re-enforced with adhesive. This is applied in transverse strips shaped like a butterfly, the middle of the strip being cut on either side so as to narrow the adhesive just where it crosses the wound. The wound itself and the narrow parts of the adhesive are both painted with two per cent tincture of iodin and the adhesive applied directly to the skin while holding the edges of the wound closely together (Cut III-F and G).

Postoperative Treatment: The babies are put head down at an angle of 45 degrees for three hours following operation. In this position, in case there is any oozing, the cut surfaces of the tumor are more liable to be pressed close up to the under surface of the liver. The baby's head is then gradually raised until the body assumes a sitting posture. This position is maintained by the use of a little swing made of gauze passing under the buttocks and tied to either side of the crib. Small pillows are adjusted at the back to make it as comfortable as possible. In case any gas accumulates in the stomach, this position gives it a more ready exit through eructation. Feeding is started as soon as the baby becomes conscious; 15 cc. are given every two hours with the same amount of water half way between feedings. Breast milk is the best food in case it is available from the baby's mother. If not, a dilution of cow's milk and water is given, which would correspond to the diet of a new-born baby. Daily cleansing enemata are given, as by keeping the lower bowel free the babies seem better able to take and hold their feedings. For the first two days following

operation, the soda and sugar enemata are given to be retained three or four times in 24 hours. By this time the normal intake of food will take care of the lowered alkaline reserve factor and dehydration will have been overcome.

After the Rammstedt operation, vomiting is seen much less than after gastroenterostomy. In case the baby cries for 15 minutes or over, we advocate giving paregoric, 30 drops, to keep them quiet during the healing of the wound. There is practically no shock when the surgical procedure is carried out on the principles outlined above. Food is taken as in a normal infant and the weight gain is immediate and progressive. So far, literature contains no account of the recurrence of the symptoms following the Rammstedt operation.

The author has operated on three cases within the past year. Two had gastroenterostomies (Cut IV) and one the Rammstedt operation (Cut V). All three are now as husky and well as though nothing had ever happened to them.

References

Hirschsprung: Jahr. d. Kinderheilk, 28, 1888, 62.
Ramstedt: Med. klinik, 1912, VIII, 1702.

Beardsley Cases and Observations: By the Medical Society of New Haven County in State of Connecticut. 1788.

Downes: J. Am. M. Ass., 1914, LXII, 2019-2023. Surg., Gyn. and Obst., 1916, XXII, 251.

Dunn and Howell: Arch. Pediat., 1915, XXXII, 423-433.

Hess: Am. J. Dis. Child., 1914, VII, 184-207.

Holt: J. Am. M. Ass., 1914, LXII, 2014-2019.

Ibrahim: Munchen. med. Wchnschr., 1905, LII, 674.

Mixter: Boston M. & S. J., 1913, CLXIX, 309.

Morgan: Am. J. Dis. Ch., 1916, XI, 245.

Scudder: Boston M. & S. J., 1915, CLXXII, 166. Ann. Surg,, 1914, LIX, 239-257.

Chronic Otitis Media.--J. F. Barnhill, Indianapolis (Journal A. M. A., Jan. 6, 1917), says that the end results in surgical cases in chronic suppurative otitis media depend on many things, the age of the patient, the condition of the nose, naso pharynx and pharynx, the nature and violence of the original aural infection, the presence of complications, the period of the disease in which the attempt to cure is made, the general physical condition of the patient and the skill and judgment of the operator. The efficiency of the after-treatment, also, has much to do with the final results, and the conduct of the patient himself, who may neglect to follow the instructions or to return to receive further instruction which may be needed. The effect on hearing is usually good from middle ear operation; and the suppuration is cured in probably 90 per cent, provided the treatment is first class. Tuberculous cases are, of course, excluded. Nonsurgical cases probably have no mortality, but when bone necrosis occurs, the life of the patient is in danger and proper surgical treatment is the best recourse.

A CASE OF FRACTURE OF THE BASE OF THE SKULL AND SOME OF ITS CHARACTERISTIC SYMPTOMS*

By ARNOLD PESKIND, M. D., Cleveland

Bessie L., aet. six years. Automobile accident.

Admitted to the East 55th Street Hospital at 2:53 P. M. on July 24, 1916.

The child, unconscious, was bleeding profusely from the mouth, nose and right ear. Respiration was labored.

Fig. 1-Bessie L
and side of skull.

The girl was first seen by Dr. Kurlander, soon after by Dr. S. Peskind, and I saw her near 4 P. M. Fracture of the base of the skull involving the temporal, parietal and occipital bones to the right of the median line was easily made out. There were also other

*Read before the Clinical and Pathological Section of the Academy of Medicine of Cleveland, December 1, 1916.

more or less extensive body injuries, but no other fractures were discovered.

X-ray at 4 P. M. corroborated the diagnosis.

Patient was taken to the operating room at 6:50 P. M.

The incision was made a little below the occipital protuberance, then carried upward in a curved line, and brought down to within one inch outside and below the mastoid process. The skin and muscle flap was pushed aside and two broken pieces of bone were found overlapping, one from the parietal, one fragment from the contiguous occipital bone, the latter partly driven under the portion of the occipital bone which was intact. Both fragments were loose, separated at their sutural junction, completely dislocated downward and outward. I removed both fragments, as in my judgment to leave such fragments in situ is to invite further mischief. The diploe was bleeding and packed with wax. Loose clots under the scalp and under the occipital bone were removed. There was much capillary oozing, but I did not deem it wise to spend too much time in the attempt to stop it completely. The child was in the operating room not more than twenty minutes. A very little chloroform was used, as the child was unconscious. The removed fragments were each one and seven-eighths inches long by one inch wide. Upon examination, these two removed fragments disclosed the peculiar effect the impact had upon the bones when the child was hit by the automobile. In the fragment of the occipital bone the outer table only was found broken; in the fragment of the contiguous parietal bone the inner table only was found split through in stellate shape. During the first four days the child was restless, tossed her hands. and feet about. The catheter was resorted to, to relieve the bladder. There were involuntary evacuations of the bowels and urine. Liquids put into the mouth were slowly swallowed. At times the muscles of the legs and arms would become rigid. In the afternoon of July 27th, the child became more conscious and spoke somewhat incoherently. July 29th the child began to talk intelligently and in twenty-four hours after that was able to sit up in bed.

A short resumé of the course of the case is as follows: From the evening of July 24th to the evening of July 26th the temperature ranged between 101.3° and 104° F.; the pulse from 132 to 146 per minute.

On July 27th the temperature was 99.4, pulse 120 to 130, and remained normal for three weeks. The child was allowed to sit up

Fig. 2 Bessie L, fragments of bone removed. Photograph shows lines of fractures in the two bones, the different surfaces involved in each bone.