will be peas, beans, and onions; for August tomatoes and green corn. The latter cooked Indian fashion with beans makes a substantial, delicious life-giving food. Sweet corn planted in succession will last until frost comes, and then follow the Brassica tribe and squashes. Through the winter the potato is preeminently the staple vegetable food, although with care many of the others can be preserved without deterioration. All sanitary rules are formulated with reference to diet or sleep. Having dilated on the first prerequisite we now consider the second

SLEEP.

(1) A large well ventilated sleeping room with a southern exposure is an important adjunct to health-a chamber being preferable to the ground floor.

(2) Allow of all the sunshine possible, keeping the windows open at night as long as the weather permits.

(3) Cleanliness of room, clothes and person is essential, cleanliness being next to godliness.

(4) Never sleep in the same clothing worn during the day.

(5) Avoid having fire or lamp burning all night in your bedroom. (6) Have the head of the bed a little higher than the foot, and pointing north.

(7) Retire as soon as you feel sleepy.

(8) Never retire with cold feet. If subject to such, dip them into cold water and rub until warm.

(9) Sleep all you can and as much as possible before midnight. (10) If troubled with wakefulness, instead of taking drugs try massage as a remedy-using a wire brush for the head. Time spent in massage of the surface of the body is not time lost-it is time lent.

These rules comprise about all we now know regarding longevity, and if carefully observed, cannot fail, unavoidable accident or misfortune excepted, to keep us alive and stirring long after we have passed the present limit of human life, and when the inevitable hour arrives, the mechanism that keeps us alive will be more apt to stop suddenly and let us drop off painlessly into the sleep from which we never awaken. [CONCLUDED.]

METATARSALGIA.*

WILLIAM E. BLODGETT, M. D.

THE object of this paper is to offer a few remarks about a somewhat rare but often striking orthopedic lesion and to illustrate the treatment of it. The condition referred to is anterior metatarsalgia or Morton's toe. The rarity of the condition is shown by a series of one thousand hospital cases of foot-trouble due to faulty weight-bearing, collected by the writer. In this series, only sixty-eight were metatarsalgia, and only ten had the sudden, severe attacks of pain. In the last six months, however, three patients with the characteristic sharp attacks have come under the writer's care, as well as three patients *Read before the ANN ARBOR MEDICAL CLUB, September 12, 1906. Journal of the American Medical Association, August 20, 1904.

with chronic metatarsalgia. These six cases form the basis of the demonstration.

The cardinal feature of metatarsalgia is pain at the base of the small toes, especially the fourth toe. The pain is provoked and aggravated by use of the foot. There are two types of this pain: first, chronic pain and soreness; and, second, intermittent, sharp attacks of pain. The chronic type is commonly accompanied by a noticeable flattening of the transverse arch of the foot made of the heads of the metatarsals, and by a callus beneath the flattened transverse arch. The acute type often occurs in an apparently normal foot. The acute type is striking because of the suddenly produced, almost complete disability. The patient, usually a woman, is forced to sit down on the curb, or wherever, and remove the shoe. One patient, particularly careful about her appearance, would often come home from the evening's entertainment stocking-foot, nauseated by the pain. The onset of the pain is often announced by a feeling of something in the front of the foot slipping; one lady said it felt like the "slipping of a cog." In the same way, some manipulation of the front of the foot will often stop the severe pain.

The cause of the pain in the chronic type of metatarsalgia, as in the ordinary pronated foot, is general abnormal tension and pressure. In the acute type, however, the pain is due to a displacement of the heads of the metatarsals in relation to each other, such that one of the digital branches of the external plantar nerve is squeezed between two of the metatarsal heads. This nerve pressure usually occurs on one side or other of the head of the fourth metatarsal, so that the pain is referred to the fourth toe. A structural change in the heads of the metatarsals, as after a fracture, is occasionally accountable for the nerve pressure.

The principle of treatment is to prevent the cause of the pain. In the chronic type, the anterior arch requires support either by natural or artificial means. The measures to favor natural support are a broad right-shaped shoe, correct toes-to-the-front gait, stimulative applications to the feet as alternately hot and cold bathing, and exercises for the feet to strengthen flexion of the toes. An exercise that is of use is for the patient with the feet bare to pick up with his toes two or three dozen one-half inch marbles and first with one foot and then with other to replace them in the box. The general health may need attention. Artificial support is supplied by adhesive plaster strapping and more permanently by a sole plate, both of which are to be demonstrated.

In treatment of the acute type, the measures for favoring natural support are the same as in the chronic type. The acute pain can usually be immediately stopped and return of it temporarily prevented by manually pushing up the middle metatarsal heads and drawing down the sides of the foot; this position is retained by a felt pad about one-quarter inch thick and one inch by one-half inch, placed under the middle metatarsals and by adhesive strapping holding the pad in place

and the sides of the foot drawn down around it, as is to be demonstrated. Permanent artificial support is supplied by a plate similar to that used for the chronic type but more extreme. Operative removal of the head of the fourth metatarsal is rarely necessary.

Detroit, Michigan.

ORIGINAL ABSTRACTS.

SURGERY.

FRANK BANGHART WALKER, PH. B., M. D.

PROFESSOR OF SURGERY AND OPERATIVE SURGERY IN THE DETROIT POSTGRADUATE SCHOOL OF MEDICINE; ADJUNCT Professor oF OPERATIVE SURGERY IN THE DETROIT COLLEGE OF MEDICINE.

AND

CYRENUS GARRITT DARLING, M. D.

CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

MORTALITY AFTER OPERATIONS UPON THE GALLBLADDER AND BILE PASSAGES.

In a summary of fifteen hundred operations upon the gall-bladder and bile passages, William J. Mayo, in the Annals of Surgery, Volume XLIV, Number II, indicates the trend of surgical practice in these cases and compares the development of surgery in this field with that of appendicitis. He states that there were 845 cholecystostomies with a mortality of 2.13 per cent. There were 319 cholecystectomies with at mortality of 3.13 per cent. There were 207 operations upon the bile passages with twenty-seven deaths, about 13 per cent, arranged in four groups: Group I, 105 cases with three deaths, 2.9 per cent, consisting of those patients in whom gall-stones were present in the common duct but without immediately active symptoms. Group II, 61 cases with ten deaths, 16 per cent. In this series there was active infection not only in the common duct but also involving the ducts of the liver. Stones were usually present. Group III, 29 cases and ten deaths; 34 per cent. In these there was complete obstruction of the common duct. In group IV, which concerned malignant disease, there were 12 cases with four deaths; 333 per cent mortality. The total number of deaths following the 1,500 operations was sixty-six, an average mortality of 4.43 per

cent.

The author states that the mortality in the first 1,000 cases was 5 per cent; in the last 500 3.2 per cent. The death rate after cholecystostomy in the last five hundred cases was 1.47 per cent. In the last 500 cases he also lowered the death rate after cholecystectomy to 1.62 per cent. This view illustrates the merit of experience and selection of cases.

From the standpoint of mortality cholecystostomy is the safest operation for the average case, and yet in the author's hands removal of the gall-bladder has been followed by nearly as good results. He reasons that as the best surgical practice removes the appendix while yet the disease is confined within it, so removal of the disease while still in the gall-bladder will show a mortality of less than one per cent. "With the

passage of the stone into the common duct we no longer have a localized disease but one fraught with grave dangers from liver infection and cholemia, and in this condition nearly one in seven of our cases came to operation, while one in twenty-five developed malignant disease of the gall-bladder, or bile tract, and in most of these cases gall-stones were present. In other words, one patient in six had allowed the favorable time to go by, although the very large majority had ample warning in the early and safe stage for operation."

F. B. W.

OBSERVATIONS UPON THE ANATOMY OF THE DUODENUM.

AGAIN, in the American Journal of the Medical Sciences, A. J. Ochsner calls attention to the finding of a marked thickening of the circular muscular fibres of the duodenum at a point below the entrance of the common duct. In some cases he has found a narrow circular band forming a distinct sphincter; in other instances the thickening was diffused, making a broad circular band; and in a few instances the thickening was in two different bands, with an intervening portion in which the circular muscular fibres were of the same thickness as the remaining portion of the duodenum. In most specimens the sphincter was located from three to ten cubic centimeters below the point of entrance of the common duct, while in a few instances a portion of the sphincter included a point of entrance of the common duct, the remaining portion however, being always located below this point.

It seemed to the author as though this arrangement of circular muscular fibres served the purpose of a sphincter to facilitate the process of mixing the bile and the pancreatic juice in the duodenum.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

F. B. W.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D.

FORMERLY FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

OVARIAN CYSTS SITUATED ABOVE THE SUPERIOR PELVIC STRAIT, COMPLICATED BY PREGNANCY. PATTON (Surgery, Gynecology, and Obstetrics, Volume III, Number III) reports three cases occurring in the University of Michigan Gynecologic Clinic, and reviews three hundred twenty-one cases collected from the literature. The writer's study was confined to a consideration of cystic tumors lying above the true pelvis and from statistics drawn from these cases he has formulated the indications for appropriate treatment. The cases are tabulated according to the treatment employed, that is: (1) Not interfered with; (2) Tapped; (3) Laparotomy; (4) The child delivered by artificial means.

(1) Treatment Expectant, Ninety-five Cases.-During pregnancy and labor the dangers from the expectant plan of treatment are not so great as in the puerperium. Twisting of the pedicle of the cyst is very apt to occur when the ligaments are lax after labor. Probably due to the torsion of the pedicle is the large number of cases of suppuration, hemorrhage, rupture, and peritonitis. The maternal deaths in this series of cases were twenty-five, or 26.3 per cent. Interrupted pregnancies, eighteen-9 per cent. Laparotomies after labor, forty-nine, or 51.5 per cent. Deaths, four, or 8.1 per cent. No operation, forty-six, or 48.5 per cent. Deaths, twenty-one, or 45.6 per cent.

(2) Laparotomy, One Hundred Twenty-four Cases.—In this series operation was done from the second month to full term. The maternal death-rate was only 4.3 per cent. Interruption of pregnancy occurred in nineteen per cent of the cases, practically the same as under the expectant method. Twisted pedicle was found forty-six times, or 25 per cent.

(3) Tapping, Thirty-one Cases.-There were twelve maternal deaths. Rupture of the cyst occurred six times before labor. Only one case of twisted pedicle was encountered. Pregnancy was interrupted in 54.8 per cent of these cases.

(4) Other Methods.-Cesarean section, accouchment forcé, delivery by forceps, version, and embryotomy were employed in eleven cases. Five cases were operated during the puerperium with successful results. In the remaining six cases, there were four deaths.

Briefly, the writer concludes that ovarian cyst is not an uncommon complication of pregnancy, and when occurring it is a dangerous condition. Complications in ovarian cysts are more frequent during pregnancy and the puerperium than in the nonpregnant state. Tapping gives only temporary relief and is a dangerous procedure. If the expectant plan is followed during pregnancy and labor, the cyst should be removed as early as possible in the puerperium. The treatment giving the most favorable results is laparotomy and removal of the tumor before labor, as soon as the diagnosis is made. Jackson, Michigan.

OBSTETRICS.

WILLIAM HORACE MORLEY, PH. B., M. D.

C. G. P.

DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

AND

ROLLAND PARMETER, B. S., M. D.

A CASE OF INTRALIGAMENTARY FULL-TERM EXTRAUTERINE PREGNANCY.

RÖDIGER (Zentralblatt für Gynäkologie, Number XXXI, August 4, 1906) describes the following case: A farmer's wife, thirty-six years of age, confined in 1897 and 1899, with one abortion in 1900 as a result of typhoid, became pregnant toward the end of November, 1904. Patient.