be thought of first. There has been too much stress placed, it seems to the writer, on the forcible or projectile vomiting. This seldom starts early enough to be of much help and in some cases is delayed so late that if waited for the hope of doing anything for the case has vanished. A characteristic of the regurgitation early is that the child so often will throw up a large amount without apparently being very nauseated. As one mother was heard to express "It just comes up without the baby being sick." The food the child has been receiving must of course not be forgotten. Quite a majority develop while on the breast, and if the nursings are at least three hours apart a large per cent will be stenosis. Some authorities say that a spasm case almost never comes in a breast-fed baby but the writer has one family in which spasm has developed on the breast in two of four children. For some unaccountable reason a change in food nearly always shows some improvement for a day or two, although it may be to a very impossible formula, but the improvement is only a temporary affair. If the trouble has developed on a relatively high cream mixture, think of spasm. The first born child is much more often affected with stenosis than later children, while it does not seem to have the same bearing on spasm. In all the long lists of stenosis cases operated, a large majority of the cases have been in boy babies. So far as the writer has seen in his own experience, or been able to find reported the opposite has been true in spasm. The two cases just mentioned which developed on the breast were both girls, while two boys in the same family were free from the trouble. The loss of weight in both is usually quite rapid, but more so in stenosis especially of course where the obstruction is quite complete. The character of the stool will depend to quite an extent on the amount of food that is able to pass the pylorus. These children are not always constipated in frequency of movement, but in amount. In a severe case the stool will be brown and meconiumlike composed nearly entirely of mucous. Curds may be present, but often these also are balls of mucous. Very little, if any, results can be obtained from the use of an enema. Some fat curds may be present in the spasm cases following fat disturbance. The stools when formed are small and ribbon-like and on seeing it the first thought is that there is nothing there to be passed, so in truth it is not a case of constipation, but a case of non-movement from lack of anything in the bowel. Early there is nothing characteristic about the appearance of these children exthin and look cept of course they are pinched, even later they only present the appearance of a malnutrition. Naturally a child that is slowly starving is fretful, crying, whining, begging and sleeps poorly, but very little of the stormy cry of pain and acute distress. The first appearance of the abdomen sometimes is suggestive as there is an enlargement of the upper abdomen and flatness of the lower, which is not normal, neither is it the appearance in intestinal food troubles. The cause of this is easily seen when the extreme dilatation of the stomach and lack of food in the intestine are thought of. In examining any baby with vomiting, it should be done before, during and after a feeding. If, when seen, it is not near a time when a child should take a feeding and can be induced to take water, the same purpose is fulfilled. On an empty stomach usually nothing can be found unless the mass at the pylorus can be palpated. This mass to the right and usually above the umbilicus can very seldom be mistaken for anything else. After the stomach has been filled and even during the process of filling the abdomen should be left uncovered and watched for peristaltic waves starting under the edge of the ribs on the left side and going slowly across the abdomen to disappear at the point where the mass was felt. Before the first wave has disappeared a second and sometimes a third make their appearance. If they do not appear in a few moments a light stroking or flicking the abdomen or placing a cool hand on the abdomen may cause them to appear. If a mass has not been previously found at the pylorus a more careful examination of the pyloric region should be made during the course of the waves and if a mass can then be felt as a wave approaches the pylorus, which disappears between waves or after emptying the stomach, we have a spasm This and not an hypertrophic stenosis. feeling the mass in spasm is rare while it is the rule in 75 to 85 per cent in stenosis. The waves are seen in almost 100 per cent in stenosis and slightly less in spasm. One means of differentiation between spasm and stenosis has it seems been used much less than it should be. None would neglect making an examination of the stomach contents in an adult, but how seldom is it done in an infant in whom the operation is much easier. If sufficient or proper quantity cannot be gotten to test the acidity, the emptying of the stomach can be quite accurately determined as well as can the pyloric reflex. If at the end of three hours after feeding, the combined amount of contents vomited and removed by tube is as great or greater than the amount of feeding, either there is an almost complete stenosis or a sustained pyloric reflex. At the end of another feeding period, in which the child has had the same feeding with the addition of about two grams of sodii bicarbonate, if there is much less returned than was given there is no question as to dealing with a pyloric reflex, which becomes a spasm in a short time. Much information can be obtained by a series of X-ray plates following a bismuth meal as to the rapidity of the emptying of the stomach. Outside of that the writer is not prepared to say how much information it gives. Very little can be said as to the cause of either of these cases. Scudder, reports a case in which an hypertrophy of the pylorus was found in a fetus, and he also reports a case in which several after a gastro-enterostomy for stenosis the years X-ray shows the food still passing through the artificial opening which is conclusive evidence that the pylorus is still obstructed. All seem to agree that the obstruction is due to an hypertrophy of the circular muscular fibers at the pylorus as nothing else is found on making sections of the mass. Still attributed all cases to spasm, or as he expressed it, a stuttering of the pylorus which produced an hypertrophic condition of the circular muscles, but this will hardly stand in the stenosis cases. It may help in the spasm cases, but here the writer is inclined to agree with Cowie that probably an hyperacidity with a sustained pyloric reflex gives a better explanation. At least the treatment on the basis of the pyloric reflex with a high protein formula decreases the effect of the free acid. This agrees again with the fact that so many spasm cases seem to have had fats as an etiological factor in the development. With the addition of sodium citrate to help prevent the large curds we can use a high protein and carbohydrate formula with low fat with the best results as far as dietetic treatment goes. Gastric lavage has been used for years but only once or twice a day, which does not give the results that will be obtained if the stomach is washed with a soda solution before each feeding. The treatment of the cases of stenosis is so imperatively surgical that it seems best to the writer to leave it open to the sur geons to discuss, except to say that every hour's delay may prove disastrous. 731 City National Bank Building. SERO-DIAGNOSIS OF PREGNANCY. PALMER FINDLEY, M. D., Omaha. The diagnosis of early pregnancy is a subject of great practical interest because of the difficulties sometimes encountered. The clinical phenomena of early pregnancy are not always reliable and are at times sadly misleading. Likewise the physical findings in the early pregnant uterus may lead the examiner into error. While in the great majority of cases where doubt exists we can rely for our safeguard upon the time-honored custom of awaiting future developments in the full assurance that in the course of time the diagnosis will be made clear, yet there are occasional cases in which it is not only advisable but mandatory that a diagnosis be we call to our aid every possible means of made with little delay. In such instances diagnosis and it is in just such cases that the sero-diagnosis of pregnancy promises to pose of the writer to discuss the diagnosis be of very special value. It is not the purof pregnancy in general, but to bring to your attention a method for the early recogintroduced by Prof. Abdehalden of Halle. nition of pregnancy that has been recently Professor Abderhalden is a biological chemist, not a clinician, and it is to men engaged in biological chemistry that we may look in the near future for great advances in medicine. Abderhalden's work in the sero-diagnosis of pals upon which his observations are pregnancy is fundamental for the princibased, are being applied to many problems in medicine and surgery. There are those who believe that he has laid a foundation making in the history of medicine. in diagnosis and therapy that will be epoch The observations of Abderhalden throw light upon the method by which the animal body protects itself against foreign bodies introduced into the blood. He finds a metab olic reaction, in that ferments are found in the blood plasma as the result of this reaction. It has been long known that foodstuffs taken into the body are variously altered by ferments in the cells of the digestive glands, and that substances introduced into the digestive tract requiring digestion do not enter the blood under normal condi tions. cerous patients which will digest cancerous proteins, of sarcoma patients which will digest sarcoma porteins, that these ferments are specific in action and will digest no other proteins. Sufficient observations have already been made to warrant the hope that we have a means of early recognizing malignant growths by means of a biological test similar to that of pregnancy. My personal experience with the test is limited to eight cases, in all of which the physical examination was not conclusive and the history was only suggestive of pregnancy. Hence, the sero-diagnosis was of real value in determining the diagnosis. All were pregnant and all gave positive reactions. The earliest was examined three weeks from the date of fruitful intercourse. In this the reaction was faint but subsequent events have confirmed the findings. In a second case the woman had never been pregnant, was believed to be sterile from an infected uterus and appendages, and she had not failed to menstruate regularly and profusely every three weeks. Two months ago at her regular menstrual period she flowed so profusely that my suspicions of a threatened abortion were aroused. The serum test was positive and a few days later an early prengancy was terminated because of the persistent loss of blood. A third case referred by Dr. Dunn, had tuberculosis of the lungs, she failed to menstruate at the expected date and six days past this date she showed a positive reaction. Subsequent events have demonstrated the correctness of the test. case is worthy of special note because of the frequency of amenorrhea in tuberculous women. A fourth case was 38 years of age, was married fifteen years, was desirous of having children but had never conceived. The test was made after the third period had missed and was positive. The physical examination disclosed an irregularly shaped uterus of about the size of a three months pregnancy, but there was a reasonable doubt as to whether she might not have a soft interstitial fibroid tumor. There was nothing unusual about the other four cases except that all had missed but one period from one to three weeks and the size, form and consistency of the uterus were not sufficiently altered from that of the normal non-pregnant state to warrant a diagnosis of pregnancy. This While we are not in a position to pass final judgment on the test yet with the observations I have made and the reports which are coming in from every quarter of the medical world, I am convinced that we are indebted to Abderhalden for the intro duction of the most dependable of all tests for the early diagnosis of pregnancy. Abderhalden claims that the test is 100 per cent efficient and that all failures are chargeable to faulty technic. Arm and Kislig made tests in 108 cases with a record of 98 per cent efficiency. Others range in their results from 80 to 100 per cent efficiency. When we consider that most of these cases are in the early weeks of gestation before the changes in the size and consisteny and form of the uterus would warrant a diagnosis of pregnancy and in some of them with histories that are altogether misleading we are impressed with the value of the tests. Certain it is that it is worthy of more extended observation. In the preparation of the test materials, fresh human placenta is cut into small pieces and washed free of blood in salt solution. The pieces are then placed in ten times their volume of boiling water, to which a few drops of glacial acetic acid are added. After boiling five minutes the water is drained off and the tissue is washed in distilled water. This process of boiling and filtering is repeated until the decanted water fails to give a reaction for peptones as determined by ninhydrin, which gives a deep blue color in the presence of peptones. The placental tissue thus prepared may be preserved for three months in chloroform water in a sterile glass container. The serum is obtained from the blood of the mother by drawing off 10 c.c. of blood from a superficial vein and placing it in a sterile centrifuge tube. Frothing of the blood should be avoided for fear of causing hemolysis. A clear serum is obtained by centrifuging. If the serum becomes hemolyzed it is to be discarded. One gram of the prepared placenta is disintegrated in a sterile mortar and transferred by sterile forceps to a sterile test tube, to which 1.5 c.c. of serum is added. Toluol is added and the tube is incubated for twenty hours at 37 C. At the same time a control tube of serum, to which toluol is added is carried through the incubator to detect the possible presence of disintegration products of albumin. After incubation the toluol is pipetted off and the tubes placed in a boiling water bath. This produces coagulation with the addition of 5 c.c. of acetic acid; 10 c.c. of distilled water is then added to the coagulum and the mixture is stirred with a sterile glass rod. The watery extract is then filtered off and is tested by boiling with 0.03 c.c. of a 1 per cent solution of ninhydrin for one minute. The appearance of a blue or violet color within a half hour denotes a positive reaction. The control should be colorless. It is readily appreciated that with such an elaborate technic errors are frequently made, but with the preparations of placental extract and ninhydrin solutions prepared by Parke, Davis & Company the technic is greatly simplified and well within the scope of the average laboratory worker. It is observed that the reaction may be positive in the non-pregnant if the blood is taken shortly after a full meal and again if the serum becomes hemolyzed in the process of its preparation. Again strict asepsis is essential to the perfect carrying out of the test. The test will be found of special value in cases of suspected abortion where temperature or hemorrhage exist, in ectopic pregnancy, in amenorrhea, in nursing mothers who are suspected of being again pregnant, in medico-legal cases, and in the differentiation of pregnancy from fibroids, ovarian cysts and subinvolution of the uterus associated with amenorrhea. Brandeis Theatre Building. ON THE 'RELATIONSHIP OF THE DUCTLESS GLANDS TO GROWTH.* A. D. DUNN, M. D., Omaha, Neb. Eugenics is being so universally discussed at this time and our attention is being so constantly directed towards the problem of evolving the superman, that it seems not inapropos to discuss briefly certain glandular factors which influence growth. In all growth three things are requisite: First, the necessity for growth; second, food; and third, the ability to grow. The first two factors need little comment here. In all multicellular life growth is a necessity. Every species has an optinum size which is best adapted for this species in its struggle to maintain itself in its environment; the tendency of all growth is towards this optinum. Individuals who do not approximate it tend to disappear, as for example the Australians and Tasmanians in the genus homo. Suitable food is admittedly necessary for all growth because growth is a manifestation of energy. It is not a form of energy, but the result of an energetic and especially of a chemical situation (Friedenthal). An investigation of the third factor, namely, the ability to grow, *Read before the Medical Society of the Missouri Valley, at Lincoln, Neb., March 26, 1914. leads us into a complexity of problems of which the solutions are far from complete. The protozoon is potentially immortal, dividing periodically and indefinitely into two new individuals. At rare intervals the union of two cells occurs which gives a new impetus to growth and we find the sexual and asexual cycles which are so well illustrated by the life history of the hematozoon of malaria. All higher forms require the union of cells from two parents to bring about the development of a new individual. The death of the parent individual follows in a longer or shorter period of time; therefore the immorality of the meatazoa resides. in its offspring. The physico-chemical factors determining the phenomena of growth are unknown. In mammals the activities of certain groups of cells seem to have much to do with the ability to grow. ability to grow. It is in their functions that we find certain determinants affecting and modifying this ability. It is with the relationship to growth of this interlocking glandular directorate, which also profoundly influences metabolism and sexual life, that this paper has to do. We will consider merely the functions of the hypophysis, thyroid and thymus and interstitial cells as they affect the problem of growth. Other physic-chemical correlations are certainly at work modifying and determining growth, but as yet our knowledge of them is so defective that such correlations may here be omitted. THE HYPOPHYSIS. The relationship of the hypophysis to growth has been extensively studied. In 1886 Perre Marie first directed attention to this hidden gland as having to do with acromegaly, although he not surprisingly attributed the disease to a destructive lesion. lesion. Observations have gone far to fix the cause of acromegaly in a hyper-function of the pars anterior. The fact that destructive lesions are often found at autopsies after the condition has become stationary does not disprove hyperactivity during the developmental stage. The operative cases of Hochenegg and Exner are experimental in their precision. Operative removal of the pars anterior in recent cases of acrome galy resulted in a regression of the anatomical manifestations. Today gigantism is considered a result of hyperpituitarism. In acromegaly the period of activity occurs after epiphyseal ossification is complete; in gigantism the hyperactive stage occurs in childhood or adolescence, before ossification is finished., As the terse phraseology of Launois and Roy has it: "Gigan |