the ligamentous bands, the tear in the capsule always being large enough to let the head of the bone escape. Putting aside the element of muscular contraction, the end of the bone should pass through the same opening by which it passed out. Even the muscles as well as all of the ligamentous structures may be torn and reduction in these cases is easy. Care must be taken to dress them in such a way that they do not recur. The indirect are accompanied by different lesions because the end of the bone takes a different direction from that of the force applied, the bone acting as a lever. The parts move and the force is deflected. Three types of levers are considered. (1) Where the fulcrum is between the power and the resistance. (2) Where the resistance is between the power and the fulcrum. (3) Where the power is between the resistance and the fulcrum. Most of the luxations of the long bones will fall in the first type according to the primary movement of the joint whether it be gliding, hinge or rotary. Gliding joints have no lever action in dislocation, but hinge and rotary joints have a lever action with a bony fulcrum. In rare instances a ligament may act as a fulcrum. In a hinge joint the soft parts prevent undue strain upon the ligaments when the hinge is closed. When the hinge opens and the muscles are off guard overextension will make the ligaments tense and compel them to yield until the luxation is produced. Ball and socket joints, as the shoulder and hip, have a basic movement to and fro which we call abduction and adduction. The shoulder is more movable and is more frequently luxated than any other joint in the body. This accident occurs with the arm in extreme abduction with the tuberosity impinging upon the acromion process which acts as a fulcrum. Continued pressure causes the capsule to be ruptured on the opposite side and the head of the bone should always find its exit at the same spot. The anatomic relations compel this course and the head generally lands under the coracoid process, which makes practical the only dislocation of the shoulder, the others being rare and unusual injuries due to peculiar forms of traumatism. Reduction will depend upon four things. Eliminate the obstruction of the muscles by anesthetic or traction; Place the arm in approximately the same position which it occupied when the head came out; rotate the arm to open the rent in the capsule; push or pull the head toward the glenoid cavity.

In dislocation of the hip there is hyperabduction to such an extent that the neck impinges upon the rim of the acetabulum and the great trochanter strikes the ilium until they form a fulcrum. Continued. pressure causes the rupture of the capsule and the ligament becomes responsible for the change of position after the head is passed through the rent in the capsule. Practically the same points are to be kept in mind in reducing this dislocation: to eliminate action; to open the rent in the capsule; bring the head of the bone into place by adduction and. rotation. The same principles will apply in all luxations, unless they are produced in some unusual manner.

C. G. D.

GYNECOLOGY.

HOWARD HASTINGS CUMMINGS, M. D.

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.
BENJAMIN ROBINSON SCHENCK, A. B., M. D.
CONSULTING OBSTETRICIAN TO THE WOMAN'S HOSPITAL OF DETROIT.

GYNECOLOGIC DISEASE IN THE INSANE AND ITS RELATIONSHIP TO THE VARIOUS FORMS OF PSYCHOSIS.

TAUSSIG (Journal of the American Medical Association, Volume LIX, Number IX) examined five hundred thirty-seven insane women in the Saint Louis Sanitarium, and of this number two hundred fiftytwo women were found to have gynecologic lesions of importance. The conditions most frequently found were retroversion of the uterus, relaxed pelvic floor, inflammatory disease, fibroid uterus, prolapse of the uterus, and endometritis.

Distributing the gynecologic lesions among the different forms of insanity, the author found that in cases of senile dementia, terminal dementia, and paranoia, about one-third had pelvic lesions. In dementia precox about one-half were diseased. About two-thirds of the imbeciles showed pelvic disorders, and the percentage in manic depressive insanity was as high as seventy-four per cent.

The author believes that the cases to be treated by operative means should be carefully selected. He uses these precautions: (1) Consent of the relatives. (2) The patient is put in the best possible psychic condition. (3) The ailment must be clearly giving rise to symptoms of moderate severity or be in itself a danger to the individual.

Taussig is of the opinion that in doing laparotomies upon insane women, ovariotomy should be performed to prevent the possibility of pregnancy, and the giving birth to defective children.

In considering manic depressive insanity and pelvic disorders, the author emphasizes these facts:

(1) The decidedly greater frequency of gynecologic disease in this form of insanity-seventy-four per cent-as compared with the average of forty-seven per cent.

(2) The large proportion of chronic inflammatory conditions of the genital tract in this form of insanity.

(3) The proportionately large percentage of mental recoveries. after gynecologic operations done on women. having this form of insanity.

H. H. C.

ATHLETICS AND THE PERFECT WOMAN.

THE divergence of both lay and medical opinions on the relation of modern athletics to the sexual life of women is well shown in an interesting preliminary study by Doctor Angenette Parry in the September issue of the American Journal of Obstetrics and Diseases of

Women and Children. This author has collected many opinions from obstetricians, directors of gymnasia and others, and while many are frankly indefinite, many more are curiously at variance with each other.

As affecting menstruation, the concensus of opinion is that moderate exercise between periods is beneficial; most schools excuse their women from physical exercise during the menstrual period but there seems to be a conviction that reasonable effort might be allowed even at that time if these women could only be trusted to interpret "reasonable" reasonably.

Practically all agree that athletics are conducive to easy and uncomplicated labor, though some fear lacerations from the unusual muscular power of the patients. As might be expected, there is a marked differ- • ence of opinion on the relation of exercise to displacements, only five out of twenty gynecologists believing that physical effort is responsible for many of these conditions, while others are convinced that many partial displacements become complete through the same means. The variation in opinion seems founded on differences in conception of the meaning of the word "athletics." It is generally believed that well directed physical training is of great value in the rapid recovery and sufficient lactation of mothers.

The author's present conclusion is that the two sexes should have equal physical advantages until the age of puberty-that the little girls should run, climb, swim and play ball as do their brothers; and that the after regulation of the woman's life should be made only after competent physical examinations with special reference to the nervous. condition and temperament of the individual. A well-known obstetrician, in commenting on the so-called upper classes, has wisely remarked "that if they won't do normal manual work, perhaps athletics is the next best thing."

OBSTETRICS.

LESLIE HIGLEY STARK DEWITT, M. D.

F. M. L.

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

WARD FRANCIS SEELEY, A. B., M. D.

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

FETAL SERUM AND THE ONSET OF LABOR.

RONGY (American Journal of Obstetrics and Diseases of Women and Children, July, 1912), in a series of experiments on the use of fetal serum to cause the onset of labor, reviews the experiments of von der Heide, who used the serum in twenty-six pregnant women with the following results:

(1) Induction of labor.-In four cases after injection of serum labor pains sufficient for expulsion set in. The cases were all in the last weeks of pregnancy.

(2) Transient pains.—In three cases, transient pains accompanied the injection.

(3) In inertia.-In six cases of uterine inertia pains sufficient for expulsion followed the injection.

(4) Negative results.-Thirteen cases showed no effect after the second or third injection.

Rongy reports a series of nineteen cases in which the fetal serum was used with the idea of bringing on labor pains. In six cases one or more injection induced pains which led to the expulsion of the child. These patients were all from ten to eighteen days before term. In two cases, admitted at term, but in which no sign of labor was observed, uterine contractions were observed after injection. Two cases of uterine inertia, and one case of threatened eclampsia were effectually treated by the use of the serum. Seven experiments proved negative. The method, dosage, and preparation of serum as suggested by von der Heide were followed. The intravenous method was used in all W. F. S.

cases.

PEDIATRICS.

ARTHUR DAVID HOLMES, C. M., M. D.

CONSULTING PEDIATRICIAN TO THE WOMAN'S HOSPITAL AND INFANT'S HOME, DETROIT. HERBERT MATTESON RICH, B. L., M. D.

ATTENDING PHYSICIAN TO THE CHILDREN'S FREE HOSPITAL OF DETROIT.

BREAST FEEDING.

DAVIS (American Journal of Clinical Medicine, Volume XVIII, Number VII, page 790) says if the medical attendant took more pains to teach patients the facts about the physiology of lactation, more mothers could and would furnish breast milk to their babies with greater ease and comfort to themselves and to their offspring. The feeding of a baby at its mother's breast is not so simple a matter that it can be done properly without some education. The following facts should be borne in mind:

In Chicago last summer, fifteen bottle-fed babies died to every one that was breast-fed. Mothers should be made to appreciate this fact when bottle-feeding is contemplated.

One can dry up a mother's milk by putting the baby to her breast only at long intervals, say morning and evening, or only at night. Such habits will spoil the best wet nurse ever created.

One can check a mother's milk by constant or too many night feedings or by disturbing the woman's hours of sleep in any other way.

One can spoil the best breast milk in the world by feeding the woman too rich food, giving her alcoholic tonics, or checking normal exercise.

One can "upset" the baby by putting it to the breast too frequently,

loading a half empty stomach with a fresh meal. Vomiting, colic, green stools and diarrhea are some of the results.

One can get the best results by first knowing what the wet nurse yields to her baby, by a system of weighing the child before and after nursing. Every baby doctor should keep suitable scales to rent or lend for this purpose until he is satisfied on the matter.

The intervals between nursing can best be regulated when one knows how much milk the baby gets in twenty-four hours. An ordinary baby will thrive best on not more than seven meals in twenty-four hours during the first four months of life and often will do as well or better on six feedings. An effort should be made early to cut down night feedings, as it favors the welfare of both mother and child.

When the yield of breast milk is scanty and the child is not gaining, an ounce or two of artificial food should be given just after its nursing, rather than omit a breast feeding altogether, if the child is under six months or even older and if the time be midsummer, as such a method keeps the breasts up to their best yielding capacity. The old way of substituting a bottle for one or two feedings only checks the yield of inilk all at once.

Mixed feeding, when properly conducted, may be begun with benefit to the nursling in its eighth or ninth month, but the physician must instruct the mother what, when and how much she shall give. The following will do no harm, but will greatly help nourish breast-fed babies, when eight or nine months old, if properly prepared, given at the proper time and in proper quantities:

Pap (stale bread) soaked in boiling water and cooked with cow's milk for a few minutes.

Farina, or any other similar cereal, boiled and served with clean.

cow's milk.

Mothers should be taught the value of a drink of pure water to the nursling. Thirst is often mistaken for hunger, especially in summer. Vegetable soup, strained, with a little toasted bread.

A. D. H.

EDITORIAL COMMENT.

A TRIBUTE TO BREAKEY AS TEACHER.

DICKENS says that a teacher is "worried and tormented into monotonous feebleness,-the best part of his life ground out of him in a mill of boys." Possibly this characterization was intended to denote the worry and torment incident to diffusing instruction in the classics. Albeit whatever conditions portend to "monotonous feebleness" in any division of literature undoubtedly obtain to greater extent in the domain. of medicine, especially when the teacher is engaged in dispensing instruction in the clinics. This additional employment of the mind