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bitter experience has felt compelled to abandon first one dish and then another, until only fluids alone can be taken, and these not always with impunity; a patient, to say the truth, whose life becomes embittered by the pangs of a suffering which he must inflict upon himself,-this patient will find, if a gastroenterostomy be done for the chronic ulcer, which is the source of all his trouble, that his return to health and appetite is at first almost beyond belief."
The paper closes with a respectful consideration of the gastric analyst, whose opinions should be tolerated, but accepted only when they fit in with clinical facts. When in doubt, use the exploratory incision.
C. G. D.
REUBEN PETERSON, A. B., M. D.
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
CHRISTOPHER GREGG PARNALL, A. B., M. D.
FORMERLY FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
SHORTENING OF THE ROUND LIGAMENTS WITHIN THE INGUINAL CANALS, THROUGH A SINGLE SUPRA
PUBIC TRANSVERSE OR MEDIAN LONGITU
PETERSON (Surgery, Gynecology, and Obstetrics, Volume III, Number I) describes an operation used in the gynecologic clinic of the University of Michigan Hospital during the last year. For the correction of retrodisplacements of the uterus the author had found Alexander's method the most satisfactory, when conditions permitted its utilization. However, the Alexander operation is limited in application to cases of nonadherent uteri, two incisions are necessary, and additional intrapelvic work is not usually feasable on account of technical difficulties arising from the location of the incisions.
In order to retain the principle of the Alexander operation, and at the same time to overcome its disadvantages, the writer has introduced a new method of shortening the round ligaments. A transverse incision is made down to the fascia just above a line joining the two pubic spines. The upper edge of the incision is retraced upward and the fascia exposed for two inches or more. The fascia is incised longitudinally in the median line, the rectus fibres separated, and the transversalis fascia and peritoneum opened high up to avoid the bladder. Adhesions of the uterus and adnexa may now be broken up and any other intrapelvic procedure can be carried out with ease. One angle of the incision is then retraced downwards and outwards, and the fascia cleared by blunt dissection over the external ring which is always located at the base of the pubic spine. The canal is opened on a grooved director, nerve filaments isolated and drawn aside, and the
round ligament sought for just inside and below the edge of the internal oblique muscle. The peritoneum is now stripped back for several inches. The opposite side is treated in the same manner. Both ligaments are drawn up while a finger inserted through the peritoneal incision holds the uterus well up and forward so that the cervix points downwards and backwards in its normal direction. The ligaments are now seized by hemostats at the level of the internal rings to indicate the amount of shortening necessary. The nerve is released and the ligament secured to the under surface of the fascia by a modified mattress suture of catgut. The edges of the fascia are united by a continuous suture. After closing the inguinal canals the median incision is closed by tier sutures of catgut. Care should be taken in approximating the superficial fat that all dead space is obliterated by appropriate sutures. The skin incision is closed as the operator desires. No drainage is necessary.
The above principle of shortening the ligaments through a single incision can be applied with the usual median longitudinal incision, which is preferred when extensive abdominal work is necessary.
C. G. P.
WILLIAM HORACE MORLEY, PH. B., M. D.
DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN,
WALES MELVIN SIGNOR, M. D.
FIRST ASSISTANT IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.
"ANESTHESIA IN THE FIRST STAGE OF LABOR."
NEWELL (Surgery, Gynecology, and Obstetrics, July, 1906), under this title, advances the idea that the older beliefs with regard to the time at which the anesthetic should be given in conducting a labor are not applicable to the present status of civilization. As an excuse for the use of ether or other anesthetic in the first stage, he maintains that the modern method of life has removed women from the normal standard, and hence makes of every case of confinement one requiring the special attention advised for all abnormal labors.
As a result of racial progress womankind is less able to stand the pain incident to the labor, and is entitled to relief as soon in the labor as the pain becomes severe. This prevents a shattering of the nervous system by the strain and makes the woman more willing to undergo a second conception. He states that a majority of his series of cases have been terminated by the application of low forceps. "This has not been due to the effect of the ether on labor pains, but to my own personal belief that the nervous and physical exhaustion entailed by a more or less severe second stage will do more permanent harm than a carefully performed operative delivery."
In support of his views he holds that the labor is not prolonged;
that there is no apparent increase in the tendency to postpartum hemorrhage; and that the infant mortality is not necessarily increased. In regard to the last point, he says that a deep etherization is often present in the child requiring careful resuscitation. He believes that the spasm of the cervical muscle is lessened and the dilatation of the cervix hastened by the use of anesthetic.
A further portion of his article deals with the use of scopolamin and morphin for similar anesthetic purpose in obstetric work. In this he points out the dangers of the drugs and that further experience may be advisable before they be taken into general use. In conclusion he gives comparisons between the different forms of anesthetization as he has met them in his work.
W. M. S.
ARTHUR DAVID HOLMES, C. M., M. D.
HYDROCEPHALUS AND RACHITIS TREATED BY
DOCTOR MARGARET CLEAVES (Archives of Pediatrics, February, 1906) says: "Judging from the pathology of hydrocephalus that the r-ray which is able to penetrate so deeply as to outline not only the bony structures, but internal organs, tuberculous lesions, that produces disturbances of the cellular equilibrium of the blood, that is destructive of germ life, and that can atrophy the Graffian follicles, can with perfect reason be expected to penetrate the cranial bones and act upon the thickened granular, endothelium and to promote and stimulate. nutritive changes."
The author reports two cases, one of congenital internal hydrocephalus, and one which had been four times diagnosed as primary hydrocephalus and in which a rachitic element was recognized. In both cases good results were secured. Doctor Cleaves said that her paper was not presented with the thought that in radiant energy is to be found a panacea for hydrocephalus and rachitis, but to call the attention of the profession to the results obtained in the cases reported that the way may open for further investigation of the subject.
Treatment should be instituted upon the first manifestation of disease, even immediately after birth in congenital hydrocephalus, but it should be administered with a full knowledge of the physics, physiologic action and therapeutic technique of radiant energy, superimposed upon a knowledge of the pathology underlying the condition.
COMPLICATIONS OF SCARLET FEVER.
HUNTER Writes (British Medical Journal, February 24, 1906) that in addition to the specific symptoms of this disease some cases present rigors and diarrhea, while a few have pains in the limbs and others epistaxis. The rash appears (in his series of one hundred fifty cases)
in half the cases on the second day, and in eighty per cent on the first three days of the illness. The rash lasted five days in more than half the cases. Desquamation began usually at the root of the neck and in most cases within the first week. The complications are set down as follows: Adenitis, nineteen per cent; albuminuria, of two or more days' standing, twenty-one per cent; actual nephritis, 2.8 per cent; otorrhea and otitis, 6.4 per cent; rhinitis and rhinorrhea, 6.4 per cent; rheumatism, 4.3 per cent; secondary tonsillitis, 3.5 per cent. We also find mastoiditis, meningitis, optic neuritis and ocular paralyses coming on after some cases of this disease. On the whole, a severe rash is more likely to be followed by complications than is a mild one. There seems to be no definite relation between the height of the temperature and the occurrence of complications. The severity of the disease and the septic complications of it are largely influenced by the degree of oral sepsis in the patient when the disease commences. Of cases without oral sepsis only thirty-five per cent had complications of moderate or severe degree, whereas of cases with oral sepsis sixtyfive per cent developed such complications. Our first duty is, therefore, in every case to get rid of this great danger, oral sepsis, as far as possible.
PREVENTION OF TUBERCULOSIS AMONG SCHOOL CHILDREN.
DOCTOR VAUTIER, of Paris, in a paper in the Revue d'Hygiene et de Medicine Infantiles, Paris, 1905, Volume IV, pages 691 and 723, has reached the following conclusions: In the common schools of Paris tubercular contagion appears to us to be very rare. This contagion may be produced in a family during the school age, but even that is not frequent. The number of children of school age, who have clearly pulmonary tuberculosis is very small. Children, in a great majority of cases, at least among the poor, are infected by latent tuberculosis at the time of their entrance into school. He therefore proposes the following rules and regulations:
(1) Add to the instructions given relative to the construction of school buildings, a rule favoring facing the building so that the sun's rays may penetrate the class rooms and court.
(2) Replace wooden floors by those without joints in schools to be built, and, if possible, in those already built.
(3) Exclude children who have evident tuberculosis, except that surgical tuberculosis may be so protected by air-tight dressing as to be safe.
(4) Send away members of the teaching force who have evidences of tuberculosis, or put them in places where they will not come in contact with children.
(5) Have schoolrooms thoroughly cleaned.
(6) Seek to increase the strength of children by walks and games for which open lawns are necessary. Fortifications or the space about them are all that is necessary.
(7) Insist that the schoolmasters advise cleanliness and if need be, require it, and that they make it possible for children to know the meaning of a bath.
(8) Insist on obtaining from the boards of health, proper aeration and size for homes and disinfection of places occupied by bacillusbearing tuberculous patients, especially at the time between the departure of the infected family and the entrance of another family.
(9) Invite the school boards to consider the matters of better food for the children, furnishing a meal to many of them and making arrangements for free medicines, especially those prescribed by the attending physician.
(10) Send children convalescent from acute sicknesses, especially those likely to become tuberculous: measles, pertussis, et cetera, to special institutions in the country.
(11) Establish seashore hospitals at convenient places, where tuberculous children may stay six months or a year, and receive suitable treatment.
IRA DEAN LOREE, M. D.
FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN.
OBSERVATIONS ON BROKEN NECKS.
REGINALD H. SAYRE, M. D., of New York (American Journal of Orthopedic Surgery for April, 1906), first corrects the deformity and after placing his patient in the Sayre position retains it by means of a plaster-of-Paris jacket and helmet. Immobilization may be obtained by extension to the head while liquid plaster-of-Paris is poured about the head and neck or supported by sandbags.
Paralysis often recurs, hence it is necessary to keep the parts at rest for a longer period than in an ordinary fracture. He does not state any required length of time (no doubt it differs in individual cases), but it is generally necessary to support the parts by means of a jurymast or other like apparatus after the patient is allowed to be up.
He has had in his practice eleven cases with results as follows: In four there was a complete cure. Two had muscular control but there remained some stiffness. One patient required support to the head; however, he had good control of all muscles. Two remained paralyzed in the lower extremities. One died soon after injury and one was under treatment at time of his report. In those cases where complete readjustment is secured he expects a perfect cure. If paralysis persists after manipulation he advises laminectomy.