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Cutaneous sensibility greatly exag

Skin tenderness insignificant as comgerated, broad, steady, deep pres- pared with the fixed deep-seated sure is grateful, though a vague excruciating tenderness. deep seated tenderness of the causative lesion may be elicited.

MUSCU'LAR RIGIDITY. Never positive nor continuous except Always reflex and continuous. Not in plumbism or great distention. easily overcome by pressure.

In Vay be overcome by gentle, steady localized disease may be circumpressure, and is not confined to a

scribed. small circumscribed area.

DIAPHRAGMATIC MOBILITY. Never impaired except by great dis- Generally reflexly diminished, espetention.

cially when the upper abdomen is Movements are not generally causa

involved. Sudden efforts, such as tive of pain.

coughing and deep breathing, are painful.

METEORISM.

May or may not occur, not charac- Generally noted early, though in teristic except in obstruction.

many cases slight, till disease be

comes well marked.

LEI'COCYTOSIS. Rarely present, and never progres- May not be present, but generally exsive.

ists, and if progressive, is of diagnostic value.

FEVER,

May or may not exist. A sudden fever, especially if preceded by rigor, points to peritonitis, though its absence is perfectly compatible with this disease.

GYNECOLOGY.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVersity of MICHIGAN.

DU MÉAT HYPOGASTRIQUE ET DE L'EPISIORRAPHIE APPLIQUÉE AU TRAITMENT DE CERTAINES FIS

TULES URETHRO-VÉSICO-VALGINALES.

CHÉNIEUX (Revue de gynécologie et de chirurgie abdominale, Volume X, Number I) describes an operation for certain cases of urethrovesico-vaginal fistula. This operation is to be used only in rare cases, for exceptional indications, when other procedures have failed, or would fail if employed. In the repair of urinary fistula the object is to restore control. Under various circumstances this cannot be done, for instance, in cases where the adhesions, the extent, or the location of the fistulous opening are such that complete closure is impossible, or when the sphincter of the bladder is involved so that repair of the fistula will not cure the incontinence.

The writer reports a case in which he employed his operation. woman, aged twenty-six, after a difficult labor, suffered from incontinence of urine. Marked leakage took place without regard to the position assumed. Examination showed practically a destruction of the cervix and the anterior vaginal wall. The borders of the extensive fistula were indurated and adherent at the sides to the pelvic bones, posteriorly to the remains of the uterus. The fistula was classified as urethro-vesico-vaginal, for the whole urethra as well as the floor of the bladder had disappeared. Such cases are extremely rare and cannot be treated by any of the more common operative procedures.

The method used in this case was a modification of that practiced by Maisonneuve, Baker-Brown, and Rose, and consisted in the establishment of a communication between the bladder and the rectum with closure of the vaginal and urethral openings. The operation is done by making two large lateral flaps consisting each of one labium majus with the surrounding tissue. The base or pedicle of one flap lies in a line from the anterior commissure, along the edge of the introitus, to the center of the perineum. The base of the second flap lies well out at the fold forming the junction of the skin of the thigh and vulva. The first flap is now turned, raw surface outward, into the bed formed by dissecting loose the other flap, and sutured in place. The second flap is now shifted over the raw surface to cover it with skin. This flap is now sutured to the margin of the incision which outlined the first flap. In this way the meatus and the vaginal orifice are securely closed. The opening between the vagina and the rectum, which is made before the vulvar introitus is occluded, is utilized, subsequently,

as an avenue through which a canula with an obturator is passed to irrigate the vesical portion of the artificial cloaca, in order to prevent the formation of calculi. With proper instruction, the patient herself will be able to carry out this procedure.

The results of the operation are not fully stated. The writer does not discuss the possibility of ascending infection of the urinary tract and no idea is given as to how long the patient could retain urine. A difficulty experienced by some surgeons after similar operations is contraction of the edges of the artificial fistula between the vagina and the rectum, necessitating a more extensive opening by a subsequent operation.

C. G. P.

PEDIATRICS.
BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN.

SUBSTITUTE FEEDING IN INFANTS. SANDERSON WELLS (British Medical Journal, July 8, 1905) says any food not conforming with the standard composition and properties of mother's milk must be rejected. He says artificial foods as a class are bad, and believes wet-nursing inadvisable as it is inaccurate, inconvenient and dangerous, because we cannot exclude syphilis. The author relies on the modification of cow's milk and draws the following conclusions :

(1) That mother's milk is the only proper food for infants and should be used whenever available.

(2) That all forms of proprietary foods are bad and to be avoided. (3) That wet-nursing is rarely permissible.

(4) That the proper substitute food for infants is some form of modified cow's milk.

Also the following special conclusions:

(1) That the standard at which we aim in modifying cow's milk is the child's natural food-mother's milk.

(2) That careful attention must be paid to each of the constituents proteid, fat, sugar and salts.

(3) That the proteid of cow's milk is less digestible than that of human milk and requires overdilution compared with that of the standard.

(4) That the whole of this indigestible proteid (caseinogen) may be removed, leaving the more easily digestible proteid (lactalbumen) as in whey mixtures, or that the proteid content may be completely or partially peptonized.

(5) That cow's milk diluted sufficiently to bring the proteid into line with the standard (that is, from four per cent to 1.5 per cent) is deficient in fat and sugar, and that these must be subsequently added.

(6) That fat may be added in the form of cream, either separated and of standard strength, or by using gravity creams.

(7) That lactose is the proper sugar to add.

(8) That cow's milk, although neutral or alkaline when drawn, owing to its certain infection as at present obtained and to the rapid growth of germs it allows, becomes acid, and that this acidity must be neutralized by bircarbonate of soda or limewater.

(9) That human milk is sterile. From this it follows that we should endeavor by all the means in our power to obtain a supply of sterile cow's milk.

(10) Germs must be killed by some method. The handiest and most generally used being heat.

To his previous conclusions he adds the following:

(1) That some attempt must be made to kill germs always present in large quantities in milk.

(2) That boiling does this most effectually and rapidly, is much the easier method, and, in the hands of the poor, often the only method available, but that certain injurious changes result, to be avoided if possible.

(3) That these changes can best be avoided at 70° centigrade (158° Fahrenheit) for half an hour (Pasteurization).

(4) That all infant's food should therefore undergo this process when possible.

ORTHOPEDICS.
By IRA DEAN LOREE, M.D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN.

CONGENITAL COXA VARA. HENRY O. Feiss, M. D., of Cleveland, in Jama, February 24, 1906.

He gives the history of one case with arguments favoring its origin as intrauterine. The article contains a summary of certain experiments performed upon the dead fetus. These consisted in fixing the limbs in certain positions that might be assumed before birth and then noting the relations of the parts by means of the radiograph.

He concludes that the deformity comes most commonly with defects of the femur of the lower limbs. That it may be intrauterine in its strictest sense, from intrauterine infection or combined with congenital rachitic deformities.

LARYNGOLOGY. BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN. ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

A CONTRIBUTION TO THE STUDY OF THE ETIOLOGY

OF NASAL OBSTRUCTION. WILHELM Roth (Revue Hebdomadaire de Laryngologie, d'Otologie et de Rhinologie, January 20, 1906) calls attention to those cases where the antrum of Highmore is involved, and where the secretion is of such consistence that none of it flows out into the nasal fossa. Examination of the nose shows no secretion, nor the usual evidence of sinus involvement. These cases are accompanied by nasal obstruction of the side corresponding to the sinus involved. The swelling in the nose involves the cavernous tissue, and it promptly shrinks after the application of cocain. No anatomical reason can be found to account for the nasal obstruction. If the antrum be thoroughly washed out, the nasal obstruction will promptly disappear. If the secretions are again allowed to accumulate in the sinus, the nasal obstruction will recur. The author believes that the cause of the swelling of the cavernous tissue is the reflex vasomotor irritation due to the accumulation of the secretion in the sinus. Roth holds that this type of sinus disease is an important factor in the etiology of unilateral nasal obstruction, where no anatomical cause can be found to account for the nasal condition.

PROCTOLOGY.
BY LOUIS JACOB HIRSCHMAN, M. D., Detroit, MICHIGAN.

CLINICAL PROFESSOR OP PROCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

DIVULSION OF THE SPHINCTER, AND FISSURE IN ANI.

Dwight H. MURRAY, under the caption, “Some Minor Rectal Lesions,” treats of a number of ano-rectal conditions, in the Buffalo Medical Journal, Volume LXI, Number IX.

Speaking of divulsion of the sphincter muscle, he judges, from the statements of many physicians and patients with whom he has come in contact, that that procedure is not well understood. At least ten minutes, on an average, should be occupied in this procedure. The muscle should be carefully and slowly tired out, or paralyzed, not quickly stretched and the muscular fibers torn. Murray has had patients who gave a history of rapid dilation of the sphincter, which resulted in a partial loss of sphincteric control. Rectal operations done after a proper divulsion cause much less pain, and a soreness only is complained of in most cases.

Fissure in ani, at the onset is indicated by a sharp cutting, tearing or burning pain coming on during or after a bowel movement. Patients do not always know just the time it began; they may first notice a little bleeding after stool, sphincteric spasm, and an increased constipation caused by fear of pain. The stool then may become dry and hard, making the fissure worse. These patients are in a very nervous condition with many direct and reflex symptoms. Sometimes the only symptom of an anal fissure is a pain in the heel, which is often treated for rheumatism.

Recent fissures, if there is no spasm of the sphincters or induration, may be successfully treated without operation. Orthoform applied to its base, followed by pure ichthyol applied every other day, is an excellent treatment for most nonoperative cases. Uncomplicated cases are

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